Quality Performance Measurement

Measure Steward

National Committee for Quality Assurance

Measure Frequency

Daily

Measure Description

Patients 18-85 years of age as of the measurement date who had a diagnosis of essential hypertension within the last 24 months as of the measurement date, and whose most recent blood pressure was adequately controlled (<140/90mmHg) within the last 12 months as of the measurement date.

Denominator

Patients 18-85 years of age as of the measurement date who had a diagnosis of essential hypertension within the last 24 months as of the measurement date.

Denominator Exclusions

Exclude patients with at least one of the following criteria within 12 months as of the measurement date:

• Evidence of end stage renal disease, dialysis, or renal transplant;

• Indication of frailty;

• Diagnosis of an advanced illness;

• Pregnancy

Numerator

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) within the last 12 months as of the measurement date.

Additional Notes

• If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled" (i.e., not included in the numerator).

• If there are multiple blood pressure readings on the same day, the result with the highest Order ID is used as the most recent blood pressure reading.

• If a blood pressure reading is recorded with a value greater than 369/359, it is assumed as a data-entry error and therefore not included in measurement.

• If a blood pressure reading has systolic or diastolic values less than 20, including values of 0 or null, it is not included in measurement.

• When selecting the “MaineCare AC” value from the Attribution Type filter option, the only organizations available in the Attribution Entity filter option will be those that have signed HealthInfoNet’s Letter of Direction (LOD) for participating in MaineCare’s Accountable Community quality measurement efforts. To confirm if your organization has an active LOD, please contact HealthInfoNet’s Client Engagement team (clientengagement@hinfonet.org);

Why are some blood pressure systolic/diastolic readings that are taken twice in one encounter not matched in the reporting?

HealthInfoNet matches systolic and diastolic values that are taken together as the same blood pressure reading. Systolic and diastolic values that are on the same orderID and resultID are always paired together. However, there are cases when two blood pressure readings are taken for the same person at the same encounter with the exact same orderID, resultID, and date/time. Without additional identifiers received from participating organizations' EHR systems to identify the proper pairing of systolic and diastolic values in these cases, it is not always possible to make the right match in our reporting.

When such cases are found, we encourage end users to notify our Clinical Education team (clinicaleducation@hinfonet.org) so that we can help our participants investigate ways to make the pairing of these values clearer in their data sets sent to the HIE.

Why aren’t some patients' most recent blood pressure readings included in measurement?

HealthInfoNet considers all blood pressure readings for a person that have been received by HIE-participating organizations. However not all organizations that submit data to the HIE send observation results that include the necessary blood pressure reading information.

If data gaps in blood pressure readings for patients are observed in the reporting, we encourage end users to reach out to our Client Engagement team (clientengagement@hinfonet.org) to confirm whether a patient’s attributed organization submits the necessary information to support the Controlling High Blood Pressure measure.

How does the Controlling High Blood Pressure eCQM methodology differ from the Hypertension predictive risk model?

Whereas the Controlling High Blood Pressure eCQM is a measure calculated based on the CMS165v10 specification, the Hypertension predictive risk model is a measure calculated based on a proprietary machine learning algorithm developed by HealthInfoNet and its partners.

Patients who are included in the denominator for the Controlling High Blood Pressure eCQM must be 18-85 years of age as of the measurement date and have had a diagnosis of essential hypertension (ICD-10 code = I10 in any diagnosis code position) within the last 24 months as of the measurement date. The measure also excludes patients from the denominator if they have had evidence of end stage renal disease, dialysis, or renal transplant; indication of frailty; diagnosis of an advanced illness; or have been pregnant in the last year as of the measurement date.

Patients who are identified as having the Present result for the Hypertension predictive risk model (i.e., identified as being hypertensive) can be any age and must have had a diagnosis of essential hypertension (ICD-10 code = I10-I16 in either the primary or secondary diagnosis position) within the last 24 months as of the measurement date. The model does not have any denominator exclusions.

For more information about the Hypertension predictive risk model, download the Technical Appendix from the Predictive Risk Modeling section.