1
North Carolina Local Public Health
Key Performance Indicators (KPI) Requirements
May 2014
2
Key Performance Indicators
Table of Contents:
Introduction
Key Performance Indicator Details
Appointments by Visit Type
No Shows by Visit Type
Program Enrollment
Percentage of No Shows
Visits by Program
Average Visit Time by Provider
Chronic Condition Percentage
Number of Obese Patients
Charge by Program
Charge by Payor
Number of Visits by Payor
Monthly Charges
Quarterly Charge by Payor
Average Charge per Visit by Payor
Meaningful Use Performance
Program Enrollment by Age Range
Percent with Action Plan
Percent of Asthma Patients with Beta Agonist Overuse
Asthma ED Visits
Asthma inpatient visits
Percent of asthma patients with symptom assessment or continued care visit
Percent with assessment of environmental triggers
Breast cancer screening-rate for women ages 50-69
Cervical cancer screening - rate for women ages 21-64
Colorectal screening- rate for ages 50-75
Percent with Ischemic Vascular Disease (IVD) using Aspirin
Percent with Blood Pressure less than 140/90
Percent with IVD or Diabetes Mellitus (DM) with LDL < 100
Percent with Ischemic Vascular Disease (IVD) and lipid testing
Percent with smoking status documented or advice given
Percent with annual visit age 2-3 met
Percent with annual visit age 4-6 met
Percent with annual visit age 7-10 met
Percent with annual visit age 11-14 met
3
Percent with annual visit age 15-18 met
Percent with annual visit age 19-21
Percent with annual visit age 2-21 met
Percent with 3 or more varnishing by 3.5
Percent with 4 or more varnishing by 3.5
Percent with A1C result < 8.0
Percent with A1C result > 9.0
Percent with A1C testing in past year
Percent with BP < 130/80
Percent with BP > 140/90
Percent with cholesterol screen in past year
Percent of Diabetes Mellitus (DM) and Hypertension (HTN) on ACE/ARB therapy
Percent with foot exam in previous year
Percent with LDL < 100
Percent with LDL > 130
Percent with neuropathy screening/treatment in past year
Percent with retinal eye exam in past 15 months
Inpatient (IP) visit rate per 1,000 heart failure member-months
Percent with adolescent well child visit in previous year met
Percent with adolescent well child in prior 3 years met
Percent well child visits- 6 in first 15 months met
Percent well child visits- between ages 3-6 met
Percent well child visits- between ages 7-11 met
Controlling High Blood Pressure
Use of High-Risk Medications In the Elderly
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Use of Imaging Studies For Low Back Pain
4
Introduction North Carolina Local Health Departments (LHDs) have adopted Electronic Health Records
(EHR) at a rapid pace in the last 2 years. Electronic Health Records enable capturing structured
data, which can be easily reported on. This data is useful for Meaningful Use reports, Clinical
Quality Measures (CQM), PQRI and others measuring patient level outcomes. For population
health (panel) management, health directors and clinical managers need access to trends and
analytics across their clinical programs and some comparative analytics across comparable
local health departments.
PIs documented here are a result of feedback collected with health directors, clinical managers,
and public health informatics specialists. Initially a pilot project was undertaken with the Stokes
and Richmond County Health Departments. The indicators and findings from this pilot were
then reviewed by a working group of LHD health directors, clinical staff, and informatics
specialists. Follow up discussion were also held with selected working group members. Actual
documentation was prepared by staff and students from Patagonia Health, UNC School of
Information and Library Sciences, and the North Carolina Institute for Public Health.
These PIs are intended to aggregate data to be used by health directors and their authorized
staff. They do not contain identifiable patient information. These PIs may be used for
understanding trends, watching cause-effect, better explaining value proposition of the LHDs
and grant writing.
Key Performance Indicator Details
KPI Title Appointments by Visit Type
KPI Description This graph displays the number of
non-deleted appointments that were
scheduled during the fiscal year (July
1 – June 30) according to the visit
type.
KPI Calculation Sum of all scheduled appointments
(including missed appointments) with
a specific visit type within the given
date range
Data Source(s) Appointments
Minimum Data Set Patient ID, Appointment Date, Visit
Type
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
5
KPI is reported in which reports Appointments-Demo
Comments
KPI Title No Shows by Visit Type
KPI Description This graph displays the number of
non-deleted appointments that were
scheduled during the fiscal year (July
1 – June 30) according to the visit
type. It displays the number of no
shows according to the visit type.
KPI Calculation Sum of all missed appointments with
a specific visit type within the given
date range
Data Source(s) Appointments
Minimum Data Set Patient ID, Appointment Date,
Appointment Status, Visit Type
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments-Demo
Comments
KPI Title Program Enrollment
KPI Description This graph displays the number of
unduplicated patients who visited the
practice for a specific program in the
practice/health department during the
fiscal year (July 1 – June 30). If a
patient had multiple visits for different
programs, they are grouped into the
program according to the most recent
visit.
KPI Calculation Sum of all unduplicated patients who
visited the practice for a specific
program within the given date range
Data Source(s) Appointments
Minimum Data Set Patient ID, Program, Appointment Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Program Breakdown-Demo
Comments
6
KPI Title Percentage of No Shows
KPI Description This graph displays the percentage of
no shows compared to the total
number of scheduled visits during the
fiscal year (July 1 - June 30) according
to the visit type.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Sum of all missed
appointments with a specific visit type
within the given date range
Denominator:Sum of all scheduled
appointments (including missed
appointments) with a specific visit type
within the given date range
Data Source(s) Appointments
Minimum Data Set Patient ID, Appointment Date,
Appointment Status, Visit Type
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments-Demo
Comments
KPI Title Visits by Program
KPI Description This graph displays the number of
visits to the practice/health department
during the fiscal year (July 1 - June 30)
according to the type of program the
visit was for.
KPI Calculation Sum of all visits for a specific program
within the given date range
Data Source(s) Appointments
Minimum Data Set Patient ID, Program, Appointment Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments-Demo
Comments
7
KPI Title Average Visit Time by Provider
KPI Description This graph displays the average visit
time for an appointment by provider
based on the check-in and check-out
time (only entries with a check-in and
check-out time are included in the
average).
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Sum of the visit times of
all visits to a specific provider within
the given date range (visit time
calculated by the difference between
check-in and check-out time, where
both values are present)
Denominator: Total number of visits to
a specific provider within the given
date range where a check-in and
check-out time were given
Data Source(s) Appointments
Minimum Data Set Patient ID, Check-in Time, Check-out
Time, Appointment Date, Provider
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments-Demo
Comments
KPI Title Chronic Condition Percentage
KPI Description This graph displays the percentage of
patients with a specific chronic
condition as a percentage of the total
number of patients that visited the
practice during the fiscal year (July 1 -
June 30). The chronic conditions for
this graph are asthma, diabetes,
hypertension, obesity and smoking.
Obesity is defined as patients who
have a BMI greater than 25. Smokers
defined as those who smoke currently,
either every day or some days.
8
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Sum of all patients
diagnosed with a specific condition that
were enrolled in the practice within the
given date range
Denominator: Sum of all patients that
were enrolled in the practice within the
given date range
Data Source(s) Encounter note, Social History
Minimum Data Set Patient ID, Encounter/Assessment
Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports-Demo
Comments
KPI Title Number of Obese Patients
KPI Description This graph displays the number of
obese patients who visited the
practice/health department during the
fiscal year (July 1-June 30). Obesity is
defined as patients who have a BMI
greater than 25.
KPI Calculation Sum of all patients with a BMI greater
than 25 that were enrolled in the
practice within the given date range
Data Source(s) Encounter note
Minimum Data Set Patient ID, Encounter Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports-Demo
Comments
KPI Title Charge by Program
KPI Description This graph displays the total amount
charged by the type of program the
charge was associated with during the
fiscal year (July 1 - June 30).
KPI Calculation Sum of all charges attributed to a
9
specific program within the given date
range
Data Source(s) Billing
Minimum Data Set Patient ID, Billing Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports-Demo
Comments
KPI Title Charge by Payor
KPI Description This graph displays the total amount
charged by insurance type the charge
was associated with during the fiscal
year (July 1 - June 30).
KPI Calculation Sum of all charges attributed to a specific
payor within the given date range
Data Source(s) Billing
Minimum Data Set Patient ID, Billing Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports-Demo
Comments
KPI Title Number of Visits by Payor
KPI Description This graph displays the total number of
visits based on the payor during the
fiscal year (July 1 - June 30).
KPI Calculation Sum of all visits for patients with a
specific payor within the given date
range
Data Source(s) Billing
Minimum Data Set Patient ID, Visit Date, Payor
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports
Comments
KPI Title Monthly Charges
KPI Description This graph displays the total amount
charged for each month during the fiscal
10
year (July 1 - June 30).
KPI Calculation Sum of all charges for a specific month
within the given date range
Data Source(s) Billing
Minimum Data Set Patient ID, Visit Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports
Comments
KPI Title Quarterly Charge by Payor
KPI Description This graph displays the total amount
charged for each quarter during the fiscal
year (July 1 - June 30). This amount is
then divided into slices, reflecting the total
amount during a specific quarter charged
to each payor.
KPI Calculation Sum of all charges attributed to a specific
payor for a specific quarter within the
given date range
Data Source(s) Billing
Minimum Data Set Patient ID, Visit Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports-Demo
Comments
KPI Title Average Charge per Visit by
Payor
KPI Description This graph displays the average charge
per visit for each payor during the fiscal
year (July 1 - June 30), determined by
dividing the total charge during that period
for each payor by the total number of
visits for each payor.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Sum of all charges attributed
to a specific payor within the given date
range
11
Denominator: Sum of all visits for
patients with a specific payor within the
given date range (where a charge was
attributed to that visit)
Data Source(s) Billing
Minimum Data Set Patient ID, Visit Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports-Demo
Comments
http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/clinical-
quality-measures
http://www.athenahealth.com/_doc/pdf/whitepapers/Paid-MU.pdf
KPI Title Meaningful Use Performance
KPI Description This graph displays the names of each
physician as well as spark bars displaying
how well each physician is meeting their
meeting their meaningful use goals, as
well as a link to jump to a page with more
detailed information. Physician names
have either green, orange or red circles
next to their names, indicating they have
either met all of their meaningful use goals
(green), failed to meet one to seven of
their goals (orange), or failed to meet eight
or more of their goals (red).
KPI Rationale From cdc.gov: the 5 purposes of
meaningful use are:
1. Improving quality, safety, efficiency,
and reducing health disparities
2. Engage patients and families in their
health
3. Improve care coordination
4. Improve population and public health
5. Ensure adequate privacy and security
12
protection for personal health
information
http://www.cdc.gov/ehrmeaningfuluse/intro
duction.html
KPI Calculation Meaningful Use measures are calculated
from a variety of sources, including
encounter notes, history, diagnoses,
medication and allergies.
These measures follow the ONC specified
calculations to match the required
thresholds
Data Source(s) Encounter note, medications, history,
assessment, procedure, allergy
Minimum Data Set Meaningful Use Performance Data
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Meaningful Use-Demo
Comments Meaningful Use Measures provides a
concise summary of provider completed
operations compared with threshold
requirements laid out by ONC.
For Stage 1 (2011 edition), following
measures are listed:
KPI Title Program Enrollment by Age
Range
KPI Description
KPI Calculation Sum of all unduplicated patients who
visited the practice for a specific
program within a specific age range
within the given date range
Data Source(s) Encounter note
Minimum Data Set Patient ID, Program, Appointment Date
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Program Breakdown-Demo
Comments
13
KPI Title Percent with Action Plan
KPI Description Relative frequency of asthma patients
have specified an action plan on their
medical chart
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: number of asthma patients
with an action plan specified on their
medical chart
Denominator: total number of patients
with asthma
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Action plan is a checkbox or some other
code in the system to indicate action
plan is setup
Probably not useful for dashboard
KPI Title Percent of Asthma Patients with
Beta Agonist Overuse
KPI Description Relative frequency of beta agonist
overuse in asthma patients
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Total number of asthma
patients with 4 or more prescription fill
dates in any 90-day window
Denominator: Total number of asthma
patients having a prescription for a beta
agonist
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
14
KPI Title Asthma ED Visits
KPI Description Frequency of emergency department
visits for patients with asthma in specified
time period (1000 asthma member-
months)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: # of emergency department
visits for asthma patients
Denominator: 1000 asthma member
months
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments This is important, but may not be able to
track this. EHR does not have ED visit
information
KPI Title Asthma inpatient visits
KPI Description Hospital admissions with asthma as
primary diagnosis per 1000 asthma
member-months
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Hospital admissions with
asthma as primary diagnosis
Denominator: 1000 asthma member-
months
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
15
Comments This is important, but may not be able to
track this. EHR does not have ED visit
informatio
KPI Title Percent of asthma patients with
symptom assessment or
continued care visit
KPI Description Continued care visit with assessment of
asthma symptoms. Symptom assessment
determined from review of progress notes
or completed patient questionnaires.
Continued care visit defined as one with a
listed diagnosis of asthma.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of asthma patients
with symptom assessment or continued
care visit
Denominator: Total number of asthma
patients
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments put this in the report, not dashboard
KPI Title Percent with assessment of
environmental triggers
KPI Description Environmental trigger assessment may
include documentation of tobacco use or
exposure. Documentation was collected
from review of progress notes, action
plans and patient questionnaires.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Percent of asthma patients
16
with records indicating an environmental
trigger
Denominator: Total number of asthma
patients
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Report. Not dashboard
KPI Title Breast cancer screening-rate for
women ages 50-69
KPI Description Rate of breast cancer screening for
women between 50-69 within the past two
years
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of women with one
or more mammograms over prior two
years
Denominator: Number of women (ages
52-69) at end of measurement period
Data Source(s) Medicaid Paid Claims
Minimum Data Set PatientID, Date of Birth, Encounter Date,
ICD-9 Code
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports
Comments Must be CA enrolled 11+ months during
the measurement year and the year prior
to measurement year. Women with
bilateral mastectomy are excluded.
KPI Title Cervical cancer screening - rate
for women ages 21-64
KPI Description Rate that women between 21-64 received
17
screening for cervical cancer in the last 3
years
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of women ages with
one or more pap smears over prior 3
years
Denominator: Number of women ages
24-64 at end of measurement period
Data Source(s) Medicaid Paid Claims
Minimum Data Set PatientID, Date of Birth, Encounter Date,
ICD-9 Code
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports
Comments Women with prior hysterectomy are
excluded.
KPI Title Colorectal screening- rate for
ages 50-75
KPI Description How often were women ages 50-75
receiving colorectal screening procedures
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with
either: FOBT within 1 year OR flex sig
within 5 years OR colonoscopy within 10
years
Denominator: Number of patients (ages
51-75) at the end of the measurement
period
Data Source(s) Medicaid Paid Claims
Minimum Data Set PatientID, Date of Birth, Encounter Date,
ICD-9 Code
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports
Comments Patients with diagnosis of colon cancer
are excluded
18
KPI Title Percent with Ischemic Vascular
Disease (IVD) using Aspirin
KPI Description Among patients with IVD, what percent of
them use aspirin
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: number of patients with
Ischemic Vascular Disease using Aspirin
Denominator: total number of patients
with IVD
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Aspirin use addressed, based on:
● Aspirin or other antiplatelet
therapy on med list or flowsheet
● Contraindication or allergy noted
● Documented discussion of
risks/benefits
KPI Title Percent with Blood Pressure less
than 140/90
KPI Description Based on most recent blood pressure
measurement (BP) documented in charts
among patients ages 18-85.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with BP <
140/90 based on most recent BP in chart
Denominator: Total number of patients in
population
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
19
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with IVD or Diabetes
Mellitus (DM) with LDL < 100
KPI Description An LDL measurement of less than 100
among qualifying patients (All IVD/CVD,
DM patients ages 18-75).
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with LDL
< 100mg/dl
Denominator: Total number of patients in
population
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with Ischemic Vascular
Disease (IVD) and lipid testing
KPI Description Lipid Panel or LDL within the past year
among qualifying patients (All IVD/CVD,
DM patients ages 18-75).
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with lipid
panel or LDL within past year
Denominator: Total number of patients
screened
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Among all ischemic vascular
20
disease/cardiovascular disease
(IVD/CVD) and Diabetes Mellitus (DM)
patients
KPI Title Percent with smoking status
documented or advice given
KPI Description Documentation that patient is non-smoker
OR documentation of cessation advice or
treatment within past year among
qualifying patients
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with
documentation that he/she is a non-
smoker or documentation of cessation
advice/treatment within past year
Denominator: Total number of patients
screened
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Among all patients with diabetes (ages
10-75) and all patients with IVD, CVD,
hypertension or heart failure (ages 18-75)
KPI Title Percent with annual visit age 2-3
met
KPI Description The percentage of patients with at least
one dental visit with a dental practitioner
among patients ages 2-3.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Number of patients ages 2-3 with at least
one dental visit with a dental practitioner
Denominator: Total number of patients
21
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with annual visit age 4-6
met
KPI Description The percentage of patients with at least
one dental visit with a dental practitioner
among patients ages 4-6.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients ages 4-6
with at least one dental visit with a dental
practitioner
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with annual visit age 7-
10 met
KPI Description The percentage patients with at least one
dental visit with a dental practitioner
among patients ages 7-10.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with at
least one dental visit with a dental
practitioner
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
22
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with annual visit age 11-
14 met
KPI Description The percentage patients with at least one
dental visit with a dental practitioner
among patients ages 11-14.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients ages 11-
14 with at least one dental visit with a
dental practitioner
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with annual visit age 15-
18 met
KPI Description The percentage patients with at least one
dental visit with a dental practitioner
among patients ages 15-18.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients ages 15-
18 with at least one dental visit with a
dental practitioner
Denominator: Total Number of Patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
23
KPI Title Percent with annual visit age 19-
21
KPI Description The percentage patients with at least one
dental visit with a dental practitioner
among patients ages 19-21.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients ages 19-
21 with at least one dental visit with a
dental practitioner
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with annual visit age 2-
21 met
KPI Description The percentage of patients with at least
one dental visit with a dental practitioner
among patients ages 2-21.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients ages 2-
21 with at least one dental visit with a
dental practitioner
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
24
KPI Title Percent with 3 or more
varnishing by 3.5
KPI Description Percent of patients with at least 3 dental
fluoride varnishing claims during first 42
months of life
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients in their
first 42 months of life with at least 3 dental
fluoride varnishing claims
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Among patients who turned 3.5 years old
during the measurement year and were
enrolled 36+ months since birth
KPI Title Percent with 4 or more
varnishing by 3.5
KPI Description Percent of patients with at least 4 dental
fluoride varnishing claims during first 42
months of life
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients in first 42
months of life with at least 4 dental
varnishing claims
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Among patients who turned 3.5 years old
during the measurement year and were
enrolled 36+ months since birth
25
KPI Title Percent with A1C result < 8.0
KPI Description Percent of patients with most recent
HbA1c < 8.0% (good control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with last
A1C result < 8.0%
Denominator: Total number of patients
with A1C screening
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with A1C result > 9.0
KPI Description Percent of patients with most recent
HbA1c > 9.0% (poor control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with last
A1C result > 9.0%
Denominator: Total number of patients
screened for A1C
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Patients with no test are counted as “poor
control”
26
KPI Title Percent with A1C testing in past
year
KPI Description Percent of patients with claim for A1c test
during the past 12 months
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with a
claim for an A1C testing in last 12 months
Denominator: Total number of patients
with claims for an A1C test
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with BP < 130/80
KPI Description Percent of patients with most recent BP <
130 systolic and < 80 diastolic (good
control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with most
recent systolic < 130 and diastolic < 80
Denominator: Total number of patients
with BP screening
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with BP > 140/90
KPI Description Percent of patients with most recent BP >
27
140 systolic or < 90 diastolic (poor
control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with most
recent BP > 140 or < 90 diastolic
Denominator: Total number of patients
with BP screening
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Patients with no test are counted as “poor
control”
KPI Title Percent with cholesterol screen
in past year
KPI Description Percent of patients with claim for LDL or
lipid panel test during past 12 months
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with
claim for LDL or lipid panel test in last
twelve months
Denominator: Total number of patients
with claim for LDL or lipid panel test
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent of Diabetes Mellitus (DM)
and Hypertension (HTN) on
ACE/ARB therapy
28
KPI Description Percent of patients who are receiving
ACE inhibitor or ARB therapy
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of DM and HTN
patients on ACE inhibitor or ARB therapy
Denominator: Total number of DM and
HTN patients
Data Source(s)
Minimum Data Set Medicaid Paid Claims
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Among patients diagnosed with HTN and
DM
KPI Title Percent with foot exam in
previous year
KPI Description Patients with any foot exam
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with foot
exam
Denominator:
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with LDL < 100
KPI Description Percent of patients with most recent LDL-
C <100 mg/dl. (Good Control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with most
recent LDL C < 100 mg/dl
Denominator: Total number of patients
29
with LDL C screening in past year
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with LDL > 130
KPI Description Percent of patients with most recent LDL-
C > 130 mg/dl. (Poor Control)
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with most
recent LDL-C > 130 mg/dl.
Denominator: Total number of patients
with recent LDL C screening
Data Source(s) Medicaid Manual Chart Abstraction
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments Patients with no test are counted as “poor
control”
KPI Title Percent with neuropathy
screening/treatment in past year
KPI Description Percent of patients screened for or
evidence of nephropathy, based on one of
the following:
● Diagnosis or treatment for
nephropathy using specific CPT
codes and ICD-9 codes
● Urine microalbumin test during
year
● ACE inhibitor/ARB therapy during
year
KPI Calculation Numerator divided by denominator
30
expressed as a percentage
Numerator: Number of patients with
evidence of nephropathy within past year
Denominator: Total number of patients
Data Source(s) Medicaid Paid Claims
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with retinal eye exam in
past 15 months
KPI Description Percent of patients with claim for eye
exam during the past 15 months
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with
retinal eye exam in past 15 months
Denominator: Total number of patients
measured
Data Source(s) Medicaid Paid Claims
Minimum Data Set Clinical Reports
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Clinical Reports
Comments
KPI Title Inpatient (IP) visit rate per 1,000
heart failure member-months
KPI Description Hospital admissions with CHF primary or
secondary diagnosis per 1000 asthma
member-months
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of hospital
admissions with CHF as primary or
secondary diagnosis
Denominator: 1000 member months
31
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent with adolescent well
child visit in previous year met
KPI Description Percent of patients who had at least one
well-care visit with a PCP or OB/GYN
practitioner in the last year
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with at
least one well-care visit in last year
Denominator: Total number of patients
measured
Data Source(s) Encounter note
Minimum Data Set Patient ID, Encounter Date, CPT Code,
Date of Birth
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments
Comments
KPI Title Percent with adolescent well
child in prior 3 years met
KPI Description Number of patients who had at least one
well-care visit with a PCP or OB/GYN
practitioner in the last 3 years
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Number of patients with at
least one well-care visit with a PCP or
OB/GYN in last 3 years
Denominator: Total number of patients
Data Source(s) Encounter note
Minimum Data Set Patient ID, Encounter Date, CPT Code,
32
Date of Birth
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Appointments
Comments
KPI Title Percent well child visits- 6 in first
15 months met
KPI Description Number of patients who had 6 or more
well-child visits during the first 15 months
of life
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation LHD
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Percent well child visits-
between ages 3-6 met
KPI Description Number of patients who received one or
more well-child visits with a PCP
practitioner
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
33
KPI Title Percent well child visits-
between ages 7-11 met
KPI Description
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Controlling High Blood Pressure
KPI Description Percentage of patients 18-85 years of
age who had a diagnosis of
hypertension and whose blood pressure
was adequately controlled
(<140/90mmHg) during the
measurement period.
KPI Rationale This measure assesses the percentage
of patients demonstrating adequate
control of systolic and diastolic blood
pressure levels. Over 50 million
Americans warrant treatment for high
blood pressure, according to the
NHANES survey (JNC 7 2003).
Financially, hypertension and
associated disorders and heath
complications, such as coronary heart
disease and congestive heart failure,
cost the U.S. economy more than $100
billion each year. The United States
Preventive Services Task Force
(USPSTF) recommends that clinicians
screen adults 18 and older for high
blood pressure (2007). This guideline is
further endorsed by research studies
34
and clinical trials that have
demonstrated decline in costly health
outcomes as a direct result of improved
blood pressure control. This measure is
important in efforts to promote blood
pressure control and improve quality of
life.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Use of High-Risk Medications In
the Elderly
KPI Description Percentage of patients 66 years of age
and older who were ordered high-risk
medications. Two rates are reported.
● Percentage of patients who were
ordered at least one high-risk
medication.
● Percentage of patients who were
ordered at least two different
high-risk medications.
KPI Rationale Certain medications are associated with
increased risk of harms from drug side-
effects and drug toxicity and pose a
concern for patient safety. There is
clinical consensus that these drugs
pose increased risks in the elderly.
Studies link prescription drug use by the
elderly with adverse drug events that
contribute to hospitalization, increased
length of hospital stay, increased
duration of illness, nursing home
35
placement and falls and fractures that
are further associated with physical,
functional and social decline in the
elderly.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
Rationale from qualityforum.org
KPI Title Preventive Care and Screening:
Tobacco Use: Screening and
Cessation Intervention
KPI Description Percentage of patients aged 18 years
and older who were screened for
tobacco use one or more times within 24
months AND who received cessation
counseling intervention if identified as a
tobacco user.
KPI Rationale There is good evidence that tobacco
screening and brief cessation
intervention (including counseling and
pharmacotherapy) in the primary care
setting is successful in helping tobacco
users quit. Tobacco users who are able
to stop smoking lower their risk for heart
disease, lung disease and stroke.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
36
Comments
https://www.auanet.org/common/pdf/practices-resources/quality/pqrs-
toolkit/2013TobaccoUse.pdf
KPI Title Use of Imaging Studies For Low
Back Pain
KPI Description Percentage of patients 18-50 years of
age with a diagnosis of low back pain
who did not have an imaging study (plain
X-ray, MRI, CT scan) within 28 days of
the diagnosis.
KPI Rationale This measure assesses the percentage of
patients in a specific age demographic
who did not receive an imaging study
(i.e., x-ray, MRI, CT scan) in the 28 days
following a new episode of low back pain.
Low back pain is the second most
frequently listed reason for physician
office visits. It is a common cause of lost
productivity and absenteeism from work
in the United States. The general
consensus from literature reviews
indicates that nearly half of American
adults will experience low back pain in a
year, and about two-thirds will suffer from
it in their lifetime. Low back pain is
particularly prevalent among men and
women between 30 and 50 years of age,
and most likely results from aging and an
inactive lifestyle. Low back pain has a
significant financial impact, costing an
average of $8,000 per claim (Atlas, Devo
2001). This measure facilitates efforts
toward improved musculoskeletal
condition and individual quality of life.
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator:
Denominator:
Data Source(s)
Minimum Data Set N/A
37
Dashboard Update Frequency N/A
KPI Reporting Aggregation
KPI is reported in which reports NOT REPORTED ON DASHBOARD
Comments
KPI Title Payor Mix by Program
KPI Description
KPI Calculation Numerator divided by denominator
expressed as a percentage
Numerator: Charges assigned to a
specific Payor within each Program
Denominator: Total Charges within each
Program
Data Source(s) Billing
Minimum Data Set Insurance Type, Encounter Date, Units,
Charges, Program
Dashboard Update Frequency Weekly
KPI Reporting Aggregation LHD
KPI is reported in which reports Financial Reports
Comments
Asthma-
● Percent with action plan
● % with beta agonist overuse
● Emergency Department (ED) visits per asthma member-months
● Inpatient (IP) visits per 1,000 asthma member-months
● % with Symptom assessment/continuous care visit
● % with assessment of triggers
Cancer Screening
● Cervical cancer screening rate for females ages 21-64
● Colorectal screening rate for ages 50-75
Cardiovascular
● % with Ischemic Vascular Disease (IVD) taking Aspirin
● % with Blood Pressure (BP) < 140/90
● % Ischemic Vascular Disease (IVD) or Diabetes mellitus (DM) with LDL < 100
● % with Ischemic Vascular Disease (IVD) and lipid testing
● % with smoking status documented or advice given
Dental Care
● % with annual visit age 2-3 met
38
● % with annual visit age 4-6 met
● % with annual visit age 7-10 met
● % with annual visit 11-14 met
● % with annual visit 15-18 met
● % with annual visit 19-21 net
● % with annual visit 2-21 met
● % with 3 or more varnishing by 3.5
● % with 4 or more varnishing by 3.5
Diabetes
● % with A1C result < 8.0
● % with A1C result > 9.0
● % with A1C testing in past year
● % Blood Pressure (BP) < 130/80
● % Blood Pressure (BP) > 140/90
● % with cholesterol screen in past year
● % of Diabetes mellitus (DM) and Hypertension (HTN) on ACE/ARB therapy
● % with foot exam in previous year
● % with LDL < 100
● % with LDL > 130
● % with neuropathy screening/treatment in past year
● % with retinal eye exam in past 15 months
Heart Failure
● Inpatient (IP) Visit rate per 1,000 heart failure member-months
Pediatric
● % with adolescent well child visit in previous year met
● % with adolescent well child visit in prior 3 years met
● % with well child visits – 6 in first 15 months met
● % with well child visits – between ages 3-6 met
● % with well child visits – between ages 7-11 met
?????
http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_AdultRecommend_Core
SetTable.pdf