Oncology Quality Clinical Data Registry

Transcription

1 Oncology Quality Clinical Data Registry Powered by Premier Inc. This registry has been approved by CMS as a Qualified Clinical Data Registry (QCDR) for eligible clinicians and group practices for the 2019 Quality Payment Program (QPP) performance period. QCDR Measures QCDR MEASURES Recommendation for Exercise to Adult Cancer Survivors ONSQIR16 Percentage of patients aged 18 or older with a current or prior diagnosis of cancer who receive an individualized recommendation for 150 minutes of moderate intensity or 75 minutes of high intensity cardio type exercise weekly along with two sessions of resistance and/or flexibility exercise at any visit during the measurement period. National Quality Strategy Domain: Effective Clinical Care Goal Setting and Attainment for Cancer Survivors ONSQIR18 Percentage of patients aged 18 years and older who completed the final component of cancer treatment that have at least one posttreatment goal documented and progress toward goal attainment documented within 12 months of completing the final component of cancer treatment. National Quality Strategy Domain: Person and Caregiver Centered Experience and Outcomes

2 QCDR MEASURES Patient Reported Health-Related Quality of Life (HRQOL) during Treatment for Advanced Cancer ONSQIR21 Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life. Two rates are reported: 1. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart. 2. Percentage of patients aged 18 and older with an active diagnosis of advanced cancer (Stage III or Stage IV) receiving chemotherapy and/or immunotherapy for treatment of cancer, who have HRQOL assessed on the FACT-G (Version 4) or PROMIS Global Health short form (Version 1.2) at least twice during the measurement period at least 90 days apart, where the most recent total score indicates the same or better quality of life. National Quality Strategy Domain: Person and Caregiver Centered Experience and Outcomes Data Submission Methods(s): Electronic Measure PCR Test with MR2 or greater result (BCR-ABL1 transcript level <= 1% [IS]) for patients receiving TKI for at least 6 months for Chronic Myelogenous Leukemia ONSQIR22 Percentage of patients aged 18 and older with chronic myelogenous leukemia who are receiving TKI therapy for at least 6 months, who have at least 1 PCR test performed with the most recent result equal to or greater than MR2 (BCR-ABL1 transcript level <= 1% [IS]) during the measurement period. National Quality Strategy Domain: Effective Clinical Care Data Submission Methods(s): Electronic Measure Assessment for and management of immune-related adverse events during cancer treatment with checkpoint inhibitors (ICPi) ONSQIR23 Percentage of patients aged 18 and older receiving a checkpoint inhibitor (ICPi) for cancer experiencing immune-related adverse events of documented grade 3+ diarrhea OR documented grade 3+ hypothyroidism OR documented grade 3+ dermatitis OR documented grade 3+ pneumonitis AND for each adverse event, there is guideline concordant intervention (per ASCO/NCCN guideline) during the measurement period. National Quality Strategy Domain: Effective Clinical Care Data Submission Methods(s): Electronic Measure 2

3 Measures for Performance & Quality Improvement Available for calculation, performance tracking and improvement activities. Not available for 2019 MIPS Submission. MEASURES FOR PERFORMANCE & QUALITY IMPROVEMENT Assessment and Intervention for Psychosocial Distress in Adults Receiving Cancer Treatment ONSQIR1 Percentage of patients aged 18 years and older with a diagnosis of cancer who are assessed for psychosocial distress, and if moderately to severely distressed, have a documented intervention during the measurement period. Recommendation for Exercise to Adult Cancer Survivors ONSQIR2 Percentage of patients aged 18 years or older with a diagnosis of cancer who received a documented recommendation for a program of exercise at any visit during the measurement period. Assessment and Intervention for Sleep-Wake Disturbance During Cancer Treatment ONSQIR3 Percentage of chemotherapy cycles for patients aged 18 years and older with a diagnosis of cancer where a sleep-wake disturbance assessment is documented, and if moderate to severe disturbance is reported, an intervention for sleep-wake disturbance is documented. Education on Neutropenia Precautions ONSQIR4 Percentage of patients aged 18 years and older receiving intravenous chemotherapy who received education on neutropenia precautions prior to or at the time of the first chemotherapy administration. Instructions include hand washing and to contact health care provider of a fever of or greater. Post-Treatment Education ONSQIR6 Percentage of patients aged 18 years and older for whom four critical areas of patient education regarding lifestyle, late effects and cancer recurrence have been provided or reinforcement of prior education has occurred. 3

4 MEASURES FOR PERFORMANCE & QUALITY IMPROVEMENT Psychosocial Distress Improvement ONSQIR8 Percentage of patients aged 18 years and older who had moderate or greater psychosocial distress at baseline (end of cancer treatment) and report improvement in psychosocial distress from baseline to most recent visit in during the 12 month period after completing the final component of the treatment plan. Fatigue Improvement ONSQIR20 Percentage of patients aged 18 years and older with a diagnosis of cancer who reported moderate or greater level of fatigue at baseline who report mild or clinically insignificant fatigue during the 12-month measurement period MIPS Clinical Quality Measures (CQMs) and ecqms * QUALITY MEASURES CQM # ecqm ID NQF # Advance Care Plan 047 N/A 0326 Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. National Quality Strategy Domain: Communication and Care Coordination Data Submission Method(s): Registry Measure Preventive Care and Screening: Influenza Immunization 110 CMS147v Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. National Quality Strategy Domain: Community/Population Health Pneumococcal Vaccination Status for Older Adults 111 CMS127v Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. National Quality Strategy Domain: Community/Population Health * CMS Clinical Quality Measure (formerly Registry Measure) specifications at 4

5 QUALITY MEASURES* CQM # ecqm ID NQF # Documentation of Current Medications in the Medical Record 130 CMS68v Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. National Quality Strategy Domain: Patient Safety Pain Assessment and Follow-Up 131 N/A 0420 Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. National Quality Strategy Domain: Communication and Care Coordination Data Submission Method(s): Registry Measure Oncology: Medical and Radiation Pain Intensity Quantified 143 CMS157v Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Oncology: Medical and Radiation Plan of Care for Moderate to Severe Pain 144 N/A 0383 Percentage of patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having moderate to severe pain with a plan of care to address pain documented on or before the date of the second visit with a clinician. National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Data Submission Method(s): Registry Measure Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 226 CMS138v Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. National Quality Strategy Domain: Community/Population Health * CMS Clinical Quality Measure (formerly Registry Measure) specifications at 5

6 QUALITY MEASURES* CQM # ecqm ID NQF # Use of High-Risk Medications in the Elderly 238 CMS156v Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication 2) Percentage of patients who were ordered at least two of the same high-risk medication National Quality Strategy Domain: Patient Safety Falls: Screening for Future Fall Risk 318 CMS139v Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. National Quality Strategy Domain: Patient Safety Data Submission Method(s): Electronic Measure Closing the Referral Loop: Receipt of Specialist Report 374 CMS50v7 N/A Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. National Quality Strategy Domain: Communication and Care Coordination * CMS Clinical Quality Measure (formerly Registry Measure) specifications at research@ons.org option 4 Inc. All rights reserved. 6