Measure Key

^ New proposed measures and improvement activities

* Existing quality measures and improvement activities with proposed revisions

** Quality measures that are proposed for submission only when included in an MVP

! High priority quality measures

!! Outcome measures

~ Improvement activities that include a health equity component

% Attestation to IA_PCMH provides full credit for the improvement activities performance category

Optimal Care for Patients with Urologic Conditions MVP

Quality

Improvement Activities

Cost

(!) Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
(Collection Type: MIPS CQMs Specifications)

(!) Q318: Falls: Screening for Future Fall Risk
(Collection Type: eCQM Specifications)

(!) Q321: CAHPS for MIPS Clinician/Group Survey
(Collection Type: CSV)

(!) Q358: Patient-Centered Surgical Risk Assessment and Communication
(Collection Type: MIPS CQMs Specifications)

(*) Q462: Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
(Collection Type: eCQM Specifications)

(!!) Q476: Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
(Collection Type: eCQM Specifications)

(!) Q481: Intravesical Bacillus-Calmette Guerin for Non-muscle Invasive Bladder Cancer
(Collection Type: eCQM Specifications)

(~)(!) Q487: Screening for Social Drivers of Health
(Collection Type: MIPS CQMs Specifications)

(*)(!!) Q503: Gains in Patient Activation Measure (PAM®) Scores at 12 Months
(Collection Type: MIPS CQMs Specifications)

(!!) AQUA8: Hospital Admissions or Infectious Complications Within 30 days of Prostate Biopsy
(Collection Type: QCDR)

(!!) AQUA14: Stones: Repeat Shock Wave Lithotripsy (SWL) Within 6 Months of Initial Treatment
(Collection Type: QCDR)

(!) AQUA15: Stones: Urinalysis or Urine Culture Performed Before Surgical Stone Procedures
(Collection Type: QCDR)

AQUA16: Non-Muscle Invasive Bladder Cancer: Repeat Transurethral Resection of Bladder Tumor (TURBT) for T1 disease
(Collection Type: QCDR)

(!) MUSIC4: Prostate Cancer: Active Surveillance/Watchful Waiting for Newly Diagnosed Low-Risk Prostate Cancer Patients
(Collection Type: QCDR)

(~) IA_AHE_3: Promote use of Patient-Reported Outcome Tools
(High)

(~) IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
(High)

IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings
(High)

IA_BE_15: Engagement of patients, family and caregivers in developing a plan of care
(Medium)

IA_CC_7: Regular training in care coordination
(Medium)

IA_CC_13: Practice improvements to align with OpenNotes principles
(Medium)

IA_CC_17: Patient Navigator Program
(High)

IA_EPA_2: Use of telehealth services that expand practice access
(Medium)

(*) IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff
(Medium)

(**) IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
(High)

(%) IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation

IA_PM_17: Participation in Population Health Research
(Medium)

IA_PM_21: Advance Care Planning
(Medium)

(~) IA_PSPA_7: Use of QCDR data for ongoing practice assessment and improvements
(Medium)

IA_PSPA_12: Participation in private payer CPIA
(Medium)

IA_PSPA_19: Implementation of formal quality improvement methods, practice changes or other practice improvement processes
(Medium)

IA_PSPA_21: Implementation of fall screening and assessment programs
(Medium)

Renal or Ureteral Stone Surgical Treatment

Medicare Spending Per Beneficiary (MSPB) Clinician

(^) Prostate Cancer

Foundational Layer

Population Health Measures

Promoting Interoperability

(!!) Q479: Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit Based Incentive Payment Systems (MIPS) Eligible Clinician Groups
(Collection Type: Administrative Claims)

(!!) Q484: Clinician and Clinician Group Risk standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions
(Collection Type: Administrative Claims)

• Security Risk Analysis
• High Priority Practices Safety Assurance Factors for EHR Resilience Guide (SAFER Guide)
• e-Prescribing
• Query of Prescription Drug Monitoring Program (PDMP)
• Provide Patients Electronic Access to Their Health Information
• Support Electronic Referral Loops By Sending Health Information

AND

• Support Electronic Referral Loops By Receiving and Reconciling Health Information

OR

• Health Information Exchange (HIE) Bi-Directional Exchange

OR

• Enabling Exchange Under the Trusted Exchange Framework and Common Agreement (TEFCA)
• Immunization Registry Reporting
• Syndromic Surveillance Reporting (Optional)
• Electronic Case Reporting
• Public Health Registry Reporting (Optional)
• Clinical Data Registry Reporting (Optional)
• Actions to Limit or Restrict Comp