OUR 2019 MEASURES
SaferMD offers two registries:
The SaferMD Qualified Registry, offering all of the standard CMS MIPS measures. This registry may be used by every specialty.
The SaferMD Qualified Clinical Data Registry (QCDR) offers exclusive measures for radiologists, and all of the standard CMS MIPS measures.
SaferMD 2019 QCDR Measures
Critical Result: Pulmonary Embolism
MEASURE ID: NJIISMD1
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Pulmonary Embolism diagnosed on radiology exams
MEASURE TITLE: Critical Result: Pulmonary Embolism
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Pulmonary Embolism
NUMERATOR: Number of exams a radiologist interprets indicating pulmonary embolism that were reported to the ordering clinician within 40 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Aortic Dissection
MEASURE ID: NJIISMD3
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Aortic Dissection diagnosed on radiology exams
MEASURE TITLE: Critical Result: Aortic Dissection
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Aortic Dissection
NUMERATOR: Number of exams a radiologist interprets indicating Aortic Dissection that were reported to the ordering clinician within 15 minutes minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Placental Abruption
MEASURE ID: NJIISMD9
MEASURE DESCRIPTION: Efficiency of
Reporting Critical Result: Placental abruption diagnosed on radiology exams
MEASURE TITLE: Critical Result: Placental Abruption
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Placental abruption
NUMERATOR: Number of exams a radiologist interprets indicating placental abruption that were reported to the ordering clinician within 20 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Result Requiring Follow Up Protocol
MEASURE ID: NJIISMD17
MEASURE DESCRIPTION: Timeliness of notification in cases of diagnostic exams when there is a recommendation to obtain a follow up exam
MEASURE TITLE: Result Requiring Follow Up Protocol
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Transfer of health information and interoperability
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that require follow up exams
NUMERATOR: Number of diagnostic exams a radiologist interprets indicating a result requiring follow up when the referring clinician is notified within 36 hours of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: CTA of GI bleed
MEASURE ID: NJIISMD20
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: CTA of GI bleed
MEASURE TITLE: Critical Result: GI bleed diagnosed on CT Angiogram exams
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of CT Angiogram exams a radiologist interprets that demonstrate GI Bleed
NUMERATOR: Number of CT Angiogram exams a radiologist interprets that demonstrate GI Bleed that were reported to the referring clinician within 25 minutes of exam completion.
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Acute Ocular Injury
MEASURE ID: NJIISMD22
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Acute Ocular Injury diagnosed on radiology exams
MEASURE TITLE: Critical Result: Acute Ocular Injury
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Acute Ocular Injury
NUMERATOR: Number of trauma exams a radiologist interprets indicating Acute Ocular Injury that were reported to the ordering clinician within 30 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Testicular Torsion
MEASURE ID: SMD24
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Testicular Torsion
MEASURE TITLE: Critical Result: Testicular Torsion
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Testicular Torsion
NUMERATOR: Number of imaging exams interpreted indicating testicular torsion that were reported to the ordering clinician within 15 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
GI Radiography Result Notification
MEASURE ID: SMD26
CRITICAL RESULT: BOWEL OBSTRUCTION
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Bowel Obstruction
MEASURE TITLE: Critical Result: Bowel Obstruction
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted indicating Bowel Obstruction
NUMERATOR: Number of imaging exams interpreted indicating bowel obstruction that were reported to the ordering clinician within 15 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD26
CRITICAL RESULT: SIGMOID VULVULUS
MEASURE DESCRIPTION:Efficiency of reporting radiographic findings of Sigmoid Volvulus
MEASURE TITLE: Critical Result: Sigmoid Volvulus
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Sigmoid Volvulus
NUMERATOR: Number of imaging exams interpreted indicating sigmoid volvulus that were reported to the ordering clinician within 15 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD26
CRITICAL RESULT: PNEUMOPERITONEUM
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of pneumoperitoneum
MEASURE TITLE: Critical Result: Pneumoperitoneum
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate pneumoperitoneum
NUMERATOR: Number of imaging exams interpreted indicating pneumperitoneum that were reported to the ordering clinician within 30 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Musculoskeletal Radiology Result Notification
MEASURE ID: SMD28
CRITICAL RESULT: C-SPINE FRACTURE
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of C-Spine fractureMEASURE TITLE: Critical Result: C-Spine fracture
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Fracture C-Spine
NUMERATOR: Number of imaging exams interpreted indicating cervical spine fracture that were reported to the ordering clinician within 10 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD28
CRITICAL RESULT: RIB FRACTURE
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of rib fracture
MEASURE TITLE: Critical Result: Rib fracture
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate rib fracture
NUMERATOR: Number of imaging exams interpreted indicating rib fracture that were reported to the ordering clinician within 25 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD28
URGENT RESULT: OSTEOMYELITIS
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of osteomyelitis
MEASURE TITLE: Urgent Result: Osteomyelitis
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Osteomyelitis
NUMERATOR: Number of imaging exams interpreted indicating osteomyelitis that were reported to the ordering clinician within 90 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD28
URGENT RESULT: MENISCAL TEAR
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of meniscal tear
MEASURE TITLE: Urgent Result: Meniscal tear
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Meniscal Tear
NUMERATOR: Number of imaging exams interpreted indicating menisceal tear that were reported to the ordering clinician within 6 hours of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Aortic Aneurism Result Notification
MEASURE ID: SMD30
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Aortic Aneurism
MEASURE TITLE: Aortic Aneurism Result Notification
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Aortic Aneurism
NUMERATOR: Number of imaging exams interpreted indicating aortic aneurism that were reported to the ordering clinician within 30 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Pathology Peer Review Duration (composite measure)
MEASURE ID: SMD32
MEASURE DESCRIPTION: Pathologists review peer review exams from a review queue. This measure evaluates pathologists’ performance initiating the peer review process
MEASURE TITLE: Pathology Peer Review Duration (composite measure)
Strata:
-Breast cancer
-Lung cancer
-Melanoma
-Colorectal cancer
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of peer review cases evaluated by the pathologist
NUMERATOR: Percentage of cases in which the pathologist peer completes 15 minutes or less after it appears on the exam queue
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Image Guided Lung Biopsy Complication Rate
MEASURE ID: SMD34
MEASURE DESCRIPTION: Frequency of complications following imaging guided percutaneous lung biopsies
MEASURE TITLE: Image Guided Lung Biopsy Complication Rate
NQS Domain: Patient Safety
MEASURE TYPE: Outcome
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging guided percutaneous lung biopsies performed
NUMERATOR: Number of pnemothoraces and other complications following imaging guided percutaneous lung biopsies
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: Yes
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Intracranial Hemorrhage
MEASURE ID: NJIISMD2
MEASURE DESCRIPTION: Efficiency of reporting Intracranial Hemorrhage diagnosed on radiology exams
MEASURE TITLE: Critical Result: Intracranial Hemorrhage
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate ICH
NUMERATOR: Number of exams a radiologist interprets indicating Intracranial hemorrhage that were reported to the ordering clinician within 35 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Occlusive Intracranial Stroke
MEASURE ID: NJIISMD8
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Occlusive intracranial stroke diagnosed on radiology exams
MEASURE TITLE: Critical Result: Occlusive Intracranial Stroke
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Occlusive intracranial stroke
NUMERATOR: Number of exams a radiologist interprets indicating occlusive intracranial stroke that were reported to the ordering clinician within 30 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: New Deep Venous Thrombosis (DVT)
MEASURE ID: NJIISMD11
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: New DVT diagnosed on radiology exams
MEASURE TITLE: Critical Result: New Deep Venous Thrombosis (DVT)
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate New DVT
NUMERATOR: Number of exams a radiologist interprets indicating a new deep venous thrombosis (DVT) that were reported to the ordering clinician within 16 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Cord Compression
MEASURE ID: NJIISMD19
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Cord Compression diagnosed on radiology exams
MEASURE TITLE: Critical Result: Cord Compression
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic exams a radiologist interprets that demonstrate Cord Compression
NUMERATOR: Number of exams a radiologist interprets indicating Cord Compression that were reported to the ordering clinician within 40 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Positive Nuclear Bleeding Scan
MEASURE ID: NJIISMD21
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Cord Compression diagnosed on radiology exams
MEASURE TITLE: Critical Result: Positive Nuclear Bleeding Scan
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of times a radiologist interprets a positive nuclear bleeding scan
NUMERATOR: Number of times a radiologist interprets indicating positive nuclear bleeding scan that were reported to the ordering clinician within 40 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Urgent Result: Breast Specimen Radiography
MEASURE ID: SMD23
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Breast Specimen Radiography
MEASURE TITLE: Urgent Result: Breast Specimen Radiograph
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of Breast Specimen Radiography exams interpreted
NUMERATOR: Number of breast specimen radiography exams interpreted that were reported to the ordering clinician within 20 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Critical Result: Subdural hematoma
MEASURE ID: SMD25
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Subdural hematoma
MEASURE TITLE: Critical Result: Subdural hematoma
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted that indicate Subdural hematoma
NUMERATOR: Number of imaging exams interpreted indicating subdural hematoma that were reported to the ordering clinician within 15 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Chest Imaging Result Notification
MEASURE ID: SMD27
CRITICAL RESULT: PNEUMOTHORAX
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Pneumothorax
MEASURE TITLE: Critical Result: Pneumothorax
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted indicating pneumothorax
NUMERATOR: Number of imaging exams interpreted indicating pneumothorax that were reported to the ordering clinician within 30 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD27
CRITICAL RESULT: TENSION PNEUMOTHORAX
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Tension Pneumothorax
MEASURE TITLE: Critical Result: Tension Pneumothorax
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted indicating tension pneumothorax
NUMERATOR: Number of imaging exams interpreted indicating tension pneumothorax that were reported to the ordering clinician within 25 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD27
FOLLOW UP RESULT: SUSPICIOUS LUNG NODULE
MEASURE DESCRIPTION: Efficiency of reporting radiographic findings of Suspicious Lung Nodule
MEASURE TITLE: Follow Up Result: Suspicious Lung Nodule
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging exams interpreted indicating a suspicious lung nodule
NUMERATOR: Number of imaging exams interpreted indicating a suspicious lung nodule that were reported to the ordering clinician within 2.5 hours of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Incidental Finding Closed Loop Work Up Rate
MEASURE ID: SMD29
MEASURE DESCRIPTION: When radiologists discover imaging exam findings that require additional workup, how often did the follow up exam take place?
MEASURE TITLE: Incidental Finding Closed Loop Work Up Rate
NQS Domain: Communication and Care Coordination
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Appropriate use of Healthcare
NQF NUMBER: Not applicable
DENOMINATOR: Number of exams in which a radiologist discovers a finding that requires follow up with an additional procedure
NUMERATOR: Number of exams in which a radiologist discovers a finding that requires follow up with an additional procedure AND the required follow up procedure takes place
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: No
CONTINUOUS VARIABLE: Yes
RATIO MEASURE INDICATOR: No
Ectopic Pregnancy Critical Results
MEASURE ID: SMD31
CRITICAL RESULT: RUPTURED ECTOPIC PREGNANCY
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Ruptured ectopic pregnancy diagnosed on radiology exams
MEASURE TITLE: Critical Result: Ruptured Ectopic Pregnancy
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic imaging exams a radiologist interprets that demonstrate Ruptured ectopic pregnancy
NUMERATOR: Number of exams a radiologist interprets indicating Ruptured ectopic pregnancy that were reported to the ordering clinician within 10 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
MEASURE ID: SMD31
CRITICAL RESULT: ECTOPIC PREGNANCY
MEASURE DESCRIPTION: Efficiency of reporting Critical Result: Ectopic Pregnancy diagnosed on radiology exams
MEASURE TITLE: Critical Result: Ectopic Pregnancy
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of diagnostic imaging exams a radiologist interprets that demonstrate Ectopic Pregnancy
NUMERATOR: Number of exams a radiologist interprets indicating ectopic pregnancy that were reported to the ordering clinician within 15 minutes of exam completion
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Radiology Peer Review Duration (composite measure)
MEASURE ID: SMD33
MEASURE DESCRIPTION: Radiologists review peer review exams from a review queue. This measure evaluates radiologists’ performance initiating the peer review process
MEASURE TITLE: Radiology Peer Review Duration (composite measure)
Strata:
-Pneumonia
-Pulmonary nodule
-Pulmonary embolism
-Stroke
-Intracranial hemorrhage
NQS Domain: Patient Safety
MEASURE TYPE: Process
MEANINGFUL MEASURE AREA: Preventable Healthcare harm
NQF NUMBER: Not applicable
DENOMINATOR: Number of peer review cases evaluated by the radiologist
NUMERATOR: Percentage of cases in which the radiologist peer completes 15 minutes or less after it appears on the exam queue
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: No
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No
Thyroid biopsy - percentage of non-diagnostic samples
MEASURE ID: SMD35
MEASURE DESCRIPTION: What percentage of image guided thyroid biopsies were non-diagnostic?
MEASURE TITLE: Thyroid biopsy – percentage of non-diagnostic samples
NQS Domain: Effective Clinical Care
MEASURE TYPE: Outcome
MEANINGFUL MEASURE AREA: Appropriate use of Healthcare
NQF NUMBER: Not applicable
DENOMINATOR: Number of imaging guided thyroid biopsies performed
NUMERATOR: Number of percutaneous imaging guided thyroid biopsies that result in non-didagnostic samples
DENOMINATOR EXCEPTIONS: None
DENOMINATOR EXCLUSIONS: None
RISK ADJUSTED: No
PERFORMANCE RATES: 1
HIGH PRIORITY STATUS: Yes
INVERSE MEASURE: Yes
PROPORTIONAL: Yes
CONTINUOUS VARIABLE: No
RATIO MEASURE INDICATOR: No