OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Data collection, implementation, and public reporting information for each measure are detailed by measure set in the following pages. Cardiac Care (Acute Myocardial Infarction and Chest Pain) Implementation* OP-1: Median Time to Fibrinolysis 2008 OP-2: Fibrinolytic Therapy Received Within 30 Minutes 2008 OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention 2008 OP-4: Aspirin at Arrival 2008 OP-5: Median Time to ECG 2008 ED-Throughput Implementation* OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients 2012 OP-19: Transition with Specified Elements Received by Discharged Patients 2012 OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional 2012 OP-22: ED- Patient Left Without Being Seen 2012 Pain Management Implementation* OP-21: Median Time to Pain Management for Long Bone Fracture 2012 Stroke Implementation* OP-23: ED- Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of Arrival 2012 Surgical Care Implementation* OP-6: Timing of Antibiotic Prophylaxis 2008 OP-7: Prophylactic Antibiotic Selection for Surgical Patients 2008 Imaging Efficiency Implementation* OP-8: MRI Lumbar Spine for Low Back Pain 2009 OP-9: Mammography Follow-up Rates 2009 OP-10: Abdomen CT Use of Contrast Material 2009 OP-11: Thorax CT Use of Contrast Material 2009 OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery 2012 OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT 2012 OP-15: Use of Brain CT in the Emergency Department (ED) for Atraumatic Headache** 2012 *The implementation date indicates the beginning of data collection for this measure. This measure has been removed; however, submission of a non-blank value is required through Q4 2013 encounters. Please see Measures for more information. **Reporting for this measure is postponed. Please see Imaging Efficiency Measures for more information. Updated January Page 1 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Web-Based Implementation* OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data 2011 OP-17: Tracking Clinical Results between Visits 2012 OP-25: Safe Surgery Checklist Use 2013 OP-26: Outpatient Volume Data on Selected Outpatient Surgical Procedures 2013 OP-27: Influenza Vaccination Coverage among Healthcare Personnel OP-29: Endoscopy/Polyp Surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients OP-30: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use OP-31: Cataracts Improvements in Patient s Visual Function within 90 Days Following Cataract Surgery For Healthcare Common Procedure Coding System (HCPCS) codes affected, see QualityNet. Updated January Page 2 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-1: Median Time to Fibrinolysis Median time from emergency department (ED) arrival to administration of fibrinolytic therapy in ED patients with STsegment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to ED arrival and prior to transfer OP-2: Fibrinolytic Therapy Received Within 30 Minutes ED acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED arrival to fibrinolysis of 30 minutes or less Cardiac Care (AMI and CP) Measures and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 2013 Aug Q2 2013 - Q1 Dec Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Updated January Page 3 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention Median time from ED arrival to time of transfer to another facility for acute coronary intervention OP-3a: Median Time to Transfer to Another Facility for Acute Coronary Intervention This rate looks at all AMI patients who were transferred out for acute coronary intervention at another facility. It calculates the time from the patient arrival to patient departure. OP-3a is the rate for all cases transferred for acute coronary intervention (OP- 3b + 3c). OP-3a will not be publicly reported. Cardiac Care (AMI and CP) Measures and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Q2 2013 Nov 2013 Q3 2013 02/01/ Q3 2013 Feb Q4 2013 05/01/ Q4 2013 May Q1 08/01/ Q1 Aug Updated January Page 4 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-3b: Median Time to Transfer to Another Facility for Acute Coronary Intervention This rate looks at all AMI patients who were transferred out for acute coronary intervention at another facility and did not have a contraindication to fibrinolytics. It calculates the time from the patient arrival to patient departure. OP-3b will be publicly reported. OP-3c: Median Time to Transfer to Another Facility for Acute Coronary Intervention Quality Improvement Measure This rate looks at all AMI patients who were transferred out for acute coronary intervention at another facility and did have a contraindication to fibrinolytics. It calculates the time from the patient arrival to patient departure. OP-3c will not be publicly reported. Cardiac Care (AMI and CP) Measures and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Q3 2013 02/01/ Q3 2013 Feb Q4 2013 05/01/ Q4 2013 May Q1 08/01/ Q1 Aug Updated January Page 5 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-4: Aspirin at Arrival ED acute myocardial infarction (AMI) patients or chest pain (CP) patients (with probable cardiac CP) who received aspirin within 24 hours before ED arrival or prior to transfer Cardiac Care (AMI and CP) Measures and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec OP-5: Median Time to ECG Median time from ED arrival to ECG (performed in the ED prior to transfer) for AMI or CP patients (with probable cardiac CP) Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Updated January Page 6 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations ED-Throughput Measures OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department OP-18a: Median Time from ED Arrival to ED Departure for Discharged ED Patients Overall Rate and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Q2 2013 Nov 2013 Q3 2013 02/01/ Q3 2013 Feb Q4 2013 05/01/ Q4 2013 May Q1 08/01/ Q1 Aug OP-18b: Median Time from ED Arrival to ED Departure for Discharged ED Patients Reporting Measure Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Updated January Page 7 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations ED-Throughput Measures OP-18c: Median Time from ED Arrival to ED Departure for Discharged ED Patients Observation Patients (Effective through December 31, 2013 encounters) OP-18c: Median Time from ED Arrival to ED Departure for Discharged ED Patients Psychiatric/Mental Health Patients (Effective beginning January 1, encounters) OP-18d: Median Time from ED Arrival to ED Departure for Discharged ED Patients Psychiatric/Mental Health Patients (Effective through December 31, 2013 encounters and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q3 2013 02/01/ Q3 2013 Feb Q4 2012 Q3 2013 July Q4 2013 05/01/ Q4 2013 May Q1 2013 Q4 2013 Oct Q1 08/01/ Q1 Aug Q1 Jan 2015 Q2 Nov Q1 Q2 Apr Q3 2013 02/01/ Q3 2013 Feb Q4 2012 Q3 2013 July Q4 2013 05/01/ Q4 2013 May Q1 2013 Q4 2013 Oct Updated January Page 8 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations ED-Throughput Measures OP-18d: Median Time from ED Arrival to ED Departure for Discharged ED Patients Transfer Patients (Effective beginning January 1, encounters) OP-18e: Median Time from ED Arrival to ED Departure for Discharged ED Patients Transfer Patients (Effective through December 31, 2013 encounters) OP-19: Transition with Specified Elements Received by Discharged Patients* and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q1 Jan 2015 Q2 2013 11/01/ Q2 Nov Q1 Q2 Apr 2015 Q3 2013 02/01/ Q3 2013 Feb Q4 2012 Q3 2013 July Q4 2013 05/01/ Q4 2013 May Q1 2013 Q4 2013 Oct Q3 2013 02/01/ Q4 2013 05/01/ *This measure has been removed; however, submission of a non-blank value is required through Q4 2013 encounters. Please see Measures for more information. Updated January Page 9 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations ED-Throughput Measures OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional Median time from ED arrival to provider contact for emergency department patients and Population and Sampling Due in OPPS Clinical Q3 2013 02/01/ Q2 2013 Q3 2013 Request (s Due 45 Days After Nov 2013 Q3 2012 Q2 2013 Apr Feb Q4 2012 Q3 2013 July Q4 2013 05/01/ Q4 2013 May Q1 2013 Q4 2013 Oct Q1 08/01/ Q1 Aug Q2 2013 Q1 Dec OP-22: ED Patient Left Without Being Seen OP-22 is a chart-abstracted measure reported via a web-based tool in the secure portion of QualityNet. More information is available in the Web-Based Measures section of this document on page 16. Updated January Page 10 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Pain Management Measure OP-21: Median Time to Pain Management for Long Bone Fracture Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF) and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Updated January Page 11 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-23: ED- Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of Arrival ED acute ischemic stroke or hemorrhagic stroke patients who arrive at the ED within 2 hours of the onset of symptoms who have a head CT or MRI scan performed during the stay and having a time from ED arrival to interpretation of the head CT or MRI scan within 45 minutes of arrival and Population and Sampling Due in OPPS Clinical Stroke Measure Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec Updated January Page 12 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations OP-6: Timing of Antibiotic Prophylaxis Surgical patients with prophylactic antibiotics initiated within one hour* prior to surgical incision Surgical Care Measures and Population and Sampling Due in OPPS Clinical Request (s Due 45 Days After Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec OP-7: Prophylactic Antibiotic Selection for Surgical Patients Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure) Q1 08/01/ Q1 Aug Q2 2013 - Q1 Dec * Patients who received Vancomycin or a fluoroquinolone for prophylaxis should have the antibiotic initiated within two hours prior to surgical incision. Due to the longer infusion time required for Vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time. Updated January Page 13 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Imaging Efficiency Measures (No additional data are required for the imaging measures.) OP-8: MRI Lumbar Spine for Low Back Pain The percentage of Magnetic Resonance Imaging (MRI) of the lumbar spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy OP-9: Mammography Follow-up Rates The percentage of patients with mammography screening studies that are followed by a diagnostic mammography, ultrasound, or MRI of the breast in an outpatient or office setting within 45 days OP-10: Abdomen Computed Tomography (CT) Use of Contrast Material The percentage of abdomen studies that are performed with and without contrast out of all abdomen studies performed (those with contrast, those without contrast, and those with both) OP-11: Thorax CT Use of Contrast Material The percentage of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both) OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non Cardiac Low Risk Surgery The percentage of stress echocardiography, single photon emission computed tomography myocardial perfusion imaging (SPECT MPI) or stress MRI studies performed at a hospital outpatient facility in the 30 days prior to a low-risk, non-cardiac surgery performed anywhere Reporting Period July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July Updated January Page 14 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Imaging Efficiency Measures (No additional data are required for the imaging measures.) OP-14: Simultaneous Use of Brain CT and Sinus CT The percentage of brain CT studies with a simultaneous sinus CT (i.e., brain and sinus CT studies performed on the same day at the same facility) OP-15: Use of Brain CT in the ED for Atraumatic Headache* The percentage of ED visits for atraumatic headache with a coincident brain CT study for Medicare beneficiaries *Reporting for this measure is postponed. Please see Imaging Efficiency Measures for more information. Reporting Period July 1, 2012 June 30, 2013 Q3 2012 Q2 2013 July July 1, 2012 June 30, 2013 Updated January Page 15 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Web-Based Measures Reference Period Submission Period OP-12: The Ability for Providers with Health Information Technology (HIT) to Receive Laboratory Data Electronically Directly into their ONC-Certified Electronic Health (EHR) System as Discrete Searchable Data Documents the extent to which a provider uses an Office of the National Coordinator for HIT-certified EHR system that incorporates an electronic data interchange with one or more laboratories, allowing for direct electronic transmission of laboratory data in the EHR as discrete searchable data elements OP-17: Tracking Clinical Results between Visits The extent to which a provider uses an ONC-certified EHR system to track pending laboratory tests, diagnostic studies (including common preventive screenings), or patient referrals OP-22: ED- Patient Left Without Being Seen Percent of patients who leave the emergency department (ED) without being evaluated by a physician/advance practice nurse/physician s assistant (physician/apn/pa) January 1 December 31, 2013 January 1 December 31, 2013 January 1 December 31, 2013 July 1 November 1, July 1 November 1, July 1 November 1, CY 2013 July 2015 CY 2013 July 2015 CY 2013 July 2015 Updated January Page 16 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Web-Based Measures Reference Period Submission Period OP-25: Safe Surgery Checklist Use The use of a safe surgery checklist for surgical procedures that includes safe surgery practices during each of the three critical perioperative periods: the period prior to the administration of anesthesia, the period prior to skin incision, and the period of closure of incision and prior to the patient leaving the operating room OP-26: Outpatient Volume Data on Selected Outpatient Surgical Procedures* The aggregate count of selected outpatient surgical procedures performed within the outpatient department (e.g., outpatient surgery, cath lab, endoscopy). This excludes procedures performed within the emergency department. OP-27: Influenza Vaccination Coverage among Healthcare Personnel Assesses the percentage of healthcare personnel who have been immunized for influenza OP-29: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients The percentage of patients aged 50 years and older receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report January 1 December 31, 2013 January 1 December 31, 2013 October 1, March 31, 2015 April 1 December 31, *For Healthcare Common Procedure Coding System (HCPCS) codes affected, see QualityNet. July 1 November 1, July 1 November 1, October 1, through the deadline of May 15, 2015 July 1 November 1, 2015 CY 2013 July 2015 CY 2013 July 2015 Q4 Q1 2015 (/2015 Flu Season) Q2 Q4 To Be Determined To Be Determined Updated January Page 17 of 18
OQR Quality Measures and Timelines for CY 2015 and Subsequent Payment Determinations Web-Based Measures Reference Period Submission Period OP-30: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps Avoidance of Inappropriate Use The percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior colonic polyp(s) in previous colonoscopy findings, who had a followup interval of 3 or more years since their last colonoscopy OP-31: Cataracts Improvements in Patient s Visual Function within 90 Days Following Cataract Surgery The percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery. April 1 December 31, April 1 December 31, July 1 November 1, 2015 July 1 November 1, 2015 Q2 Q4 Q2 Q4 To Be Determined To Be Determined This material was prepared by FMQAI, the Support Center for the Outpatient Quality Reporting program, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-FS4T11-2-57 Updated January Page 18 of 18