eCQM Performance Measurement

Measure Steward

National Committee for Quality Assurance

Measure Domain

Effective Clinical Care

Measure Description

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

Reporting Periods

A new reporting period is generated each month for the defined measurement period. The date when the new reporting period is generated is called the reporting period end date - the date from which the relevant measurement lookback period is applied.

Denominator

Patients 18-85 years of age as of the reporting period end date who are included in MaineCare’s most recent custom attribution file AND who have been active eligible MaineCare members at any time in the last 365 days, and who had a diagnosis of essential hypertension within the last 24 months from the reporting period end date.

Denominator Exclusions

Exclude patients with:

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

• Indication of frailty;

• Diagnosis of an advanced illness;

• Pregnancy

within 12 months from the reporting period end date.

Additionally, exclude all patients who:

• Are included in MaineCare’s most recent custom attribution file but who have not been active eligible MaineCare members at any time in the last 365 days;

• Belong to an organization that has not yet signed HealthInfoNet’s and MaineCare’s “letter of direction” (LOD).

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 from the reporting period end 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, they are not included in measurement.

• If patients meeting the defined denominator criteria have died as of the reporting period end date, but who were active eligible MaineCare members at some time in the last 365 days, they are being included in measurement.

• If patients included in measurement as of the reporting period end date (and therefore included in the reporting period’s denominator/numerator) have since passed away, their results will continue to be reflected in the aggregate organization measure result for all time but will be dropped from the member measure result detail 365 days following their death. This is due to the way in which HealthInfoNet has defined its patient inclusion/exclusion criteria to meet other MaineCare reporting needs.

Are patients who are deceased included in measurement?

Deceased persons are currently included in the measurement’s reporting period if they appear in MaineCare’s most recent custom attribution file and if they were an active eligible MaineCare member at any time in the last 365 days.

To give a sense of the impact that deceased persons have on measurement, there were 465 deceased members included in the Controlling High Blood Pressure denominator for the September reporting period out of a total of 14,135 members.

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

HealthInfoNet does its best to match 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 providers' EHR systems to infer 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. For those organizations that do submit the necessary information, the Controlling High Blood Pressure measure is run on a monthly basis (the first weekend of each month), which means that any new blood pressure readings that have been received from the organizations since the last monthly refresh will be included at that time.

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.