Request for Proposal: Assuring feasibility, reliability, validity and usability of eMeasures Project Information

Project Name: Testing Dental Quality Alliance (DQA) eMeasures Deadline for receipt of proposals: June 30, 2013
(Please submit a letter of intent by June 1, 2013. While not mandatory it will help us plan our review process)

Earliest Possible Award Date: July 30, 2013 Expected Completion Date: November 15, 2013 Primary Contact: Dr. Krishna Aravamudhan
Project Plan

Project Goal

Propose and test an efficient/ sustainable process to assure validity, reliability and feasibility of eMeasures in dentistry. Establish feasibility, reliability, validity and usability of two DQA eMeasures (Run report level: Practice site )

Project Deliverables Protocol for testing eMeasures in dentistry [Through this effort we would like to establish a sustainable cost-effective process for eMeasure validation and identify existing resources that can be used to validate additional measures in future.] Reports on feasibility, reliability and validity of two DQA e-measures using proposed methodology Final specifications and complete value sets Bi-weekly updates to DQA Committee (This partnership ensures that knowledge gathered through the testing process is used in refining and finalizing the measure specifications. Measure specifications provided may be considered as draft. We do not want to be in a situation where the testing is completed based on the draft provided and then we have to modify the specifications to address feasibility issues resulting in significant modifications to the measures such the reliability and validity data are no longer useful. Feasibility should be tested as and when specifications are iterated. Please think about an integrated approach to validation rather than looking at feasibility/ reliability and validity as separate phases. The Appendix had information on what the DQA has already accomplished. So please do not duplicate effort.) Presentation of findings at next DQA meeting Assistance with National Quality Forum (NQF) application

Background materials to develop proposal

DQA document on exploring feasibility of e-Measures in dentistry National Quality Forum (NQF) Guidance for testing methodology

Investigator / Contractor Qualifications

Required

Previous experience testing eMeasures or conducting similar research Informatics expertise (within project team; not necessarily PI; dental preferred) Ability to test/ generate reports in Meaningful Use certified EHR/ EDR product

Optional (Additional Credits)

Access to existing test bed/ data repository with known values of critical elements Ability to test/ generate reports in multiple certified EHR products/ practice locations Ability to test in an integrated (medical/dental) product/setting

Guidelines for information to be included in proposals

Name and Contact Information of principal investigator (PI) Biographical sketches of PI and proposed co-investigators Proposed methodology with sampling methodologies and statistical tests that will be used (not to exceed 10 page double spaced with 1 margins. Use Appendices for biosketches, references etc.) Description of EHR systems/ test beds used within the proposal Detailed budget (Note: A budget limit has not been provided. The proposed methodology should justify the resources being sought. Indirect rates are not applicable. This will be a competitive selection process based on the criteria below with one funded proposal) Proposed timeline with milestones based on suggested start and end dates Letters of support from co-investigators, vendors and practice sites etc. Conflict of Interest declaration

Only complete proposals will be reviewed

Proposal Evaluation Criteria

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Investigators and experience (20%) Proposed methodology (50%) Budget (20%) Timeline (10%)

Terms
Neither this RFP nor any responses hereto shall be considered a binding offer or agreement. If the DQA (through the ADA) and any responding Respondent decide to pursue a business relationship for any or all of the services or equipment specified in this RFP, the parties will negotiate the terms and conditions of a definitive, binding written agreement which shall be executed by the parties. Until and unless a definitive written agreement is executed, DQA shall have no obligation with respect to any Respondent in connection with this RFP. (NOTE: The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) is interested in pursuing dental eMeasures for the Meaningful Use program. Funding for this project is contingent upon an award to the DQA from CMS/ONC.) This RFP is not an offer to contract, but rather an invitation to a Respondent to submit a bid. Submission of a proposal or bid in response to this RFP does not obligate the DQA to award a contract to a Respondent or to any Respondent, even if all requirements stated in this RFP are met. The DQA (through the ADA) reserves the right to contract with a Respondent for reasons other than lowest price. Any final agreement between ADA (on behalf of the DQA) and Respondent will contain additional terms and conditions regarding the provision of services or equipment described in this RFP. Any final agreement shall be a written instrument executed by duly authorized representatives of the parties. Respondents RFP response shall be an offer by Respondent which may be accepted by the DQA. The pricing, terms, and conditions stated in Respondents response must remain valid for a period of one hundred twenty (120) days after submission of the RFP to the DQA. This RFP and Respondents response shall be deemed confidential DQA information. Any discussions that the Respondent may wish to initiate regarding this RFP should be undertaken only between the Respondent and DQA. Respondents are not to share any information gathered either in conversation or in proposals with any third parties, including but not limited to other business organizations, subsidiaries, partners or competitive companies without prior written permission from the DQA. The DQA reserves the right to accept or reject a Respondents bid or proposal to this RFP for any reason and to enter into discussions and/or negotiations with one or more qualified Respondents at the same time, if such action is in the best interest of the DQA. The DQA reserves the right to select a limited number of Respondents to make a Best and Final Offer for the services or equipment which are the subject of this RFP. Respondents selected to provide a Best and Final Offer shall be based on Respondent qualifications, the submitted proposal and responsiveness as determined solely by the DQA. All Respondents costs and expenses incurred in the preparation and delivery of any bids or proposals (response) in response to this RFP are Respondents sole responsibility. Applicants should limit the budget to direct costs. Indirect and F & A costs are not allowed. The DQA reserves the right to award contracts to more than one Respondent for each of the services identified in this RFP.

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All submissions by Respondents shall become the sole and exclusive property of the DQA (through the ADA) and will not be returned by the DQA or ADA to Respondents.

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Assuring Feasibility, Validity, Reliability and Usability of eMeasures in Dentistry

This document provides guidance regarding the testing of e-measures developed by the Dental Quality Alliance (DQA). The sections below provide an overview of the information that needs to be gathered to test the feasibility, validity, reliability, and usability of e-measures.

Feasibility
A measure will be considered feasible if the data necessary to score the measure are readily available. 1 The National Quality Forum recently published a document regarding the feasibility of eMeasures at http://www.qualityforum.org/Projects/eg/eMeasure_Feasibility_Testing/eMeasure_Feasibility_Testing.aspx#t=2&s=&p . The DQA has conducted a preliminary assessment of feasibility for the two measures identified in this RFP. Appendix 1 provides the results of this assessment.

Reliability
Reliability is the degree to which the measure is free from random error. 2 Reliability testing demonstrates the measure data elements are repeatable, producing the same results a high proportion of the time when assessed in the same population in the same time period and/or that the measure score is precise. reliability testing allows for meaningful comparisons across states, programs, individual providers or institutional providers.
3

Good

Validity
Validity demonstrates extent to which a measure truly measures that which it is intended and designed to measure. Face validity can be established though expert consensus. Evidence from the literature for comparable measurements can provide additional support.

Usability
Assessing usability assures that the information produced by the measure is meaningful, understandable, and useful to the intended audience. More information is available from the NQF at http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=70845 .

Mangione-Smith R, Schiff J, Dougherty D. Identifying children's health care quality measures for Medicaid and CHIP: an evidence-informed, publicly transparent expert process. Acad Pediatr. 2011 May-Jun;11(3 Suppl):S11-21 2 Mangione-Smith R, Schiff J, Dougherty D. Identifying children's health care quality measures for Medicaid and CHIP: an evidence-informed, publicly transparent expert process. Acad Pediatr. 2011 May-Jun;11(3 Suppl):S11-21 3 National Quality Forum. Measure Testing task Force Report Accessed at http://www.qualityforum.org/docs/measure_evaluation_criteria.aspx

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Assuring Scientific Soundness: NQF Guidelines

In order to meet the criteria for scientific soundness (reliability and validity), acceptable protocols for testing must provide information to, at a minimum, achieve the Moderate evaluation rating for validity and reliability. (REFER complete NQF recommendations at http://www.qualityforum.org/Publications/2011/01/Measure_Testing_Task_Force.aspx )
Rating Reliability Description and Evidence All EHR measure specifications are unambiguous+ and include only data elements from the Quality Data Model (QDM)* including quality data elements, code lists, and measure logic; OR new data elements are submitted for inclusion in the QDM; AND Empirical evidence of reliability of both data element AND measure score within acceptable norms: Da ta e le m e nt: re lia bilit y (repeatability) assured with computer programmingmust test data element validity AND Me a s ure s core : a ppropria te m e thod, s cope , and reliability statistic within acceptable norms Validity Description and Evidence The measure specifications (numerator, denominator, exclusions, risk factors) reflect the quality of care problem (1a,1b) and evidence cited in support of the measure focus (1c) under Importance to Measure and Report; AND Empirical evidence of validity of both data elements AND measure score within acceptable norms: Data element: validity demonstrated by analysis of agreement between data elements electronically extracted and data elements visually abstracted from the entire EHR with statistical results within acceptable norms; OR complete agreement between data elements and computed measure scores obtained by applying the EHR measure specifications to a simulated test EHR data set with known values for the critical data elements; AND Me a s ure s core : a ppropria te m e thod, s cope , a nd va lidity te s ting re s ult within acceptable norms; AND Identified threats to validity (lack of risk adjustment/stratification, multiple data types/methods, systematic missing or incorrect data) are empirically assessed and adequately addressed so that results are not biased The measure specifications reflect the evidence cited under Importance to Measure and Report as noted above; AND Empirical evidence of validity within acceptable norms for either data elements OR measure score as noted above; OR Systematic assessment of face validity of measure score as a quality indicator (as described in Table A-3) explicitly addressed and found substantial agreement that the scores obtained from the measure as specified will provide an accurate reflection of quality and can be used to distinguish good and poor quality AND Identified threats to validity noted above are empirically assessed and adequately addressed so that results are not biased

High

Moderate

All EHR measure specifications are unambiguous+ and include only data elements from the QDM;* OR new data elements are submitted for inclusion in the QDM; AND Empirical evidence of reliability within acceptable norms for either data elements OR measure score as noted above

The above referenced NQF document on guidance for measure testing also provides examples for: Table A-1: Examples of Reliability Testing at the Level of the Computed Performance Measure Score Table A-2: Examples of Reliability Testing at the Level of the Data Elements Table A-3: Examples of Validity Testing at the Level of the Computed Performance Measure Score Table A-4: Examples of Validity Testing at the Level of Data Elements Table A-5: Examples of Testing Related to Threats to Validity Table A-6: Examples of Interpretation of Statistical Results 6|Page

Research Objectives
The testing effort must help in finalizing the measure specifications and values sets (Appendix 1); and generate data required for a successful NQF application. As noted in the guidance provided by NQF some aspects of validity and reliability can be assessed in a simulated test EHR data set (data repositories) with known values for the critical data elements. Such a test data set may provide a viable option to establish a cost-effective sustainable option for testing the some aspects of validity and reliability of eMeasures. Respondents are encouraged to evaluate feasibility of using such a data set. The table below provides a list of the questions that must be answered through the testing effort with empirical data generated through this project. The proposal must provide details of how the researchers plan to address each of these questions. Process Measure Intent/concept validity Question Is there an opportunity for quality improvement? Is the health care construct underlying the measure associated with important health care processes and/or outcomes? Are all individuals in the denominator equally eligible for inclusion in the numerator? Have all the data elements required to compute the numerator/denominator and exclusions been identified within the technical specifications? How well do the measure specifications capture the event that is the subject of the measure? Is the measure result under control of those whom the measure evaluates? Is the data captured during the typical course of clinical care? Will the measure rationale and results be easily understood by users of the measure and resulting data? Is the data element coded using a nationally accepted terminology standards? Are the appropriate Quality Data Model (QDM) elements available to construct the measure logic? Are the value sets valid? Are the data elements necessary to define numerator/denominator and exclusions readily available in a structured format across EHR systems? To what extent does capturing the data element fit the typical EHR workflow for that user/system? Is the data element accurate i.e. is it generally captured by the most appropriate person involved in the clinical workflow? Are there differences between medical and dental systems that need to be accounted for in the logic? Will there be interpretation issues if vendors rely on the human readable logic alone to program into their systems? Will the systems generate the correct score for a test data set? (Data element validity requires demonstration that there is complete agreement between data elements and computed measure scores obtained by applying the measure specifications to a simulated test EHR data set with known values for the critical data elements) Can a performance report be generated? Are the results from the measure repeatable between systems? (Especially needs testing if 7|Page

Technical/ Data Element Feasibility

Implementation Feasibility/ Data Element Reliability & Validity

Measure Score reliability

Final e-Measure Usability

vendors use the human readable form of the measure to program into their systems). What is percentage of missing or invalid data for each data element? Does this vary by system? Does the measurement score truly represent what it is intended to measure? Does the score have reliability statistic within accepted norms? Does the measure provide for fair comparisons of the performance of providers or facilities? Does the measure allow for adjustment of the measure to exclude patients when appropriate? Are there additional exclusions not included in the specifications that impact the measure score? Do data elements for exclusions score low on feasibility? To what extent do the exclusions due to missing or invalid data impact the measurement score? (The National Quality Forum provides additional guidance on testing for threats to validity from missing or incorrect data or exclusions (selection/attrition bias) (http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=59116 ). Sensitivity analyses with and without the exclusion, and variability of exclusions across measured entities can be used to determine the impact of missing or incorrect data on the resulting measure. To what extent are the measure rationale and results easily understood by the providers, vendors, and other users of the measure and resulting data? To what extent are the measure results reportable in a manner useful to health care organizations and other interested stakeholders?

In developing the draft specifications and this RFP the DQA has completed some preliminary work towards answering the questions listed above. Please ensure that your proposal DOES NOT duplicate any of this effort. The work accomplished by the DQA includes: 1. Measure Intent: Performance gaps using claims data for the same measure concepts. 2. Technical/ Data Element Feasibility: Phase 1 feasibility survey (Appendix 2)

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Appendix 1: DRAFT specifications to develop the e-Measures E-Measure: Care Continuity

Measure Concept: Children who receive a comprehensive or periodic oral evaluation in two consecutive years Measure intent in plain language

This measure is based on the evidence that kids should at least have an annual exam. The initial patient population captures all kids under age 21 who had a visit. The first visit should start at 1 year. So the kids need to be 1 year in the year prior to the measurement year i.e. 2 years at start of measurement year.

The denominator is the children who had an exam in the measurement year. The numerator then captures the kids who had an oral exam in the measurement year and in the year prior to the measurement year. Note that with a true electronic patient record that follows a patient through the healthcare system continuity of care across practices can be determined. When the patients record does not follow them and they switch providers, this measure will only capture patients who were provided an oral evaluation by the same provider/practice over two years.

There are no exclusions. This measure is usable in a dental setting as well as in a pediatricians office. Pediatricians usually provide comprehensive oral exam for young children. Measurement period = a year

Description: Percentage of children who were seen by a practitioner during the measurement period who received a comprehensive or periodic oral evaluation in the year prior to the measurement year who also received a comprehensive or periodic evaluation in the measurement year. Numerator: Unique number of children under age 21 who received a comprehensive or periodic oral evaluation in the measurement year and in the year prior to the measurement year. Denominator: Unique number of children under age 21 who received a comprehensive or periodic oral evaluation in the measurement year. Exclusions/Exceptions: None. Stratifications: 1. Race 2. Ethnicity 3. Payer Type 9|Page

E-Measure Specification: Care Continuity

Population and Data Criteria Initial Patient Population = Include all patients who meet the following criteria Age >= 2 years starts before start of Measurement Start Date AND Age <= 20 years starts before start of Measurement Start Date AND Visit during the measurement period AND: "Patient Characteristic Birthdate: birth date" >= 2 year(s) starts before start of "Measurement Start Date" AND: "Patient Characteristic Birthdate: birth date" <= 20 year(s) starts before start of "Measurement Start Date" AND: OR: "Encounter, Performed: Face-to-Face Interaction" OR: "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" OR: "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" OR: "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" OR: "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" OR: "Encounter, Performed: Office Visit" OR: "Encounter, Performed: Oral Evaluation" OR: Procedure, Performed: Oral Evaluation during "Measurement Period" Denominator Population = Include all patients from the initial patient population who meet the following criteria Initial Patient Population AND Children who received comprehensive and periodic oral exam in the measurement year AND: "Initial Patient Population AND: OR: Encounter Performed: Oral Evaluation OR: Procedure, Performed: Oral Evaluation during the Measurement Period Denominator Exclusions = Remove all patients who meet the following criteria None Numerator = Include all patients from the denominator population who meet the following criteria Children who received comprehensive and periodic oral evaluation in the year prior to the measurement year. AND: Encounter Performed: Oral Evaluation) starts before start of Measurement Period <= 1 Year Denominator Exceptions = Remove all patients who meet the following criteria from denominator None Supplemental Data Elements (Standardized by ONC) "Patient Characteristic Documented: Race" using "Race CDC Value Set" "Patient Characteristic Documented: Ethnicity" using "Ethnicity CDC Value Set" "Patient Characteristic Documented: Payer" using "Payer Source of Payment Typology Value Set

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E-Measure: Prevention: Sealants for 6-9 year olds

Measure Concept: Children aged 6-9 years who receive sealants in the first permanent molar Measure intent in plain language

This measure is based on strong evidence that use of sealants reduces the incidence of caries/cavities. The measure applies to dental practices only. However there are practices such as those within an FQHC setting which might thought to be integrated with a medical practice. This measure would apply to such practices.

The initial patient population captures all children between age 6 - 9 who had a preventive visit/ oral evaluation The denominator captures all children between ages 6 9 years who at high risk for cavities The numerator captures kids who meet the denominator criteria and have received sealants in their permanent first molar tooth. We all have 4 permanent first molars and this measure does not discriminate between the teeth but only intends to capture if a kid received sealant in any one of the four permanent first molars.

Capturing risk can be done in two ways in the normal clinical workflow. It can just be done using professional judgment and recorded as a diagnosis using a SNOMED code or some EHRs have a risk assessment tool built into the EHR workflow. The risk assessment tools are not standardized and hence we need to allow for different options to capture risk. Risk should be captured during the measurement year and remain an active diagnosis until procedure is performed. Risk status is usually reconciled at each examination visit. The status could have been diagnosed prior to the measurement year.

The exclusions used are whether the procedure was not performed due to patient or system reasons. The intent to just use these as radio buttons within the EHR rather than have more granular reasons captured. The exclusion should be related to the sealant rather than something else in the treatment plan during the visit.

Description: Percentage of children between 6-9 years seen by the practitioner for an oral evaluation during the measurement period who are at elevated risk who received a sealant on a one or more first permanent molar tooth within the measurement period. Numerator: Unique number of children aged 6-9 at elevated risk who received a sealant on one or more first permanent molar tooth in the measurement period

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Denominator: Unique number of children between 6-9 years seen by a practitioner for an oral evaluation during the measurement period who are at elevated risk Exceptions: Medical reason (e.g. non-sealable surface) Patient reasons (e.g., refusal of treatment, did not return for treatment) Stratifications: 1. Race 2. Ethnicity 3. Payer Type
E-Measure Specification: Sealants 6-9 year olds Population and Data Criteria Initial Patient Population = Include all patients who meet the following criteria Age >= 6 years starts before start of Measurement Start Date AND Age <= 9 years starts before start of Measurement Start Date AND Visit during the measurement period AND: "Patient Characteristic Birthdate: birth date" >= 6 year(s) starts before start of "Measurement Start Date" AND: "Patient Characteristic Birthdate: birth date" <= 9 year(s) starts before start of "Measurement Start Date" AND: OR: "Encounter, Performed: Oral Evaluation" OR: Procedure, Performed: Oral Evaluation during "Measurement Period" Denominator Population = Include all patients from the initial patient population who meet the following criteria Initial Patient Population AND Children who are at elevated risk for caries during the measurement year

AND: "Initial Patient Population AND: OR: Diagnosis, Active Result: Elevated Caries Risk: Diagnosis OR: Risk Evaluation Assessed Method: Elevated Caries Risk: Diagnosis from Risk Assessment Module OR: Procedure Performed: Elevated Caries Risk: Procedure with finding during Measurement Period Denominator Exclusions = Remove all patients who meet the following criteria None Numerator = Include all patients from the denominator population who meet the following criteria Children who received sealants in their first permanent molar AND: Procedure performed: Sealants Value set (Anatomical Structure: First Permanent Molar Value Set) during Measurement Period Denominator Exceptions = Remove all patients who meet the following criteria from denominator Children for whom sealants were not provided due to medical, patient or system reasons AND: OR: Procedure not performed: Sealants Value set (Anatomical Structure: First Permanent Molar Value Set); Declined Reason: Exclusion reasons during the Measurement period Supplemental Data Elements (Standardized by ONC) "Patient Characteristic Documented: Race" using "Race CDC Value Set" "Patient Characteristic Documented: Ethnicity" using "Ethnicity CDC Value Set" "Patient Characteristic Documented: Payer" using "Payer Source of Payment Typology Value Set

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DRAFT Value Sets for Measures

Value set, (previously referred to as code list), is a set of values that contain specific codes derived from a particular taxonomy. With respect to value sets, a value is a specific code defined by a given taxonomy. Values are included in value sets. The National Library of Medicine (NLM), in collaboration with the Office of the National Coordinator for Health Information Technology (ONC) and Centers for Medicare & Medicaid Services (CMS), has launched the NLM Value Set Authority Center (VSAC) and thus coordinates the data elements and vocabularies included within the value sets for clinical quality measures within the Meaningful Use program. Presented below are the value sets for the concepts used within the specifications of this measure set. For each concept, codes from vocabularies specified as standards within the Meaningful Use regulation are included within the tables.
Sealant QDM Category Procedure Oral Evaluation QDM Category Encounter/ Procedure Encounter/ Procedure Encounter/ Procedure Code System CDT CDT CDT Code System Version 2013 2013 2013 Code D0120 D0145 D0150 Descriptor Code System CDT Code System Version 2013 Code D1351 Descriptor

Elevated Caries Risk: Diagnosis QDM Category Diagnosis Diagnosis Diagnosis Code System SNOMED SNOMED SNOMED Code System Version 2013 2013 2013 Code TBD TBD TBD Descriptor TBD (available May 2013) TBD (available May 2013) TBD (available May 2013)

Elevated Caries Risk: Procedure with finding QDM Category Procedure Procedure Code System CDT CDT Code System Version 2013 2013 Code TBD TBD Descriptor TBD (available May 2013) TBD (available May 2013)

First Permanent Molar QDM Category Attribute Code System SNOMED Code System Version 2013 Code 304565009 Descriptor Entire permanent first molar tooth

Face to Face Interaction (NCQA) QDM Category Encounter Encounter Encounter Encounter Encounter Encounter Code System SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT Code System Version 2012-07 2012-07 2012-07 2012-07 2012-07 2012-07 Code 12843005 18170008 185349003 185463005 185465003 19681004 Descriptor Subsequent hospital visit by physician (procedure) Subsequent nursing facility visit (procedure) Encounter for "check-up" (procedure) Visit out of hours (procedure) Weekend visit (procedure) Nursing evaluation of patient and report (procedure)

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Encounter Encounter Encounter Encounter Encounter Encounter Encounter Encounter Encounter Encounter

SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT SNOMEDCT

2012-07 2012-07 2012-07 2012-07 2012-07 2012-07 2012-07 2012-07 2012-07 2012-07

207195004 270427003 270430005 308335008 390906007 406547006 439708006 4525004 87790002 90526000

History and physical examination with evaluation and management of nursing facility patient (procedure) Patient-initiated encounter (procedure) Provider-initiated encounter (procedure) Patient encounter procedure (procedure) Follow-up encounter (procedure) Urgent follow-up (procedure) Home visit (procedure) Emergency department patient visit (procedure) Follow-up inpatient consultation visit (procedure) Initial evaluation and management of healthy individual (procedure)

Preventive Care - Established Office Visit, 0 to 17 (NCQA) QDM Category Encounter Code System CPT Code System Version 2012 Code Descriptor

99391

Encounter

CPT

2012

99392

Encounter

CPT

2012

99393

Encounter

CPT

2012

99394

Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age 1 through 4 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)

Preventive Care- Initial Office Visit, 0 to 17 (NCQA) QDM Category Encounter Code System CPT Code System Version 2012 Code Descriptor

99381

Encounter

CPT

2012

99382

Encounter

CPT

2012

99383

Encounter

CPT

2012

99384

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood (age 1 through 4 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)

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Preventive Care Services - Established Office Visit, 18 and Up (NCQA) QDM Category Encounter Code System CPT Code System Version 2012 Code Descriptor

99395

Encounter

CPT

2012

99396

Encounter

CPT

2012

99397

Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older

Preventive Care Services-Initial Office Visit, 18 and Up (NCQA) QDM Category Encounter Code System CPT Code System Version 2012 Code Descriptor

99385

Encounter

CPT

2012

99386

Encounter

CPT

2012

99387

Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 65 years and older

Performed: Office Visit (NCQA) QDM Category Encounter Code System CPT Code System Version 2012 Code Descriptor

99201

Encounter

CPT

2012

99202

Encounter

CPT

2012

99203

Encounter

CPT

2012

99204

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or

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Encounter

CPT

2012

99205

Encounter

CPT

2012

99212

Encounter

CPT

2012

99213

Encounter

CPT

2012

99214

Encounter

CPT

2012

99215

coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

Exclusion Reasons QDM Category Attribute Attribute Attribute Code System SNOMED-CT SNOMED-CT SNOMED-CT Code System Version 07/2011 07/2011 07/2011 Code 105480006 184081006 183964008 Descriptor refusal of treatment by patient (situation) patient has moved away (finding) treatment not indicated (situation)

Race (ONC Standard) QDM Category Patient Characteristic Patient Characteristic Patient Characteristic Patient Characteristic Patient Characteristic Patient Characteristic Code System CDCREC CDCREC CDCREC CDCREC CDCREC CDCREC Code System Version 1.0 1.0 1.0 1.0 1.0 1.0 Code 1002-5 2028-9 2054-5 2076-8 2106-3 2131-1 Description American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race

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Ethnicity (ONC Standard) QDM Category Patient Characteristic Patient Characteristic Code System CDCREC CDCREC Code System Version 1.0 1.0 Code 2135-2 2186-5 Description Hispanic or Latino Not Hispanic or Latino

Payer Type (ONC Standard) QDM Category Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient Code System SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP Code System Version 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 Code 611 612 613 619 62 63 64 69 7 71 72 73 79 8 81 82 821 822 823 83 84 85 89 9 91 92 93 Description BC Managed Care - HMO BC Managed Care - PPO BC Managed Care - POS BC Managed Care - Other BC Indemnity BC (Indemnity or Managed Care) - Out of State BC (Indemnity or Managed Care) - Unspecified BC (Indemnity or Managed Care) - Other MANAGED CARE, UNSPECIFIED (to be used only if one can't distinguish public from private) HMO PPO POS Other Managed Care, Unknown if public or private NO PAYMENT from an Organization/Agency/Program/Private Payer Listed Self-pay No Charge Charity Professional Courtesy Research/Clinical Trial Refusal to Pay/Bad Debt Hill Burton Free Care Research/Donor No Payment, Other MISCELLANEOUS/OTHER Foreign National Other (Non-government) Disability Insurance

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characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic

SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP

5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

94 95 951 953 954 959 96 98 99 9999 1 11 111 112 113 119 12 121 122 123 129 19 2 21 211 212 213 219 22 23 24 25

Long-term Care Insurance Worker's Compensation Worker's Comp HMO Worker's Comp Fee-for-Service Worker's Comp Other Managed Care Worker's Comp, Other unspecified Auto Insurance (no fault) Other specified (includes Hospice - Unspecified plan) No Typology Code available for payment source Unavailable / Unknown MEDICARE Medicare (Managed Care) Medicare HMO Medicare PPO Medicare POS Medicare Managed Care Other Medicare (Non-managed Care) Medicare FFS Medicare Drug Benefit Medicare Medical Savings Account (MSA) Medicare Non-managed Care Other Medicare Other MEDICAID Medicaid (Managed Care) Medicaid HMO Medicaid PPO Medicaid PCCM (Primary Care Case Management) Medicaid Managed Care Other Medicaid (Non-managed Care Plan) Medicaid/SCHIP Medicaid Applicant Medicaid - Out of State

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Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient

SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP

5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

29 3 31 311 3111 3112 3113 3114 3115 3116 3119 312 3121 3122 3123 313 32 321 3211 3212 32121 32122 32123 32124 32125 32126 322 3221 3222 3223 3229 33 331

Medicaid Other OTHER GOVERNMENT (Federal/State/Local) (excluding Department of Corrections) Department of Defense TRICARE (CHAMPUS) TRICARE Prime-HMO TRICARE Extra-PPO TRICARE Standard - Fee For Service TRICARE For Life--Medicare Supplement TRICARE Reserve Select Uniformed Services Family Health Plan (USFHP) -- HMO Department of Defense - (other) Military Treatment Facility Enrolled Prime-HMO Non-enrolled Space Available TRICARE For Life (TFL) Dental --Stand Alone Department of Veterans Affairs Veteran care--Care provided to Veterans Direct Care--Care provided in VA facilities Indirect Care--Care provided outside VA facilities Fee Basis Foreign Fee/Foreign Medical Program(FMP) Contract Nursing Home/Community Nursing Home State Veterans Home Sharing Agreements Other Federal Agency Non-veteran care Civilian Health and Medical Program for the VA (CHAMPVA) Spina Bifida Health Care Program (SB) Children of Women Vietnam Veterans (CWVV) Other non-veteran care Indian Health Service or Tribe Indian Health Service - Regular

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characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic

SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP

5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

332 333 334 34 341 342 343 349 35 36 361 362 369 37 371 3711 3712 3713 372 379 38 381 3811 3812 3813 3819 382 389 39 4 41 42

Indian Health Service - Contract Indian Health Service - Managed Care Indian Tribe - Sponsored Coverage HRSA Program Title V (MCH Block Grant) Migrant Health Program Ryan White Act Other Black Lung State Government State SCHIP program (codes for individual states) Specific state programs (list/ local code) State, not otherwise specified (other state) Local Government Local - Managed care HMO PPO POS FFS/Indemnity Local, not otherwise specified (other local, county) Other Government (Federal, State, Local not specified) Federal, State, Local not specified managed care Federal, State, Local not specified - HMO Federal, State, Local not specified - PPO Federal, State, Local not specified - POS Federal, State, Local not specified - not specified managed care Federal, State, Local not specified - FFS Federal, State, Local not specified - Other Other Federal DEPARTMENTS OF CORRECTIONS Corrections Federal Corrections State

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Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic Patient characteristic

SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP SOP

5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0 5.0

43 44 5 51 511 512 513 514 515 519 52 521 522 523 529 53 54 55 59 6 61

Corrections Local Corrections Unknown Level PRIVATE HEALTH INSURANCE Managed Care (Private) Commercial Managed Care - HMO Commercial Managed Care - PPO Commercial Managed Care - POS Exclusive Provider Organization Gatekeeper PPO (GPPO) Managed Care, Other (non HMO) Private Health Insurance - Indemnity Commercial Indemnity Self-insured (ERISA) Administrative Services Only (ASO) plan Medicare supplemental policy (as second payer) Private health insurance-other commercial Indemnity Managed Care (private) or private health insurance (indemnity), not otherwise specified Organized Delivery System Small Employer Purchasing Group Other Private Insurance BLUE CROSS/BLUE SHIELD BC Managed Care

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Appendix 2: Dental Quality Alliance eMeasures Phase I Feasibility Assessment: Summary of findings
This information was compiled from the following individuals/teams through semi-structured surveys and phone interviews. Respondents include vendors, IT programmers in large group practices, IT programmers in FQHCs/ CHCs, and practitioners. The vendors we surveyed all have dental systems. One vendor answered the survey for an ambulatory product in addition to their dental product. In that product many of these data elements and standard vocabularies such as even CDT code will not be feasible. The table below provides the summary from the dental systems/ practices. We did not survey a practices/ vendors that have a truly integrated/ interoperable EHR. DATA ELEMENTS
Concept Data Availability as structured data elements* (NQF 4 Score) Workflow: Typically captured during routine clinical care and documentation (NQF Score) Data accuracy: Who captures this information? (NQF Score) Stored using standard taxonomies such as CDT, SNOMED, RxNorm, LOINC (NQF Score) CDT (3) If interface terminologies are used at the provider end, are validated maps available to standard taxonomies? Interface not used Does the system use encounters to embed procedure codes or are they indexed by visit date

Procedure - oral evaluation

Yes (3)

Yes (3)

Procedure sealant

Yes (3)

Yes (3)

Dentist or team member chair side (3) Dentist or team member chair side (3)

CDT (3)

Interface not used

Dental systems index by visit date and dont embed in encounters. It is possible for vendors to artificially link a procedure to encounter within the system. FQHCs that are reimbursed based on encounter rates also record procedures by visit date. Each visit date is considered an encounter. This does not fit into the description of encounter used in the QDM. One of the respondent participated in MU2 testing. They used the human readable version to program their system and pulled data based on visit date ignoring any written logic. One vendor requested that if the logic only stipulates the use of encounters the DQA should define these

The National Quality Forum recently published a document regarding the feasibility of eMeasures at http://www.qualityforum.org/Projects/eg/eMeasure_Feasibility_Testing/eMeasure_Feasibility_Testing.aspx#t=2&s=&p .

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appropriately and standardize. The use of the Procedure performed clause will alleviate this concern for these two measures. Diagnosis/ Caries Risk assessment patient level Only No but do not Dentist or Currently EZ Code Sometimes anticipate too team stored as proposed but can be much burden. member custom SNOMED: chair side (3) implemented (Current: 2; codes. Validated map Future 3) for 2016 MU (SNOMED available. 1:1 3. From 2014 codes and map for this CDT under data element this can be development. captured as a Can be CDT code as implemented well. (Current: 2; for 2016) (Current: 2; Future 3) Future 3) Note: Diagnosis typically remains ACTIVE unless manually resolved Some systems have pop ups while others have a specific UI for capturing exclusions. In systems that have the UI, all the exclusion concepts are listed in drop down menus against the measure name and providers have the ability to select a reason for exclusion of that patient when closing out the record. Other systems typically include logic to search for specific items in the chart including text search of clinical notes. Providers would like some of the major exclusions addressed without burden to the workflow. Further testing is required to understand impact of exclusions. Yes (3) Yes (3) Dentist or Tooth team Numbering member System in chair side (3) itself is considered standard taxonomy. That is universally used although SNOMED codes are available. Again no one uses SNOMED (Current: 2; Future 3) Yes (3) Yes (3) Office staff (3) Yes (3) Only sometimes but can be included (Current: 2; Future 3) Yes (3) Sometimes (Current: 2; Future 3) Office staff (3) Office staff (3) So far the dental vendors are not using the ONC value sets except one Custom codes used. Map validity unknown

Exclusion Reasons

Tooth number

Visit Date/ Date of Service Patient Date of Birth Race (STRATIFICATION VARIABLE: Not a critical data element)

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Ethnicity (STRATIFICATION VARIABLE: Not a critical data element)

Only sometimes but can be included (Current: 2; Future 3)

Sometimes (Current: 2; Future 3)

Office staff (3)

Dental Benefit plan /Insurance type (STRATIFICATION VARIABLE: Not a critical data element)

Only sometimes but can be included (Current: 2; Future 3)

Sometimes (Current: 2; Future 3)

Office staff (3)

(Current: 2; Future 3) So far the dental vendors are not using the ONC value sets except one (Current: 2; Future 3) So far the dental vendors are not using the ONC value sets except one (Current: 2; Future 3)

Custom codes used. Map validity unknown

Custom codes used. Map validity unknown

MEASURE LOGIC AND VALUE SETS

Interpretation issues with human readable format No issues identified upon eyeball review of logic and value sets. As mentioned the ONC standard value sets were new to some. No issues identified upon eyeball review of logic and value sets. As mentioned the ONC standard value sets were new to some. Implementability of measures Can be implemented but uncertain whether MAT generated HQMF will be usable Can be implemented but uncertain whether MAT generated HQMF will be usable Automated report for measure Can be implemented. Not done currently. Some have Crystal Reports but not easy to use.

Care continuity

Sealants

Can be implemented. Not done currently. Some have Crystal Reports but not easy to use.

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