2009 physician quality reporting system - top 5 measures ... · 2009 physician quality reporting...

2009 Physician Quality Reporting System - Top 5 Measures Submitted By SpecialtyDate: September 17, 2010

The purpose of this report is to provide information on the measures most frequently submitted by each specialty type.

Note: This report includes data for services rendered in CY 2009 and processed into NCH by February 26, 2010.

• The most commonly submitted measure for Physician providers was #57: Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation with 21.95% of participating physicians reporting the measure, followed by Measure #54: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain (21.83%), Measure #55: 12-Lead Electrocardiogram (ECG) Performed for Syncope (20.28%), Measure #56: Community-Acquired Pneumonia (CAP): Vital Signs (20.24%), and Measure #58: Community-Acquired Pneumonia (CAP): Assessment of Mental Status (19.24%).• The most commonly submitted measures for Non-Physician providers were: #30: Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician (29.92%), #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records (16.45%), #54: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain (13.11%), #154: Falls: Risk Assessment (13.05%), and #130: Documentation and Verification of Current Medications in the Medical Record (12.58%).• Measure #124: Health Information Technology (HIT): Adoption/Use of Electronic Health Records was the most often commonly submitted measure for 16 different provider specialties.• Across all provider specialties, Measure #54: 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain was the most commonly submitted measure, with 19.46% of all participating providers submitting this measure.

Top Five Measures Submitted by Provider Specialty Report contains data for services rendered during CY 2009 and processed into NCH by February 26, 2010.

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2009 Top 5 Measures Submitted By Specialty - Quick ReferenceReport includes data for services rendered in CY 2009 and processed into NCH by February 26, 2010.

Measure # Measure Title Measure # Measure Title Measure # Measure Title Measure # Measure Title Measure # Measure Title

Allergy/Immunology 124

Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) 114

Preventive Care and Screening: Inquiry Regarding Tobacco Use 115

Preventive Care and Screening: Advising Smokers to Quit 110

Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old 64 Asthma: Asthma Assessment 171

Anesthesiology 30Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician 76

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol 130

Documentation and Verification of Current Medications in the Medical Record 128

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 124

Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) 16,040

Cardiology 6

Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 5

Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 8

Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 124


Coronary Artery Disease (CAD): Lipid Profile in Patients with CAD 5,418

Colon/Rectal Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 23

Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) 22

Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) 21

Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin 124


Critical Care 51Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 52

Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy 76

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol 47 Advance Care Plan 124


Dermatology 136 Melanoma: Follow-Up Aspects of Care 137Melanoma: Continuity of Care – Recall System 138 Melanoma: Coordination of Care 124


Preventive Care and Screening: Inquiry Regarding Tobacco Use 1,805

Emergency Medicine 5412-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 57

Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 55

12-Lead Electrocardiogram (ECG) Performed for Syncope 56

Community-Acquired Pneumonia (CAP): Vital Signs 58

Community-Acquired Pneumonia (CAP): Assessment of Mental Status 23,177

Endocrinology 1Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 2

Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 3

Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 124


Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients 851

Family Practice 1Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 2




Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 13,205

Gastroenterology 124


Preventive Care and Screening: Colorectal Cancer Screening 185

Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use 114


Documentation and Verification of Current Medications in the Medical Record 1,371

General Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21





General Practice 57Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 54

12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 58

Community-Acquired Pneumonia (CAP): Assessment of Mental Status 56


Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 261

Geriatrics 1Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 2




Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older 539

Hand Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21





Infectious Disease 124


Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old 130


Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older 1


Internal Medicine 1Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 2





Intervent Radiology 145Radiology: Exposure Time Reported for Procedures Using Fluoroscopy 11

Stroke and Stroke Rehabilitation: Carotid Imaging Reports 10

Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports 76

Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol 147

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy 370

Provider Specialty

Top 5 Measures Submitted

# NPI Submitting1 (most commonly submitted) 5432


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Provider Specialty



Nephrology 122Chronic Kidney Disease (CKD): Blood Pressure Management 123

Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA) 121

Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile) 124


Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 1,110

Neurology 124



Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage 32

Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy 36

Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services 1,193

Neurosurgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21





Nuclear Medicine 147

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy 6



Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 145

Radiology: Exposure Time Reported for Procedures Using Fluoroscopy 95

OB/Gynecology 124


Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 112

Preventive Care and Screening: Screening Mammography 39

Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older 114

Preventive Care and Screening: Inquiry Regarding Tobacco Use 1,700

Oncology/Hematology 69Multiple Myeloma: Treatment with Bisphosphonates 70

Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry 71

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 67

Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow 72

Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients 2,530

Ophthalmology 14Age-Related Macular Degeneration (AMD): Dilated Macular Examination 12

Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 18

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 117

Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 140

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 6,514

Oral/Maxillofacial Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 22





Orthoped Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21





Other Physician 6


Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy 5


Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services 47 Advance Care Plan 840

Otolaryngology 124




Acute Otitis Externa (AOE): Topical Therapy 130


Pathology 99

Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade 100

Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade 124



Community-Acquired Pneumonia (CAP): Vital Signs 4,312

Pediatrics 124






Physical Medicine 124

Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) 154 Falls: Risk Assessment 114




Plastic Surgery 124


Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21




Psychiatry 124


Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD 107

Major Depressive Disorder (MDD): Suicide Risk Assessment 106

Major Depressive Disorder (MDD): Diagnostic Evaluation 114


Pulmonary Disease 51Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation 52

Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy 114



Preventive Care and Screening: Advising Smokers to Quit 1,167

Radiation Oncology 105Prostate Cancer: Three-Dimensional (3D) Radiotherapy 104

Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients 102

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients 156

Oncology: Radiation Dose Limits to Normal Tissues 71

Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 684


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Provider Specialty



Radiology 10

Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports 145

Radiology: Exposure Time Reported for Procedures Using Fluoroscopy 11

Stroke and Stroke Rehabilitation: Carotid Imaging Reports 146

Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening 147

Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy 9,721

Rheumatology 108

Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy 41 Osteoporosis: Pharmacologic Therapy 124


Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older 178

Rheumatoid Arthritis (RA): Functional Status Assessment 692

Thoracic/Cardiac Surgery 43

Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery 20



Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery 45

Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures) 1,024

Urology 48

Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 49

Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older 50

Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older 124


Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 1,701

Vascular Surgery 20Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 21




Endarterectomy: Use of Patch During Conventional Endarterectomy 603

MD/DO Total 57Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 54




Community-Acquired Pneumonia (CAP): Assessment of Mental Status 119,541

Audiologist 124




Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) N/A N/A 106

Chiropractor 131Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up 182

Functional Outcome Assessment in Chiropractic Care 124


Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 154 Falls: Risk Assessment 438

Dentist 124


Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician 114




Dietitian/Nutritionist 1Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 2





Health Center 57Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 54





Nurse Anesthetist 30Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician 130



Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol N/A N/A 10,513

Nurse Practitioner 124





Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 5,585

Optometry 12Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 14

Age-Related Macular Degeneration (AMD): Dilated Macular Examination 117

Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 18

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 140

Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement 5,464

Other Non-Physician Provider 124





12-Lead Electrocardiogram (ECG) Performed for Syncope 6,451

Physical/Occupational Therapy 154 Falls: Risk Assessment 131Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up 130

Documentation and Verification of Current Medications in the Medical Record 155 Falls: Plan of Care 128

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 5,414

Physician Assistant 5412-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 57





Podiatry 126

Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation 127

Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear 163 Diabetes Mellitus: Foot Exam 124



Psychologist 124


Screening for Clinical Depression and Follow-Up Plan 9




Registered Nurse 30Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician 124






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Provider Specialty



Social Worker 124




Screening for Clinical Depression and Follow-Up Plan 9


Other Eligible Professional Total 30Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician 124


12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 154 Falls: Risk Assessment 130

Documentation and Verification of Current Medications in the Medical Record 44,369

MISSING 5412-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 57





Total 5412-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain 57






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2009 Top 5 Measures Submitted By Specialty - Full ReportReport includes data for services rendered in CY 2009 and processed into NCH by February 26, 2010.

Measure # % NPI

Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

Rate

Allergy/Immunology 124 50.88% 100.00% 114 32.75% 90.75% 115 22.22% 53.87% 110 21.64% 67.42% 64 19.88% 84.31% 171

Anesthesiology 30 98.48% 91.56% 76 37.04% 82.06% 130 3.64% 49.73% 128 1.40% 16.19% 124 0.64% 100.00% 16,040

Cardiology 6 89.42% 97.56% 5 75.91% 97.57% 8 60.59% 97.78% 124 30.82% 100.00% 152 30.34% 83.24% 5,418

Colon/Rectal Surgery 20 83.52% 98.16% 23 65.39% 98.30% 22 62.09% 99.81% 21 34.07% 92.99% 124 29.67% 100.00% 182

Critical Care 51 31.06% 89.10% 52 28.33% 99.62% 76 26.62% 91.59% 47 24.57% 45.92% 124 19.45% 100.00% 293

Dermatology 136 84.60% 97.67% 137 80.11% 97.28% 138 33.85% 98.13% 124 21.72% 100.00% 114 3.55% 73.87% 1,805

Emergency Medicine 54 90.58% 96.06% 57 88.26% 94.46% 55 86.00% 96.38% 56 81.62% 96.09% 58 80.00% 96.92% 23,177

Endocrinology 1 77.67% 13.34% 2 73.80% 73.93% 3 73.33% 65.60% 124 32.67% 100.00% 119 19.04% 87.65% 851

Family Practice 1 62.76% 11.70% 2 59.96% 66.82% 3 58.07% 58.20% 124 25.65% 100.00% 57 15.01% 88.18% 13,205

Gastroenterology 124 48.36% 100.00% 113 47.27% 87.01% 185 31.80% 94.07% 114 22.25% 91.39% 130 16.41% 90.67% 1,371

General Surgery 20 65.78% 94.46% 21 52.89% 91.16% 23 52.64% 93.60% 22 41.16% 94.27% 124 25.57% 100.00% 2,405

General Practice 57 36.40% 90.92% 54 34.10% 94.37% 58 33.72% 95.76% 56 32.57% 92.16% 1 31.42% 10.61% 261

Geriatrics 1 43.60% 11.28% 2 38.96% 64.34% 3 37.11% 61.44% 124 31.54% 100.00% 111 21.52% 81.24% 539

Hand Surgery 20 40.88% 94.70% 21 37.96% 96.40% 124 37.96% 100.00% 23 31.39% 95.29% 22 25.55% 99.77% 137

Infectious Disease 124 47.85% 100.00% 110 24.73% 69.35% 130 22.85% 96.48% 111 21.77% 70.14% 1 18.82% 14.16% 372

Internal Medicine 1 45.87% 10.34% 2 43.80% 67.88% 3 41.57% 60.49% 6 28.41% 87.44% 124 24.50% 100.00% 13,073

Intervent Radiology 145 59.73% 47.17% 11 52.70% 59.44% 10 49.46% 65.87% 76 35.68% 57.67% 147 21.08% 59.34% 370

Nephrology 122 47.75% 97.11% 123 41.62% 98.57% 121 37.12% 77.02% 124 31.08% 100.00% 3 29.91% 59.59% 1,110

Neurology 124 49.37% 100.00% 114 28.75% 79.75% 31 25.31% 93.46% 32 22.55% 95.03% 36 21.54% 88.28% 1,193

Neurosurgery 20 65.69% 98.41% 21 61.38% 96.18% 23 45.52% 93.79% 22 42.76% 94.87% 124 31.55% 100.00% 580

Nuclear Medicine 147 52.63% 79.89% 6 23.16% 99.92% 5 18.95% 96.88% 8 13.68% 97.16% 145 11.58% 40.97% 95

OB/Gynecology 124 45.88% 100.00% 48 33.88% 81.95% 112 32.12% 73.36% 39 29.77% 66.55% 114 26.35% 74.09% 1,700

Provider Specialty


# NPI Submitting

1 (most commonly submitted) 2 3 4 5


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Measure # % NPI

Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

Rate

Provider Specialty


# NPI Submitting


Oncology/Hematology 69 55.69% 92.04% 70 50.40% 96.06% 71 41.50% 99.12% 67 40.79% 95.79% 72 39.13% 99.31% 2,530

Ophthalmology 14 76.62% 97.75% 12 75.08% 96.37% 18 65.75% 98.19% 117 58.92% 97.96% 140 42.39% 93.68% 6,514

Oral/Maxillofacial Surgery 20 46.15% 100.00% 22 30.77% 25.00% 114 23.08% 100.00% 124 23.08% 100.00% 23 7.69% 80.00% 13

Orthoped Surgery 20 71.34% 98.47% 21 62.12% 96.59% 23 55.59% 96.91% 22 39.96% 97.78% 124 25.77% 100.00% 3,186

Other Physician 6 32.38% 87.41% 32 29.88% 90.60% 5 26.43% 94.95% 36 24.52% 77.16% 47 20.71% 70.36% 840

Otolaryngology 124 58.48% 100.00% 114 45.53% 87.40% 115 35.25% 64.50% 91 20.16% 89.01% 130 18.43% 81.25% 749

Pathology 99 91.14% 96.69% 100 88.17% 97.39% 124 0.07% 100.00% 54 0.05% 97.73% 56 0.05% 100.00% 4,312

Pediatrics 124 34.06% 100.00% 54 23.55% 91.88% 1 22.83% 15.70% 2 21.74% 66.15% 3 21.74% 53.54% 276

Physical Medicine 124 51.36% 100.00% 154 26.63% 79.76% 114 23.90% 80.89% 130 19.71% 89.77% 115 17.82% 63.03% 477

Plastic Surgery 124 51.10% 100.00% 20 39.01% 89.72% 21 36.26% 87.35% 23 30.77% 97.21% 114 21.98% 74.92% 182

Psychiatry 124 45.98% 100.00% 9 39.46% 91.19% 107 34.48% 94.50% 106 28.16% 93.23% 114 13.99% 81.51% 522

Pulmonary Disease 51 59.21% 92.73% 52 51.50% 98.45% 114 33.51% 92.66% 124 31.53% 100.00% 115 21.59% 81.02% 1,167

Radiation Oncology 105 55.85% 24.61% 104 47.22% 22.59% 102 42.25% 15.01% 156 30.12% 95.87% 71 20.47% 94.22% 684

Radiology 10 74.67% 65.98% 145 59.77% 40.45% 11 58.46% 62.52% 146 47.53% 1.74% 147 37.75% 56.38% 9,721

Rheumatology 108 56.21% 94.06% 41 47.69% 93.52% 124 40.90% 100.00% 39 36.27% 86.47% 178 24.42% 86.66% 692

Thoracic/Cardiac Surgery 43 71.97% 96.67% 20 64.84% 96.12% 21 54.30% 94.27% 44 51.47% 91.61% 45 48.73% 99.52% 1,024

Urology 48 67.08% 86.64% 49 58.55% 96.57% 50 55.32% 95.53% 124 41.15% 100.00% 20 35.27% 96.79% 1,701

Vascular Surgery 20 67.83% 94.91% 21 57.55% 94.72% 22 42.79% 96.48% 124 21.23% 100.00% 158 20.23% 94.18% 603

MD/DO Total 57 21.95% 93.24% 54 21.83% 95.80% 55 20.28% 96.15% 56 20.24% 94.83% 58 19.42% 96.71% 119,541

Audiologist 124 92.45% 100.00% 130 16.98% 41.80% 20 0.94% 100.00% 22 0.94% 100.00% N/A N/A N/A 106

Chiropractor 131 92.47% 97.44% 182 31.74% 87.96% 124 19.18% 100.00% 2 0.46% 93.75% 154 0.46% 0.00% 438

Dentist 124 33.33% 100.00% 30 26.67% 100.00% 114 26.67% 88.75% 115 20.00% 100.00% 128 13.33% 91.67% 15

Dietitian/Nutritionist 1 76.35% 16.70% 2 73.65% 61.48% 3 68.24% 58.17% 124 44.60% 100.00% 130 16.89% 59.60% 148

Health Center 57 20.24% 97.29% 54 19.64% 96.94% 58 19.05% 97.04% 56 17.86% 98.08% 55 17.26% 97.72% 168


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Measure # % NPI

Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

RateMeasure #

% NPI Submitting

Avg. Performance

Rate

Provider Specialty


# NPI Submitting


Nurse Anesthetist 30 99.82% 91.64% 130 5.63% 30.88% 128 3.25% 13.39% 76 3.05% 76.43% N/A N/A N/A 10,513

Nurse Practitioner 124 27.34% 100.00% 1 23.71% 13.73% 54 22.42% 86.03% 2 22.29% 65.25% 3 21.90% 57.85% 5,585

Optometry 12 80.27% 95.98% 14 78.40% 96.31% 117 60.43% 95.25% 18 55.16% 98.22% 140 37.99% 93.31% 5,464

Other Non-Physician Provider 124 19.28% 100.00% 30 13.94% 89.50% 54 12.82% 95.70% 57 12.11% 93.59% 55 11.04% 95.78% 6,451

Physical/Occupational Therapy 154 85.28% 94.64% 131 80.70% 98.44% 130 49.21% 84.58% 155 45.18% 91.52% 128 20.63% 77.10% 5,414

Physician Assistant 54 40.05% 86.81% 57 37.15% 95.05% 58 33.68% 96.85% 56 32.68% 95.35% 55 26.05% 95.36% 8,041

Podiatry 126 71.51% 90.09% 127 68.47% 84.62% 163 53.60% 98.57% 124 19.48% 100.00% 114 13.51% 89.01% 888

Psychologist 124 44.90% 100.00% 134 38.78% 83.94% 9 33.16% 98.29% 106 26.02% 97.10% 107 26.02% 95.53% 392

Registered Nurse 30 65.68% 91.57% 124 13.84% 100.00% 2 7.93% 62.86% 3 7.93% 54.94% 1 7.75% 10.77% 542

Social Worker 124 52.45% 100.00% 107 27.94% 87.58% 106 26.47% 92.17% 134 23.53% 84.52% 9 20.59% 92.78% 204

Other Eligible Professional Total 30 29.92% 91.44% 124 16.45% 100.00% 54 13.11% 88.01% 154 13.05% 93.83% 130 12.58% 75.45% 44,369

MISSING 54 23.85% 93.87% 57 18.35% 98.16% 30 16.51% 86.93% 55 16.51% 97.97% 58 15.60% 99.60% 109

Total 54 19.46% 94.39% 57 19.29% 93.43% 30 18.68% 91.51% 56 17.64% 94.90% 55 17.17% 96.05% 164,019


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Measure Number-Title Reference

1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)6 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)9 Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD10 Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports11 Stroke and Stroke Rehabilitation: Carotid Imaging Reports12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care20 Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin22 Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures)23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)24 Osteoporosis: Communication with the Physician Managing On-going Care Post-Fracture28 Aspirin at Arrival for Acute Myocardial Infarction (AMI)30 Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage32 Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy35 Stroke and Stroke Rehabilitation: Screening for Dysphagia36 Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older40 Osteoporosis: Management Following Fracture41 Osteoporosis: Pharmacologic Therapy43 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery45 Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures)46 Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility47 Advance Care Plan48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

Measure Number Measure Title


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49 Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older50 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older51 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation52 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy53 Asthma: Pharmacologic Therapy54 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain55 12-Lead Electrocardiogram (ECG) Performed for Syncope56 Community-Acquired Pneumonia (CAP): Vital Signs57 Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic64 Asthma: Asthma Assessment65 Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use66 Appropriate Testing for Children with Pharyngitis67 Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow68 Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy69 Multiple Myeloma: Treatment with Bisphosphonates70 Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry71 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer72 Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients76 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol79 End Stage Renal Disease (ESRD): Influenza Immunization in Patients with ESRD84 Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment85 Hepatitis C: HCV Genotype Testing Prior to Treatment86 Hepatitis C: Antiviral Treatment Prescribed87 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment89 Hepatitis C: Counseling Regarding Risk of Alcohol Consumption90 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy91 Acute Otitis Externa (AOE): Topical Therapy92 Acute Otitis Externa (AOE): Pain Assessment93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use94 Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of Tympanic Membrane Mobility99 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients104 Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients


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105 Prostate Cancer: Three-Dimensional (3D) Radiotherapy106 Major Depressive Disorder (MDD): Diagnostic Evaluation107 Major Depressive Disorder (MDD): Suicide Risk Assessment108 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy109 Osteoarthritis (OA): Function and Pain Assessment110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older112 Preventive Care and Screening: Screening Mammography113 Preventive Care and Screening: Colorectal Cancer Screening114 Preventive Care and Screening: Inquiry Regarding Tobacco Use115 Preventive Care and Screening: Advising Smokers to Quit116 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients121 Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile)122 Chronic Kidney Disease (CKD): Blood Pressure Management123 Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA)124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR)126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up130 Documentation and Verification of Current Medications in the Medical Record131 Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up134 Screening for Clinical Depression and Follow-Up Plan135 Chronic Kidney Disease (CKD): Influenza Immunization136 Melanoma: Follow-Up Aspects of Care137 Melanoma: Continuity of Care – Recall System138 Melanoma: Coordination of Care139 Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with Intraocular Lens (IOL) Placement140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care142 Osteoarthritis (OA): Assessment for Use of Anti-Inflammatory or Analgesic Over-the-Counter (OTC) Medications145 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy146 Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Mammography Screening147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy152 Coronary Artery Disease (CAD): Lipid Profile in Patients with CAD


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153 Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula154 Falls: Risk Assessment155 Falls: Plan of Care156 Oncology: Radiation Dose Limits to Normal Tissues157 Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection158 Endarterectomy: Use of Patch During Conventional Endarterectomy163 Diabetes Mellitus: Foot Exam172 Hemodialysis Vascular Access Decision-Making by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula173 Preventive Care and Screening: Unhealthy Alcohol Use – Screening175 Pediatric End Stage Renal Disease (ESRD): Influenza Immunization176 Rheumatoid Arthritis (RA): Tuberculosis Screening177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity178 Rheumatoid Arthritis (RA): Functional Status Assessment179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis180 Rheumatoid Arthritis (RA): Glucocorticoid Management181 Elder Maltreatment Screen and Follow-Up Plan182 Functional Outcome Assessment in Chiropractic Care183 Hepatitis C: Hepatitis A Vaccination in Patients with HCV184 Hepatitis C: Hepatitis B Vaccination in Patients with HCV185 Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use186 Wound Care: Use of Compression System in Patients with Venous Ulcers188 Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear189 Referral for Otologic Evaluation for Patients with History of Active Drainage From the Ear Within the Previous 90 Days190 Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly Progressive Hearing Loss193 Perioperative Temperature Management194 Oncology: Cancer Stage Documented195 Stenosis Measurement in Carotid Imaging Studies201 Ischemic Vascular Disease (IVD): Blood Pressure Management Control202 Ischemic Vascular Disease (IVD): Complete Lipid Profile203 Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL–C) Control204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic


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2009 physician quality reporting system - top 5 measures ... · 2009 physician quality reporting...

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