CECity's Registry Cloud Platform Achieves ONC HIT 2014 Edition Modular EHR Certification from ICSA Labs for all 64 Ambulatory Clinical Quality Measures
Ambulatory Clinical Quality Measures
The clinical quality measures for which CECity's Registry Cloud Platform (v4.0) has been certified include all 64 Ambulatory Clinical Quality Measures.

MEASURE
DOMAIN
NQF #
CMS2
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Population/Public Health
NQF 0418
 
Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.
   
CMS22
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Population/Public Health
N/A
 
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
   
CMS50
Closing the referral loop: receipt of specialist report
Care Coordination
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.
   
CMS52
HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis
Clinical Process/Effectiveness
NQF 0405
 
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis
   
CMS56
Functional status assessment for hip replacement
Patient & Family Engagement
N/A
 
Percentage of patients aged 18 years and older with primary total hip arthroplasty (THA) who completed baseline and follow-up (patient-reported) functional status assessments.
   
CMS61
Preventive Care and Screening: Cholesterol – Fasting Low Density Lipoprotein (LDL-C) Test Performed
Clinical Process/Effectiveness
N/A
 
Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed.
   
CMS62
HIV/AIDS: Medical Visit
Clinical Process/Effectiveness
NQF 0403
 
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 60 days between each visit
   
CMS64
Preventive Care and Screening: Risk- Stratified Cholesterol
Fasting—Low Density Lipoprotein (LDL-C)
Clinical Process/Effectiveness
N/A
 
Percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal.
   
CMS65
Hypertension: Improvement in blood pressure
Clinical Process/Effectiveness
N/A
 
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
   
CMS66
Functional status assessment for knee replacement
Patient & Family Engagement
N/A
 
Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up (patient-reported) functional status assessments.
   
CMS68
Documentation of Current Medications in the Medical Record
Patient Safety
NQF 0419
 
Percentage of specified visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.
   
CMS69
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Population/Public Health
NQF 0421
 
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current reporting period documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current reporting period. Normal Parameters: Age 65 years and older BMI - 23 and < 30 Age 18-64 years BMI - 18.5 and < 25
   
CMS74
Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists
Clinical Process/Effectiveness
N/A
 
Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.
   
CMS75
Children who have dental decay or cavities
Clinical Process/Effectiveness
N/A
 
Percentage of children ages 0-20, who have had tooth decay or cavities during the measurement period.
   
CMS77
HIV/AIDS: RNA control for Patients with HIV
Clinical Process/Effectiveness
N/A
 
Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS, with at least two visits during the measurement year, with at least 60 days between each visit, whose most recent HIV RNA level is <200 copies/mL.
   
CMS82
Maternal depression screening
Population/Public Health
NQF 1401
 
The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.
   
CMS90
Functional status assessment for complex chronic conditions
Patient & Family Engagement
N/A
 
Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments
   
CMS117
Childhood Immunization Status
Population/Public Health
NQF 0038
 
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.
   
CMS122
Diabetes: Hemoglobin A1c Poor Control
Clinical Process/Effectiveness
NQF 0059
 
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
   
CMS123
Diabetes: Foot Exam
Clinical Process/Effectiveness
NQF 0056
 
Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period.
   
CMS124
Cervical Cancer Screening
Clinical Process/Effectiveness
NQF 0032
 
Percentage of women 21-64 years of age, who received one or more Pap tests to screen for cervical cancer.
   
CMS125
Breast Cancer Screening
Clinical Process/Effectiveness
NQF 0031
 
Percentage of women 40-69 years of age who had a mammogram to screen for breast cancer.
   
CMS126
Use of Appropriate Medications for Asthma
Clinical Process/Effectiveness
NQF 0036
 
Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the measurement period.
   
CMS127
Pneumonia Vaccination Status for Older Adults
Clinical Process/Effectiveness
NQF 0043
 
Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.
   
CMS128
Anti-depressant Medication Management
Clinical Process/Effectiveness
NQF 0105
 
Percentage of patients 18 years of age and older who were diagnosed with major depression and treated with antidepressant medication, and who remained on antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).
   
CMS129
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients
Efficient Use of Healthcare Resources
NQF 0389
 
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer
   
CMS130
Colorectal Cancer Screening
Clinical Process/Effectiveness
NQF 0034
 
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
   
CMS131
Diabetes: Eye Exam
Clinical Process/Effectiveness
NQF 0055
 
Percentage of patients 18-75 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 exam (no evidence of retinopathy) in the 12 months prior to the measurement period
   
CMS132
Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures
Patient Safety
NQF 0564
 
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence.
   
CMS133
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery
Clinical Process/Effectiveness
NQF 0565
 
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery.
   
CMS134
Diabetes: Urine Protein Screening
Clinical Process/Effectiveness
NQF 0062
 
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
   
CMS135
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Clinical Process/Effectiveness
NQF 0081
 
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
   
CMS136
ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication
Clinical Process/Effectiveness
NQF 0108
 
Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
   
CMS137
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Clinical Process/Effectiveness
NQF 0004
 
Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.
   
CMS138
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Population/Public Health
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
   
CMS139
Screening for Future Fall Risk
Patient Safety
NQF 0101
 
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
   
CMS140
Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
Clinical Process/Effectiveness
NQF 0387
 
Percentage of female patients aged 18 years and older with Stage IC through IIIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period
   
CMS141
Colon Cancer: Chemotherapy for AJCC Stage III Colon Cancer Patients
Clinical Process/Effectiveness
NQF 0385
 
Percentage of patients aged 18 through 80 years with Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period
   
CMS142
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Clinical Process/Effectiveness
NQF 0089
 
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months
   
CMS143
Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation
Clinical Process/Effectiveness
NQF 0086
 
Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic nerve head evaluation during one or more office visits within 12 months
   
CMS144
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Clinical Process/Effectiveness
NQF 0083
 
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge
   
CMS145
Coronary Artery Disease (CAD): Beta-Blocker Therapy- Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)
Clinical Process/Effectiveness
NQF 0070
 
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy
   
CMS146
Appropriate Testing for Children with Pharyngitis
Efficient Use of Healthcare Resources
NQF 0002
 
Percentage of children 2-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.
   
CMS147
Preventative Care and Screening: Influenza Immunization
Population/Public Health
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
   
CMS148
Hemoglobin A1c Test for Pediatric Patients
Clinical Process/Effectiveness
NQF 0060
 
Percentage of patients 5-17 years of age with diabetes with an HbA1c test during the measurement period
   
CMS149
Dementia: Cognitive Assessment
Clinical Process/Effectiveness
N/A
 
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period.
   
CMS153
Chlamydia Screening for Women
Population/Public Health
NQF 0033
 
Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period.
   
CMS154
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Efficient Use of Healthcare Resources
NQF 0069
 
Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.
   
CMS155
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Population/Public Health
NQF 0024
 
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. 1. Percentage of patients with height, weight, and body mass index (BMI) percentile documentation 2. Percentage of patients with counseling for nutrition 3. Percentage of patients with counseling for physical activity
   
CMS156
Use of High-Risk Medications in the Elderly
Patient Safety
NQF 0022
 
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a.    Percentage of patients who were ordered at least one high-risk medication. b.    Percentage of patients who were ordered at least two different high-risk medications.
   
CMS157
Oncology: Medical and Radiation – Pain Intensity Quantified
Patient & Family Engagement
NQF 0384
 
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
   
CMS158
Pregnant women that had HBsAg testing
Clinical Process/Effectiveness
NQF 0608
 
This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.
   
CMS159
Depression Remission at Twelve Months
Clinical Process/Effectiveness
NQF 0710
 
Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.
   
CMS160
Depression Utilization of the PHQ-9 Tool
Clinical Process/Effectiveness
NQF 0712
 
Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4 month period in which there was a qualifying visit.
   
CMS161
Major Depressive Disorder (MDD): Suicide Risk Assessment
Clinical Process/Effectiveness
NQF 0104
 
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.
   
CMS163
Diabetes: Low Density Lipoprotein (LDL) Management
Clinical Process/Effectiveness
NQF 0064
 
Percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (< 100 mg/dL) during the measurement period.
   
CMS164
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
Clinical Process/Effectiveness
NQF 0068
 
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.
   
CMS165
Controlling High Blood Pressure
Clinical Process/Effectiveness
NQF 0018
 
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
   
CMS166
Use of Imaging Studies for Low Back Pain
Efficient Use of Healthcare Resources
NQF 0052
 
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
   
CMS167
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy
Clinical Process/Effectiveness
NQF 0088
 
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months
   
CMS169
Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use
Clinical Process/Effectiveness
NQF 0110
 
Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.
   
CMS177
Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment
Patient Safety
NQF 1365
 
Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.
   
CMS179
ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range
Patient Safety
N/A
 
Average percentage of time in which individuals with atrial fibrillation who are on chronic anticoagulation have International Normalized Ratio (INR) test results within the therapeutic range during the measurement period.
   
CMS182
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
Clinical Process/Effectiveness
NQF 0075
 
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had a complete lipid profile performed during the measurement period and whose LDL-C was adequately controlled (<100 mg/dL).