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

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