OUR 2020 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 2020 QCDR Measures

Timely Gastrointestinal Radiology Result Notification

MEASURE ID : SMD26

MEASURE TITLE : Timely Gastrointestinal Radiology Result Notification

MEASURE DESCRIPTION: Percentage of gastrointestinal (GI) imaging exams that were reported to the referring provider within the appropriate timeframe based on the findings

NQS DOMAIN: Patient Safety

MEASURE TYPE: Process

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

STRATUM 1: Bowel obstruction

Denominator: Imaging exams with a finding of bowel obstruction

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

STRATUM 2: Sigmoid Volvulus

Denominator: Imaging exams with a finding of sigmoid volvulus

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

STRATUM 3: Pneumoperitoneum

Denominator: Imaging exams with a finding of pneumoperitoneum

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Patient Safety

RATIO MEASURE: No

Timely Radiology Peer Review

MEASURE ID:  SMD33

MEASURE TITLE: Timely Radiology Peer Review

MEASURE DESCRIPTION: Percentage of radiology peer review cases that were completed within 15 minutes following its appearance in the exam queue

NQS DOMAIN: Patient Safety

MEASURE TYPE: Process

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

DENOMINATOR: Radiology peer review cases completed

NUMERATOR: Cases that were completed within 15 minutes of its appearance in the exam queue

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Patient Safety

RATIO MEASURE: No

Timely Aorta Result Notification

MEASURE ID:  SMD37

MEASURE TITLE : Timely Aorta Result Notification

MEASURE DESCRIPTION: Aorta findings notification

NQS DOMAIN: Patient Safety

MEASURE TYPE: Process

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

STRATUM 1: Aortic Dissection

Denominator: Diagnostic exams with a finding of aortic dissection

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

STRATUM 2: Aortic Aneurism

Denominator: Imaging exams with a finding of aortic aneurism

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Patient safety

RATIO MEASURE: No

Effective Image Guided Biopsies

MEASURE ID:  SMD39

MEASURE TITLE: Effective Image Guided Biopsies

MEASURE DESCRIPTION: Image guided Biopsy performance 

NQS DOMAIN: Patient Safety

MEASURE TYPE: Outcome

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

STRATUM 1: Percutaneous lung biopsies

DENOMINATOR: Imaging guided percutaneous lung biopsies performed

NUMERATOR: Number of pnemothoraces and other complications within 24 hours following imaging guided percutaneous lung biopsies

STRATUM 2: Thyroid biopsies

DENOMINATOR: Imaging guided thyroid biopsies performed

NUMERATOR: Biopsies that result in non-diagnostic samples

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: Yes

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Outcome

RATIO MEASURE: No

Timely Pathology Peer Review

MEASURE ID:  SMD32

MEASURE TITLE: Timely Pathology Peer Review

MEASURE DESCRIPTION: Percentage of pathology peer review cases that were completed within 15 minutes following its appearance in the exam queue

NQS DOMAIN: Patient Safety

MEASURE TYPE: Process

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

DENOMINATOR: Pathology peer review cases completed

NUMERATOR: Cases that were completed within 15 minutes of its appearance in the exam queue

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Patient Safety

RATIO MEASURE: No

Timely Notification of Diagnostic Exams That Require Follow-up

MEASURE ID: SMD36

MEASURE TITLE: Timely Notification of Diagnostic Exams That Require Follow-up

MEASURES DESCRIPTION: Incidental finding workups

NQS DOMAIN: Effective Clinical Care

MEASURE TYPE: Intermediate Outcome

MEANINGFUL MEASURE AREA: Transfer of Health Information and Interoperability

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

STRATUM 1: Diagnostic exams require follow-up

Denominator: Diagnostic exams interpreted with a finding that requires follow-up

Numerator: Exams in which the referring clinician is notified within 36 hours of exam completion

STRATUM 2: Results require additional procedure

Denominator: Exams in which the results yield a finding that requires an additional procedure
Numerator: Exams in which the required follow up procedure was completed

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Outcome

RATIO MEASURE: No

Timely Vascular Ultrasound Result Notification

MEASURE ID:  SMD38

MEASURE TITLE: Timely Vascular Ultrasound Result Notification

MEASURE DESCRIPTION: Vascular ultrasound emergency notification performance

NQS DOMAIN: Patient Safety

MEASURE TYPE: Process

MEANINGFUL MEASURE AREA: Preventable Healthcare Harm

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

STRATUM 1: New DVT

Denominator: Diagnostic exams with a finding of a new DVT

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

STRATUM 2: Testicular torsion

Denominator: Diagnostic exams with a finding of testicular torsion

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

STRATUM 3: Ovarian torsion

Denominator: Diagnostic exams with a finding of ovarian torsion

Numerator: Exams that were reported to the referring provider within 15 minutes of exam completion

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Patient Safety

RATIO MEASURE: No

Optimized Thrombolysis in Ischemic Stroke

MEASURE ID:  SMD40

MEASURE TITLE: Optimized Thrombolysis in Ischemic Stroke

MEASURE DESCRIPTION: Degree of revascularization following intervention for ischemic stroke

NQS DOMAIN: Effective Clinical Care

MEASURE TYPE: Intermediate Outcome

MEANINGFUL MEASURE AREA: Functional Outcomes

NATIONAL QUALITY FORUM (NQF) NUMBER: N/A

DENOMINATOR: Neuro-interventional revascularization procedures performed for ischemic stroke

NUMERATOR: Interventions in which TICI2B level re-perfusion is achieved

DENOMINATOR EXCEPTIONS: None

DENOMINATOR EXCLUSIONS: None

NUMERATOR EXCLUSIONS: None

RISK ADJUSTED: No

PERFORMANCE RATES REQUIRED: 1

HIGH PRIORITY STATUS: Yes

INVERSE MEASURE: No

PROPORTIONAL MEASURE: Yes

CONTINUOUS VARIABLE MEASURE: No

HIGH PRIORITY TYPE: Outcome

RATIO MEASURE: No 

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