Hypertension: Improvement in Blood Pressure

eCQM / NQF #: CMS65v7 / XXXX
Measure: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
Numerator: Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled. If a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed "not improved."
Denominator: All patients aged 18-85 years of age, who had at least one outpatient visit in the first six months of the measurement year, who have a diagnosis of essential hypertension documented during that outpatient visit, and who have uncontrolled baseline blood pressure at the time of that visit.
Denominator Exclusions: Exclude from the denominator all patients with evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year. Documentation of dialysis or kidney transplant also meets the criteria for evidence of ESRD. Exclude from the denominator all patients with a diagnosis of pregnancy during the measurement year. Exclude patients who were in hospice care during the measurement year.
Domain: Effective Clinical Care


In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the patient, age 18-84 years, at least two times (within the first 6 months and last 6 months of the measurement period) during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator: 

Required Data Elements for the Numerator: 

EXCLUSION DETAILS: 

This measure makes an exclusion for patients who have evidence of end-stage renal disease (including documentation of a kidney transplant or dialysis) on or before December 31st of the measurement year.  There is also an exclusion for all patients who have a diagnosis of pregnancy OR were in hospice care during the measurement year.

In order to meet the requirements for this exclusion, the appropriate information must be documented in the chart (at least one of the following):

ADDITIONAL INFORMATION:

•  The patient must be of the appropriate specified age (>= 18 and < 85) prior to the start of the measurement period.

• Blood pressure readings must be taken while the patient is sitting. If multiple measurements occur on the same date, the last systolic and diastolic readings should be used.

•  If a follow-up blood pressure reading is not recorded during the measurement year, the patient’s blood pressure is assumed “not improved.”

•  The systolic blood pressure change should be 10mmHg less than the patient's baseline (first visit) systolic blood pressure

If using a SNOMED code for the Kidney Transplant Exclusion Code, it must be attached to a procedure code (other than the office code) in order to count in the exclusion.

•  The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.