Quality Measure Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 6.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cqf-measures/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/uv/cqfmeasures/Measure/EXM125-FHIR | Version: 8.0.000 | |||
Active as of 2022-02-22 | Computable Name: EXM125 | |||
Other Identifiers: http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms#125 (use: official, ), http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips#112 (use: official, ) | ||||
Usage:Venue: EC |
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Copyright/Legal: This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved. The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com. |
Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer
This measure has been developed to support improvement in clinical care.
Knowledge Artifact Metadata | |
---|---|
Name (machine-readable) | EXM125 |
Title (human-readable) | EXM125 - Breast Cancer Screening |
Status | Active |
Experimental | true |
Description | Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer |
Purpose | This measure has been developed to support improvement in clinical care. |
Approval Date | 2016-01-01 |
Effective Period | 2018-01-01..2018-12-31 |
Use Context | Venue = EC |
Topic | Health Quality Measure Document |
Measure Steward | HL7 International / Clinical Quality Information |
Steward Contact Details | http://www.hl7.org/Special/committees/cqi |
Copyright | This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved. The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com. |
Measure Metadata | |
Version Number | 8.0.000 |
Measure Scoring | Proportion |
Measure Type | Process |
Rationale | Breast cancer is one of the most common types of cancers, accounting for a quarter of all new cancer diagnoses for women in the U.S. (BreastCancer.Org, 2011). It ranks as the second leading cause of cancer-related mortality in women, accounting for nearly 40,000 estimated deaths in 2013 (American Cancer Society, 2011). According to the National Cancer Institute's Surveillance Epidemiology and End Results program, the chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 30, it is one in 2,212. By age 40, the chances increase to one in 235, by age 50, it becomes one in 54, and, by age 60, it is one in 25. From 2004 to 2008, the median age at the time of breast cancer diagnosis was 61 years among adult women (Tangka et al, 2010). In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits, and varying procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (Lavigne et al, 2008; Boykoff et al, 2009). |
Clinical Recommendation Statement | The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms (C recommendation). The Task Force concludes the evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years and older (I statement). U.S. Preventive Services Task Force (2009) Grade: B recommendation. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: C recommendation. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: D recommendation. The USPSTF recommends against teaching breast self-examination (BSE). Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. |
Improvement Notation | Increased score indicates improvement |
Guidance | Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Patient self-report is not allowed for laboratory tests. This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or tomosynthesis (3D mammography), because they are not appropriate methods for primary breast cancer screening. |
Measure Population Criteria | |
Initial Population | Description: No description provided Logic Definition: Initial Population |
Numerator | Description: No description provided Logic Definition: Numerator |
Denominator | Description: No description provided Logic Definition: Denominator |
Denominator Exclusion | Description: No description provided Logic Definition: Denominator Exclusion |
Supplemental Data Elements | |
Supplemental Data Element |
Usage Code: Supplemental Data
Description: No description provided Logic Definition: SDE Ethnicity |
Supplemental Data Element |
Usage Code: Supplemental Data
Description: No description provided Logic Definition: SDE Payer |
Supplemental Data Element |
Usage Code: Supplemental Data
Description: No description provided Logic Definition: SDE Race |
Supplemental Data Element |
Usage Code: Supplemental Data
Description: No description provided Logic Definition: SDE Sex |
Measure Logic | |
Primary Library | EXM125 - Breast Cancer Screening Library |
Dependency |
Description: Library SDE
Resource: Supplemental Data Elements Libraryversion: null2.0.0) Canonical URL: http://hl7.org/fhir/uv/cqfmeasures/Library/SupplementalDataElements|2.0.000 |
Dependency |
Description: Library FHIRHelpers
Resource: http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1
Canonical URL: http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1 |
Dependency |
Description: Library Global
Resource: MAT Global Common Functions FHIR Libraryversion: null5.0.000) Canonical URL: http://hl7.org/fhir/uv/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000 |
Dependency |
Description: Library AdultOutpatientEncounters
Resource: Adult Outpatient Encounters Common Libraryversion: null2.0.000) Canonical URL: http://hl7.org/fhir/uv/cqfmeasures/Library/AdultOutpatientEncounters|2.0.000 |
Dependency |
Description: Library Hospice
Resource: Hospice FHIR Libraryversion: null2.0.000) Canonical URL: http://hl7.org/fhir/uv/cqfmeasures/Library/Hospice|2.0.000 |
Dependency |
Description: Code system SNOMEDCT:2017-09
Resource: http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709
Canonical URL: http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709 |
Dependency |
Description: Code system ConditionClinicalStatusCodes
Resource: Condition Clinical Status Codes Canonical URL: http://terminology.hl7.org/CodeSystem/condition-clinical |
Dependency |
Description: Value set Mammography
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018 |
Dependency |
Description: Value set Office Visit
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001 |
Dependency |
Description: Value set Annual Wellness Visit
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240 |
Dependency |
Description: Value set Preventive Care Services - Established Office Visit, 18 and Up
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025 |
Dependency |
Description: Value set Preventive Care Services-Initial Office Visit, 18 and Up
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023 |
Dependency |
Description: Value set Home Healthcare Services
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016 |
Dependency |
Description: Value set Payer
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 |
Dependency |
Description: Value set Encounter Inpatient
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307 |
Dependency |
Description: Value set Hospice care ambulatory
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15 |
Dependency |
Description: Value set Unilateral Mastectomy
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020 |
Dependency |
Description: Value set Status Post Right Mastectomy
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070 |
Dependency |
Description: Value set Unilateral Mastectomy, Unspecified Laterality
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071 |
Dependency |
Description: Value set Right
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1035
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1035 |
Dependency |
Description: Value set Status Post Left Mastectomy
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069 |
Dependency |
Description: Value set Left
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036 |
Dependency |
Description: Value set History of bilateral mastectomy
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068 |
Dependency |
Description: Value set Bilateral Mastectomy
Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005
Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005 |
Direct Reference Code |
Display: Discharge to home for hospice care (procedure)
Code: 428361000124107 System: http://snomed.info/sct |
Direct Reference Code |
Display: Discharge to healthcare facility for hospice care (procedure)
Code: 428371000124100 System: http://snomed.info/sct |
Direct Reference Code |
Code: active
System: http://terminology.hl7.org/CodeSystem/condition-clinical |
Parameter |
Name: Measurement Period
Use: In Min Cardinality: 0 Max Cardinality: 1 Type: Period |
Parameter |
Name: SDE Sex
Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: Coding |
Parameter |
Name: Numerator
Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: boolean |
Parameter |
Name: Denominator
Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: boolean |
Parameter |
Name: SDE Payer
Use: Out Min Cardinality: 0 Max Cardinality: * Type: Resource |
Parameter |
Name: Initial Population
Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: boolean |
Parameter |
Name: SDE Ethnicity
Use: Out Min Cardinality: 0 Max Cardinality: * Type: Coding |
Parameter |
Name: Denominator Exclusion
Use: Out Min Cardinality: 0 Max Cardinality: 1 Type: boolean |
Parameter |
Name: SDE Race
Use: Out Min Cardinality: 0 Max Cardinality: * Type: Coding |
Measure Logic Data Requirements | |
Data Requirement |
Type: Coverage
Profile(s): Coverage Must Support Elements: period, type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
|
Data Requirement |
Type: Patient
Profile(s): Patient Must Support Elements: extension, value, url |
Data Requirement |
Type: Condition
Profile(s): Condition Must Support Elements: code, clinicalStatus Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070
|
Data Requirement |
Type: Condition
Profile(s): Condition Must Support Elements: code, clinicalStatus Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069
|
Data Requirement |
Type: Condition
Profile(s): Condition Must Support Elements: bodySite, code, clinicalStatus Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071
|
Data Requirement |
Type: Condition
Profile(s): Condition Must Support Elements: code, clinicalStatus, onset Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068
|
Data Requirement |
Type: Procedure
Profile(s): Procedure Must Support Elements: code, performed, status Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005
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Data Requirement |
Type: Procedure
Profile(s): Procedure Must Support Elements: code, performed, status Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020
|
Data Requirement |
Type: Procedure
Profile(s): Procedure Must Support Elements: code, performed, status Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: type Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016
|
Data Requirement |
Type: Encounter
Profile(s): Encounter Must Support Elements: period, hospitalization, hospitalization.dischargeDisposition, type, status Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307
|
Data Requirement |
Type: ServiceRequest
Profile(s): ServiceRequest Must Support Elements: code, authoredOn, intent Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15
|
Data Requirement |
Type: DiagnosticReport
Profile(s): DiagnosticReport Must Support Elements: effective, code, status Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018
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Measure Logic Definitions | |
Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: AdultOutpatientEncounters |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: Hospice |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: EXM125-FHIR |
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Logic Definition | Library Name: SupplementalDataElements |
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Logic Definition | Library Name: EXM125-FHIR |
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