The Wound Care Collaborative Registry
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- Melvin Blake
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1 In collaboration with CECity The Wound Care Collaborative Registry This registry is approved by CMS as a Qualified Clinical Data Registry (QCDR) for Eligible Professionals and GPRO Practices for the 2016 Physician Quality Reporting System (PQRS) program year. CUSTOM SPECIALTY MEASURES WCQIC 8 - Hyperbaric Oxygen Therapy: Timeliness of Starting HBOT Time in days from day of HBO order to start of HBO treatment. WCQIC 10 - Chronic Wound Care: Non-Invasive Arterial Testing in Patients with Lower Extremity Ulcer(s) During patient visit 1 or 2, the practitioner orders non-invasive arterial testing. WCQIC 14 - Chronic Wound Care: Timeliness of Referral of Pressure Ulcer Patients to Plastic/Reconstructive Surgeon Patients presenting to a wound care clinic or physician office with a full thickness, Stage 4, or unstageable pressure ulcer above the knee and seen by a non-plastic surgeon should be referred to a reconstructive plastic surgeon within one week after the initial wound care onsult to for an evaluation. Type: Outcome Measure WCQIC 15 - Chronic Wound Care: Appropriate Offloading of plantar Diabetic Foot Ulcers Patients offloaded using Total Contact Casting. WCQIC 16 - Process Measure: Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who undergo nutritional screening with a validated tool (such as the Nestlé MNA) within the 12- month reporting period, and for whom an appropriate nutritional intervention was ordered based on the results of the tool. Using the MNA Short Form algorithm, if a patient at risk of malnutrition has an MNA score of 8-11 and documented weight loss, the clinician would be provided with general treatment, monitoring or rescreening recommendations. These include: nutrition interventions (e.g. diet enhancement and oral supplementation of 400 kcal/d2 ), close weight monitoring, and a more in depth nutrition assessment. Malnourished patients with scores of 0-7 would be offered treatment with nutritional intervention (ONS kcal/d2 and diet enhancement), close weight monitoring and a more in depth nutrition assessment. No specific products will be recommended as part of the measure. WCQIC 17 - Efficacy of Human Amnion/Chorion Membrane Allograft 1) Time in days from first application of Human Amnion/Chorion Membrane Allograft to complete wound healing. 2) Number of Human Amnion/Chorion Membrane Allograft applications from first application to complete wound healing. support@medconcert.com option 4 Page 1 of 6
2 PQRS MEASURES PQRS #1 - Diabetes: Hemoglobin A1c Poor Control (NQF 0059) Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement PQRS #2 - Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dl) Percentage of patients years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dl) during the measurement PQRS #110 - Preventive Care and Screening: Influenza Immunization (NQF 0041) 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. PQRS #111 - Pneumonia Vaccination Status for Older Adults (NQF 0043) Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. PQRS #117 - Diabetes: Eye Exam (NQF 0055) Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement PQRS #119 - Diabetes: Medical Attention for Nephropathy (NQF 0062) The percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement PQRS #126 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy Neurological Evaluation (NQF 0417) Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months. PQRS #127 - Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation of Footwear (NQF 0416) Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing. support@medconcert.com option 4 Page 2 of 6
3 PQRS MEASURES PQRS #128 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (NQF 0421) Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 Age years BMI 18.5 and < 25 kg/ m 2 PQRS #130 - Documentation of Current Medications in the Medical Record (NQF 0419) Percentage of visits for patients aged 18 years and older for which the eligible professional 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, overthe-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. PQRS #131 - Pain Assessment and Follow-Up (NQF 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. PQRS #154 - Falls: Risk Assessment (PQRS Measure #154) (NQF 0101) Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months. PQRS #155 - Falls: Plan of Care (NQF 0101) Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months. PQRS #163 - Diabetes: Foot Exam (NQF 0056) Percentage of patients aged years of age with diabetes who had a foot exam during the measurement PQRS #226 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (NQF 0028) Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. PQRS #236 - Controlling High Blood Pressure (NQF 0018) Percentage of patients 18 through 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmhg) during the measurement support@medconcert.com option 4 Page 3 of 6
4 PQRS MEASURES PQRS #318 - Falls: Screening for Fall Risk Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement PQRS #321 - Participation by a Hospital, Physician, or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality Measures Participation in a systematic qualified clinical database registry involves: a. Physician or other clinician submits standardized data elements to registry b. Data elements are applicable to consensus endorsed quality measures c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry s clinical topic(s) and report on all patients eligible for the selected measures d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians e. Registry must receive data from more than 5 separate practices and may not be located (warehoused) at an individual group s practice. Participation in a national or state-wide registry is encouraged for this measure f. Registry may provide feedback directly to the provider s local registry if one exists National Quality Strategy Domain: Person and Caregiver-Centered Experience and Outcomes Type: Patient Engagement/Experience Measure PQRS #374 - Closing the Referral Loop: Receipt of Specialist Report 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. PQRS #420 - Varicose Vein Treatment with Saphenous Ablation: Outcome Survey Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment. PQRS #437 - Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure Inpatients assigned to endovascular treatment for obstructive arterial disease, the percent of patients who undergo unplanned major amputation or surgical bypass within 48 hours of the index procedure. Type: Outcome Measure ECQM MEASURES CMS50v4 - Closing the Referral Loop: Receipt of Specialist Report (PQRS #374) 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. support@medconcert.com option 4 Page 4 of 6
5 ECQM MEASURES CMS68v5 - Documentation of Current Medications in the Medical Record (NQF 0419) (PQRS #130) Percentage of visits for patients aged 18 years and older for which the eligible professional 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, overthe-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosage, frequency and route of administration. CMS69v4 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan (NQF 0421) (PQRS #128) Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 65 years and older BMI 23 and < 30 kg/m 2 ; Age years BMI 18.5 and < 25 kg/m 2 CMS122v4 - Diabetes: Hemoglobin A1c Poor Control (NQF 0059) (PQRS #001) Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement Type: Outcome Measure CMS123v4 - Diabetes: Foot Exam (NQF 0056) (PQRS #163) Percentage of patients aged years of age with diabetes who had a foot exam during the measurement CMS127v4 - Pneumonia Vaccination Status for Older Adults (NQF 0043) (PQRS #111) Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. CMS131v4 - Diabetes: Eye Exam (NQF 0055) (PQRS #117) Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement CMS134v4 - Diabetes: Medical Attention for Nephropathy (NQF 0062) (PQRS #119) The percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement CMS138v4 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (NQF 0028) (PQRS #226) Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. support@medconcert.com option 4 Page 5 of 6
6 ECQM MEASURES CMS139v4 - Falls: Screening for Fall Risk (NQF 0101) (PQRS #318) Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement CMS147v5 - Preventive Care and Screening: Influenza Immunization (NQF 0041) (PQRS #110) 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. CMS156v4 - Use of High-Risk Medications in the Elderly (NQF 0023) (PQRS #238) Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. 1) Percentage of patients who were ordered at least one high-risk medication. 2) Percentage of patients who were ordered at least two different high-risk medications. CMS163v4 - Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dl) (PQRS #002) Percentage of patients years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dl) during the measurement CMS165v5 - Controlling High Blood Pressure (NQF 0018) (PQRS #236) Percentage of patients years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement support@medconcert.com option 4 Page 6 of 6
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