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Stigler Health Wellness Center, Inc.Meaningful Use - Clinical Measures

01/01/2016 - 12/31/2016

Measure Domain Provider Den Num Rate Goal PagesCurrent

ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Anderson 772 539 80.81% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Anderson 669 189 35.86% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Anderson 229 134 58.52% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Anderson 64 41 64.06% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Anderson 146 61 41.78% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Anderson 398 88 22.34% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Anderson 41 13 31.71% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Anderson 61 40 65.57% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Anderson 88 81 92.05% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Anderson 47 6 12.77% 28%CQM-68 Documentation of Current Medications PS Anderson 1267 1243 98.11% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Anderson 3 3 100.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Anderson 676 625 93.14% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Anderson 106 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Anderson 107 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Anderson 125 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Anderson 338 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Anderson 338 2 0.59% 0%CQM-82 Maternal Depression Screening PH Anderson 5 0 0.00% 0%CQM-117 Childhood Immunization Status PH Anderson 18 0 0.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Anderson 57 15 26.32% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Anderson 57 52 91.23% 55% 55%CQM-124 Cervical Cancer Screening CE Anderson 401 237 72.04% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Anderson 194 95 49.48% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Anderson 5 3 60.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Anderson 1 1 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Anderson 6 4 66.67% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Anderson 3 1 33.33% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Anderson 16 3 42.86% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Anderson 16 2 28.57% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Anderson 151 66 44.00% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Anderson 57 34 59.65% 18% 18%CQM-134 Diabetes: Urine Screening CE Anderson 57 53 92.98% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Anderson 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Anderson 14 1 50.00% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Anderson 13 1 50.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Anderson 454 4 0.99% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Anderson 454 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Anderson 38 2 6.67% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Anderson 38 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Anderson 416 2 0.54% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Anderson 416 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Anderson 307 304 99.02% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Anderson 3 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Anderson 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Anderson 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Anderson 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Anderson 22 14 66.67% 39%CQM-147 Influenza Immunization PH Anderson 87 5 5.81% 10% 10%CQM-149 Dementia: Cognitive Assessment CE Anderson 2 2 100.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Anderson 23 2 8.70% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Anderson 16 3 18.75% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Anderson 39 5 12.82% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Anderson 31 1 14.29% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Anderson 234 233 99.57% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Anderson 234 195 83.33% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Anderson 234 179 76.50% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Anderson 147 146 99.32% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Anderson 147 123 83.67% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Anderson 147 117 79.59% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Anderson 87 87 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Anderson 87 72 82.76% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Anderson 87 62 71.26% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Anderson 3 2 66.67% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Anderson 3 1 33.33% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Anderson 32 19 61.29% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Anderson 50 31 63.27% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Anderson 50 23 46.94% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Anderson 53 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Anderson 57 10 17.54% 24% 24%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-164 IVD: Aspirin/Antithrombotic Therapy CE Anderson 9 9 100.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Anderson 134 65 48.51% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Anderson 42 41 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Anderson 57 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Anderson 11 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Anderson 9 5 55.56% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Anderson 9 3 33.33% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Blome 992 561 66.23% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Blome 865 242 38.72% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Blome 290 173 59.66% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Blome 135 66 48.89% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Blome 219 64 29.22% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Blome 456 124 27.25% 27% 26%CQM-62 HIV/AIDS: Medical Visit CE Blome 2 0 0.00% 33%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Blome 66 21 31.82% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Blome 64 40 62.50% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Blome 124 111 89.52% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Blome 93 20 21.51% 28%CQM-68 Documentation of Current Medications PS Blome 1780 1771 99.49% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Blome 10 6 60.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Blome 875 469 53.66% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Blome 119 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Blome 104 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Blome 140 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Blome 363 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Blome 363 4 1.10% 0%CQM-82 Maternal Depression Screening PH Blome 8 0 0.00% 0%CQM-117 Childhood Immunization Status PH Blome 15 0 0.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Blome 124 21 16.94% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Blome 124 96 77.42% 55% 55%CQM-124 Cervical Cancer Screening CE Blome 494 261 66.08% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Blome 283 137 48.75% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Blome 5 4 80.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Blome 2 2 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Blome 7 6 85.71% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Blome 8 2 25.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Blome 20 11 100.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Blome 20 11 100.00% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Blome 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Blome 265 95 35.85% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Blome 124 22 17.74% 18% 18%CQM-134 Diabetes: Urine Screening CE Blome 124 107 86.29% 88% 88%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-135 Heart Failure: ACE/ARB for LVSD CE Blome 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Blome 13 1 50.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Blome 12 1 50.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Blome 815 1 0.14% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Blome 815 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Blome 92 1 1.25% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Blome 92 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Blome 723 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Blome 723 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Blome 428 424 99.07% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Blome 8 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Blome 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Blome 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Blome 1 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Blome 32 0 0.00% 39%CQM-147 Influenza Immunization PH Blome 407 25 6.22% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Blome 35 2 5.71% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Blome 16 2 12.50% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Blome 51 4 7.84% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Blome 33 0 0.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Blome 239 238 99.58% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Blome 239 78 32.64% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Blome 239 67 28.03% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Blome 140 140 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Blome 140 50 35.71% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Blome 140 44 31.43% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Blome 99 98 98.99% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Blome 99 28 28.28% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Blome 99 23 23.23% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Blome 8 3 37.50% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Blome 8 1 12.50% 1% 1%CQM-159 Depression Remission at Twelve Months CE Blome 20 1 5.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Blome 57 26 45.61% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Blome 58 22 38.60% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Blome 54 23 43.40% Not Set -- 55%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-161 Adult MDD: Suicide Risk Assessment CE Blome 10 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Blome 124 19 15.32% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Blome 21 16 76.19% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Blome 245 122 49.80% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Blome 39 37 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Blome 37 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Blome 6 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Blome 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Blome 21 8 38.10% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Blome 21 4 19.05% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Broadway 955 212 40.08% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Broadway 718 130 21.45% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Broadway 202 101 50.00% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Broadway 50 30 60.00% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Broadway 209 29 13.88% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Broadway 411 75 18.29% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Broadway 30 6 20.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Broadway 29 18 62.07% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Broadway 75 68 90.67% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Broadway 34 9 26.47% 28%CQM-68 Documentation of Current Medications PS Broadway 2152 2134 99.16% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Broadway 6 3 50.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Broadway 731 350 47.95% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Broadway 41 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Broadway 267 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Broadway 223 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Broadway 531 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Broadway 531 0 0.00% 0%CQM-122 Diabetes: HbA1c Poor Control PH Broadway 41 11 26.83% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Broadway 41 23 56.10% 55% 55%CQM-124 Cervical Cancer Screening CE Broadway 441 143 44.00% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Broadway 235 80 34.19% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Broadway 4 3 75.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Broadway 2 1 50.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Broadway 3 3 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Broadway 9 7 77.78% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Broadway 5 0 0.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Broadway 79 48 97.96% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Broadway 79 46 93.88% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Broadway 182 48 26.37% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Broadway 41 11 26.83% 18% 18%CQM-134 Diabetes: Urine Screening CE Broadway 41 31 75.61% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Broadway 147 6 46.15% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Broadway 134 5 41.67% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Broadway 247 0 0.00% 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Broadway 247 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Broadway 33 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Broadway 33 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Broadway 214 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Broadway 214 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Broadway 538 445 82.71% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Broadway 5 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Broadway 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Broadway 1 0 0.00% 80%CQM-147 Influenza Immunization PH Broadway 655 24 3.71% 10% 10%CQM-149 Dementia: Cognitive Assessment CE Broadway 5 2 40.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Broadway 16 2 12.50% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Broadway 8 1 12.50% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Broadway 24 3 12.50% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Broadway 1 1 100.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Broadway 466 464 99.57% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Broadway 466 80 17.17% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Broadway 466 67 14.38% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Broadway 260 259 99.62% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Broadway 260 46 17.69% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Broadway 260 41 15.77% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Broadway 206 205 99.51% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Broadway 206 34 16.50% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Broadway 206 26 12.62% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Broadway 5 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Broadway 5 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Broadway 21 0 0.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Broadway 213 74 35.24% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Broadway 228 69 30.53% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Broadway 164 24 14.81% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Broadway 88 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Broadway 41 5 12.20% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Broadway 10 5 50.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Broadway 114 50 43.86% 70% 35 54% 54%CQM-169 Bipolar & Depression: AOD Appraisal CE Broadway 150 0 0.00% Not Set -- 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Broadway 313 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Broadway 10 6 60.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Broadway 10 2 20.00% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Butler 865 577 75.92% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Butler 698 274 46.36% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Butler 396 170 42.93% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Butler 54 40 74.07% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Butler 153 67 44.08% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Butler 410 118 28.99% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Butler 40 12 30.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Butler 67 41 61.19% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Butler 119 107 90.68% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Butler 10 0 0.00% 28%CQM-68 Documentation of Current Medications PS Butler 1243 1225 98.55% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Butler 7 6 85.71% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Butler 709 537 76.82% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Butler 129 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Butler 165 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Butler 186 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Butler 480 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Butler 480 1 0.21% 0%CQM-82 Maternal Depression Screening PH Butler 8 0 0.00% 0%CQM-117 Childhood Immunization Status PH Butler 25 0 0.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Butler 43 20 46.51% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Butler 43 34 79.07% 55% 55%CQM-124 Cervical Cancer Screening CE Butler 361 167 59.86% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Butler 165 59 36.20% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Butler 5 3 60.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Butler 1 1 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Butler 6 4 66.67% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Butler 6 0 0.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Butler 12 7 100.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Butler 12 7 100.00% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Butler 155 52 33.55% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Butler 43 12 27.91% 18% 18%CQM-134 Diabetes: Urine Screening CE Butler 43 38 88.37% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Butler 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Butler 7 0 0.00% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Butler 7 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Butler 184 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Butler 184 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Butler 19 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Butler 19 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Butler 165 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Butler 165 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Butler 303 301 99.34% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Butler 6 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Butler 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Butler 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Butler 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Butler 23 11 61.11% 39%CQM-147 Influenza Immunization PH Butler 0 0 0.00% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Butler 44 8 18.18% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Butler 24 9 37.50% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Butler 68 17 25.00% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Butler 21 8 88.89% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Butler 334 332 99.40% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Butler 334 189 56.59% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Butler 334 172 51.50% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Butler 194 194 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Butler 194 116 59.79% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Butler 194 108 55.67% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Butler 140 138 98.57% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Butler 140 73 52.14% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Butler 140 64 45.71% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Butler 6 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Butler 6 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Butler 14 7 50.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Butler 52 37 74.00% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Butler 69 54 79.41% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Butler 7 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Butler 43 9 20.93% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Butler 12 9 75.00% 90% 51 75%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-165 Controlling High Blood Pressure CE Butler 94 45 47.87% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Butler 47 47 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Butler 54 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Butler 7 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Butler 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Butler 12 11 91.67% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Butler 12 5 41.67% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Campbell 664 122 22.43% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Campbell 580 204 47.55% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Campbell 243 142 58.44% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Campbell 82 42 51.22% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Campbell 175 35 20.00% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Campbell 270 70 26.02% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Campbell 42 17 40.48% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Campbell 35 21 60.00% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Campbell 71 59 84.29% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Campbell 35 7 20.00% 28%CQM-68 Documentation of Current Medications PS Campbell 1261 1254 99.44% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Campbell 19 6 31.58% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Campbell 576 177 30.84% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Campbell 62 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Campbell 65 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Campbell 111 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Campbell 238 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Campbell 238 1 0.42% 0%CQM-82 Maternal Depression Screening PH Campbell 5 0 0.00% 0%CQM-117 Childhood Immunization Status PH Campbell 9 1 11.11% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Campbell 68 21 30.88% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Campbell 68 20 29.41% 55% 55%CQM-124 Cervical Cancer Screening CE Campbell 263 131 68.95% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Campbell 166 79 47.88% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Campbell 4 4 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Campbell 4 4 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Campbell 5 4 80.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Campbell 1 0 0.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Campbell 14 12 92.31% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Campbell 17 1 5.88% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Campbell 14 10 90.91% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Campbell 14 4 36.36% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Campbell 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Campbell 216 77 35.65% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Campbell 68 6 8.82% 18% 18%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-134 Diabetes: Urine Screening CE Campbell 68 58 85.29% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Campbell 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Campbell 3 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Campbell 1 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Campbell 457 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Campbell 457 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Campbell 44 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Campbell 44 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Campbell 413 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Campbell 413 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Campbell 301 282 93.69% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Campbell 17 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Campbell 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Campbell 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Campbell 2 2 100.00% 80%CQM-146 Testing for Children with Pharyngitis ER Campbell 8 0 0.00% 39%CQM-147 Influenza Immunization PH Campbell 232 22 9.73% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Campbell 19 3 15.79% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Campbell 12 3 25.00% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Campbell 31 6 19.35% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Campbell 65 16 88.89% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Campbell 147 146 99.32% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Campbell 147 35 23.81% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Campbell 147 32 21.77% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Campbell 86 86 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Campbell 86 29 33.72% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Campbell 86 26 30.23% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Campbell 61 60 98.36% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Campbell 61 6 9.84% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Campbell 61 6 9.84% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Campbell 15 2 13.33% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Campbell 15 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Campbell 19 0 0.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Campbell 30 18 60.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Campbell 22 15 71.43% Not Set -- 58%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Campbell 24 9 37.50% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Campbell 2 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Campbell 68 16 23.53% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Campbell 22 16 72.73% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Campbell 151 98 64.90% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Campbell 20 20 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Campbell 19 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Campbell 3 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Campbell 22 10 45.45% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Campbell 22 3 13.64% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Collins 1054 460 75.66% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Collins 858 206 29.47% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Collins 268 146 54.48% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Collins 75 55 74.32% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Collins 263 87 33.46% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Collins 448 186 41.80% 27% 26%CQM-62 HIV/AIDS: Medical Visit CE Collins 1 0 0.00% 33%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Collins 55 22 40.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Collins 88 59 67.82% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Collins 188 171 91.94% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Collins 34 6 17.65% 28%CQM-68 Documentation of Current Medications PS Collins 2098 2022 96.38% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Collins 10 9 90.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Collins 868 697 81.05% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Collins 44 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Collins 228 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Collins 196 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Collins 468 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Collins 468 2 0.43% 0%CQM-122 Diabetes: HbA1c Poor Control PH Collins 60 18 30.00% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Collins 60 29 48.33% 55% 55%CQM-124 Cervical Cancer Screening CE Collins 491 197 49.87% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Collins 245 91 37.14% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Collins 3 1 33.33% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Collins 3 2 66.67% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Collins 10 9 90.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Collins 3 2 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Collins 19 14 77.78% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Collins 8 2 25.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Collins 102 58 76.32% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Collins 102 48 63.16% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Collins 175 65 37.14% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Collins 60 9 15.00% 18% 18%CQM-134 Diabetes: Urine Screening CE Collins 60 51 85.00% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Collins 102 10 45.45% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Collins 89 9 52.94% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Collins 882 1 0.14% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Collins 882 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Collins 126 1 0.92% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Collins 126 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Collins 756 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Collins 756 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Collins 489 429 87.73% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Collins 8 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Collins 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Collins 1 1 100.00% 80%CQM-147 Influenza Immunization PH Collins 351 37 10.69% 10% 10%CQM-148 Diabetes: HbA1c Test for Children CE Collins 1 1 100.00% 100%CQM-149 Dementia: Cognitive Assessment CE Collins 1 1 100.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Collins 34 5 14.71% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Collins 23 5 21.74% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Collins 57 10 17.54% 17% 16%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Collins 401 399 99.50% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Collins 401 126 31.42% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Collins 401 87 21.70% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Collins 237 236 99.58% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Collins 237 81 34.18% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Collins 237 50 21.10% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Collins 164 163 99.39% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Collins 164 45 27.44% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Collins 164 37 22.56% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Collins 8 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Collins 8 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Collins 68 1 1.69% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Collins 137 88 67.18% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Collins 132 104 86.67% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Collins 84 60 75.00% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Collins 231 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Collins 60 19 31.67% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Collins 18 14 77.78% 90% 51 75%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-165 Controlling High Blood Pressure CE Collins 160 84 52.50% 70% 35 54% 54%CQM-169 Bipolar & Depression: AOD Appraisal CE Collins 200 1 0.50% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Collins 236 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Collins 18 14 77.78% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Collins 18 5 27.78% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Conaway 767 410 64.47% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Conaway 631 245 49.20% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Conaway 243 151 62.14% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Conaway 66 35 53.03% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Conaway 168 39 23.21% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Conaway 345 73 21.22% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Conaway 35 9 25.71% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Conaway 39 24 61.54% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Conaway 74 65 89.04% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Conaway 27 11 40.74% 28%CQM-68 Documentation of Current Medications PS Conaway 1333 1281 96.10% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Conaway 16 14 87.50% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Conaway 634 388 61.39% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Conaway 132 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Conaway 135 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Conaway 157 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Conaway 424 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Conaway 424 2 0.47% 0%CQM-82 Maternal Depression Screening PH Conaway 11 0 0.00% 0%CQM-117 Childhood Immunization Status PH Conaway 28 2 7.14% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Conaway 61 15 24.59% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Conaway 61 45 73.77% 55% 55%CQM-124 Cervical Cancer Screening CE Conaway 359 228 79.17% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Conaway 200 108 54.82% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Conaway 3 3 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Conaway 3 3 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Conaway 6 4 66.67% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Conaway 12 10 83.33% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Conaway 14 3 21.43% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Conaway 22 16 94.12% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Conaway 22 12 70.59% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Conaway 190 77 40.53% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Conaway 61 11 18.03% 18% 18%CQM-134 Diabetes: Urine Screening CE Conaway 61 54 88.52% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Conaway 6 1 50.00% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Conaway 2 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Conaway 540 1 0.21% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Conaway 540 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Conaway 77 1 1.43% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Conaway 77 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Conaway 463 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Conaway 463 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Conaway 347 318 91.64% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Conaway 14 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Conaway 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Conaway 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Conaway 39 25 73.53% 39%CQM-147 Influenza Immunization PH Conaway 335 42 12.92% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Conaway 40 9 22.50% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Conaway 15 1 6.67% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Conaway 55 10 18.18% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Conaway 62 9 47.37% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Conaway 283 281 99.29% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Conaway 283 127 44.88% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Conaway 283 125 44.17% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Conaway 178 178 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Conaway 178 92 51.69% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Conaway 178 90 50.56% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Conaway 105 103 98.10% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Conaway 105 35 33.33% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Conaway 105 35 33.33% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Conaway 12 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Conaway 12 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Conaway 19 1 5.56% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Conaway 42 21 51.22% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Conaway 32 14 45.16% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Conaway 29 9 31.03% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Conaway 24 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Conaway 61 9 14.75% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Conaway 5 2 40.00% 90% 51 75%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-165 Controlling High Blood Pressure CE Conaway 132 94 71.21% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Conaway 12 11 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Conaway 44 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Conaway 7 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Conaway 5 0 0.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Conaway 5 0 0.00% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Gale 1213 537 63.55% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Gale 1206 342 41.06% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Gale 400 244 61.00% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Gale 163 88 54.66% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Gale 334 116 34.94% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Gale 636 230 36.51% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Gale 89 25 28.41% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Gale 116 70 60.34% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Gale 231 219 95.22% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Gale 128 31 24.22% 28%CQM-68 Documentation of Current Medications PS Gale 2695 2671 99.11% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Gale 17 13 76.47% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Gale 1196 660 55.70% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Gale 36 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Gale 36 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Gale 36 0 0.00% 0%CQM-122 Diabetes: HbA1c Poor Control PH Gale 152 53 34.87% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Gale 152 82 53.95% 55% 55%CQM-124 Cervical Cancer Screening CE Gale 734 347 61.20% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Gale 440 170 39.26% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Gale 2 2 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Gale 2 2 100.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Gale 16 0 0.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Gale 33 18 85.71% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Gale 33 18 85.71% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Gale 389 89 22.94% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Gale 152 24 15.79% 18% 18%CQM-134 Diabetes: Urine Screening CE Gale 152 128 84.21% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Gale 0 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Gale 297 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Gale 297 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Gale 297 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Gale 297 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Gale 644 542 84.16% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Gale 16 0 0.00% 0% 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Gale 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Gale 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Gale 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Gale 1 1 100.00% 39%CQM-147 Influenza Immunization PH Gale 432 22 5.16% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Gale 28 5 17.86% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Gale 21 3 14.29% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Gale 49 8 16.33% 17% 16%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Gale 14 2 14.29% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Gale 14 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Gale 1 0 0.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Gale 36 14 38.89% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Gale 38 11 28.95% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Gale 34 19 55.88% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Gale 4 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Gale 152 22 14.47% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Gale 15 10 66.67% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Gale 375 183 48.80% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Gale 22 21 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Gale 12 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Gale 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Gale 15 7 46.67% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Gale 15 4 26.67% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Hamilton 720 288 48.65% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Hamilton 399 111 32.27% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Hamilton 450 226 50.22% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Hamilton 19 11 57.89% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Hamilton 76 18 23.68% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Hamilton 242 56 23.73% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Hamilton 11 4 36.36% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Hamilton 18 12 66.67% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Hamilton 56 54 96.43% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Hamilton 19 3 15.79% 28%CQM-68 Documentation of Current Medications PS Hamilton 657 647 98.48% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Hamilton 3 3 100.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Hamilton 418 196 47.69% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Hamilton 554 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Hamilton 455 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Hamilton 312 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Hamilton 1321 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Hamilton 1321 2 0.15% 0%CQM-82 Maternal Depression Screening PH Hamilton 45 0 0.00% 0%CQM-117 Childhood Immunization Status PH Hamilton 96 1 1.04% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Hamilton 18 6 33.33% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Hamilton 18 9 50.00% 55% 55%CQM-124 Cervical Cancer Screening CE Hamilton 207 100 59.88% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Hamilton 86 34 39.53% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Hamilton 11 10 90.91% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Hamilton 7 5 71.43% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Hamilton 2 2 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Hamilton 20 17 85.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Hamilton 3 0 0.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Hamilton 5 5 100.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Hamilton 5 5 100.00% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Hamilton 73 21 28.77% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Hamilton 18 3 16.67% 18% 18%CQM-134 Diabetes: Urine Screening CE Hamilton 18 16 88.89% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Hamilton 36 1 11.11% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Hamilton 35 1 12.50% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Hamilton 118 1 1.12% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Hamilton 118 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Hamilton 21 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Hamilton 21 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Hamilton 97 1 1.37% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Hamilton 97 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Hamilton 150 140 93.33% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Hamilton 3 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Hamilton 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Hamilton 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Hamilton 130 87 76.99% 39%CQM-147 Influenza Immunization PH Hamilton 248 7 2.83% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Hamilton 48 13 27.08% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Hamilton 18 3 16.67% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Hamilton 66 16 24.24% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Hamilton 159 49 81.67% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Hamilton 926 925 99.89% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Hamilton 926 439 47.41% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Hamilton 926 408 44.06% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Hamilton 648 647 99.85% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Hamilton 648 322 49.69% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Hamilton 648 300 46.30% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Hamilton 278 278 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Hamilton 278 117 42.09% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Hamilton 278 108 38.85% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Hamilton 2 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Hamilton 2 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Hamilton 4 2 50.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Hamilton 9 6 66.67% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Hamilton 7 6 85.71% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Hamilton 4 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Hamilton 18 4 22.22% 24% 24%CQM-165 Controlling High Blood Pressure CE Hamilton 58 28 48.28% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Hamilton 12 11 100.00% 100%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-169 Bipolar & Depression: AOD Appraisal CE Hamilton 12 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Hamilton 35 0 0.00% Not Set -- 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Hoang 0 0 0.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Hoang 0 0 0.00% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Hoang 0 0 0.00% 92% 92%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Hoang 283 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Hoang 206 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Hoang 146 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Hoang 635 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Hoang 635 0 0.00% 0%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Hoang 1 1 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Hoang 1 1 100.00% 85% 13-14 100%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Hoang 1 1 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Hoang 1 1 100.00% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Hoang 1 1 100.00% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Hoang 1 1 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Hoang 1 1 100.00% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Hoang 1 1 100.00% 95% 97-98 51%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Hoang 6 2 33.33% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Hoang 8 6 75.00% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Hoang 10 8 80.00% Not Set -- 55%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Horton 311 221 75.95% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Horton 7 3 42.86% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Horton 228 124 54.39% 70% 28-30 54% 54%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Horton 0 0 0.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Horton 0 0 0.00% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Horton 0 0 0.00% 92% 92%CQM-68 Documentation of Current Medications PS Horton 28 28 100.00% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Horton 15 14 93.33% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Horton 594 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Horton 534 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Horton 236 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Horton 1364 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Horton 1364 4 0.29% 0%CQM-82 Maternal Depression Screening PH Horton 71 0 0.00% 0%CQM-117 Childhood Immunization Status PH Horton 111 7 6.31% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Horton 1 1 100.00% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Horton 1 1 100.00% 55% 55%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Horton 23 19 82.61% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Horton 11 10 90.91% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Horton 34 29 85.29% 85% 13-14 100%CQM-131 Diabetes: Eye Exam CE Horton 1 0 0.00% 18% 18%CQM-134 Diabetes: Urine Screening CE Horton 1 1 100.00% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Horton 21 4 57.14% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Horton 12 4 80.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Horton 28 1 4.35% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Horton 28 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Horton 27 1 4.55% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Horton 27 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Horton 1 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Horton 1 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Horton 6 6 100.00% 90% 90-91 92% 91%CQM-146 Testing for Children with Pharyngitis ER Horton 329 15 4.98% 39%CQM-147 Influenza Immunization PH Horton 593 80 13.79% 10% 10%CQM-148 Diabetes: HbA1c Test for Children CE Horton 2 2 100.00% 100%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Horton 31 6 19.35% 16%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-153 Chlamydia Screening for Women All Ages (16-24) PH Horton 31 6 19.35% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Horton 423 40 31.75% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Horton 1001 995 99.50% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Horton 1001 994 99.40% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Horton 1001 993 99.30% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Horton 724 721 99.59% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Horton 724 721 99.59% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Horton 724 721 99.59% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Horton 277 274 99.28% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Horton 277 273 98.91% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Horton 277 272 98.55% 95% 97-98 39%CQM-163 Diabetes: LDL Management CE Horton 1 0 0.00% 24% 24%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Horton 32 0 0.00% Not Set -- 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Kautz 343 237 86.50% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Kautz 275 83 40.69% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Kautz 158 85 53.80% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Kautz 27 25 92.59% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Kautz 63 33 52.38% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Kautz 161 64 40.51% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Kautz 25 9 36.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Kautz 33 21 63.64% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Kautz 66 60 93.75% 92% 92%CQM-68 Documentation of Current Medications PS Kautz 301 287 95.35% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Kautz 6 5 83.33% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Kautz 282 144 51.80% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Kautz 93 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Kautz 71 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Kautz 68 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Kautz 232 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Kautz 232 1 0.43% 0%CQM-82 Maternal Depression Screening PH Kautz 3 0 0.00% 0%CQM-117 Childhood Immunization Status PH Kautz 19 3 15.79% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Kautz 24 7 29.17% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Kautz 24 19 79.17% 55% 55%CQM-124 Cervical Cancer Screening CE Kautz 168 85 66.93% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Kautz 98 53 55.21% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Kautz 4 3 75.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Kautz 1 1 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Kautz 2 2 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Kautz 7 6 85.71% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Kautz 4 2 50.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Kautz 8 7 100.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Kautz 8 6 85.71% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Kautz 88 44 50.00% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Kautz 24 6 25.00% 18% 18%CQM-134 Diabetes: Urine Screening CE Kautz 24 24 100.00% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Kautz 5 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Kautz 4 0 0.00% Not Set -- 41%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Kautz 126 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Kautz 126 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Kautz 21 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Kautz 21 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Kautz 105 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Kautz 105 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Kautz 37 37 100.00% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Kautz 4 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Kautz 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Kautz 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Kautz 19 14 82.35% 39%CQM-147 Influenza Immunization PH Kautz 0 0 0.00% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Kautz 16 4 25.00% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Kautz 12 3 25.00% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Kautz 28 7 25.00% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Kautz 51 0 0.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Kautz 156 155 99.36% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Kautz 156 62 39.74% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Kautz 156 55 35.26% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Kautz 101 101 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Kautz 101 42 41.58% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Kautz 101 38 37.62% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Kautz 55 54 98.18% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Kautz 55 20 36.36% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Kautz 55 17 30.91% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Kautz 4 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Kautz 4 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Kautz 8 6 75.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Kautz 9 5 62.50% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Kautz 12 11 91.67% Not Set -- 55%CQM-163 Diabetes: LDL Management CE Kautz 24 8 33.33% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Kautz 4 4 100.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Kautz 71 40 56.34% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Kautz 3 3 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Kautz 3 0 0.00% Not Set -- 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Kautz 4 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Kautz 4 4 100.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Kautz 4 2 50.00% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Kidd 424 121 33.52% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Kidd 368 81 26.82% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Kidd 143 74 51.75% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Kidd 34 21 63.64% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Kidd 67 23 34.33% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Kidd 237 43 18.38% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Kidd 22 9 42.86% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Kidd 23 16 69.57% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Kidd 44 38 88.37% 92% 92%CQM-68 Documentation of Current Medications PS Kidd 449 373 83.07% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Kidd 9 6 66.67% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Kidd 369 180 49.45% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Kidd 84 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Kidd 96 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Kidd 57 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Kidd 237 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Kidd 237 0 0.00% 0%CQM-82 Maternal Depression Screening PH Kidd 1 0 0.00% 0%CQM-117 Childhood Immunization Status PH Kidd 8 0 0.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Kidd 26 15 57.69% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Kidd 26 18 69.23% 55% 55%CQM-124 Cervical Cancer Screening CE Kidd 232 105 54.97% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Kidd 118 32 27.35% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Kidd 4 4 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Kidd 2 2 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Kidd 1 1 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Kidd 7 7 100.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Kidd 8 1 12.50% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Kidd 3 2 66.67% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Kidd 3 2 66.67% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Kidd 96 32 33.33% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Kidd 26 8 30.77% 18% 18%CQM-134 Diabetes: Urine Screening CE Kidd 26 22 84.62% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Kidd 8 2 100.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Kidd 7 2 100.00% Not Set -- 41%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Kidd 147 1 0.88% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Kidd 147 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Kidd 19 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Kidd 19 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Kidd 128 1 1.01% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Kidd 128 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Kidd 113 57 50.44% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Kidd 8 0 0.00% 0% 0%CQM-142 Diabetic Retinopathy: Managing Diabetes Care CE Kidd 1 0 0.00% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Kidd 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Kidd 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Kidd 15 11 78.57% 39%CQM-147 Influenza Immunization PH Kidd 0 0 0.00% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Kidd 13 2 15.38% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Kidd 11 2 18.18% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Kidd 24 4 16.67% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Kidd 27 4 66.67% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Kidd 176 129 73.30% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Kidd 176 47 26.70% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Kidd 176 43 24.43% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Kidd 132 92 69.70% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Kidd 132 35 26.52% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Kidd 132 32 24.24% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Kidd 44 37 84.09% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Kidd 44 12 27.27% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Kidd 44 11 25.00% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Kidd 8 1 12.50% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Kidd 8 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Kidd 5 3 60.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Kidd 11 6 60.00% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Kidd 39 35 92.11% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Kidd 6 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Kidd 26 6 23.08% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Kidd 6 6 100.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Kidd 65 29 44.62% 70% 35 54% 54%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-166 Low Back Pain: Use of Imaging Studies ER Kidd 9 9 100.00% 100%CQM-167 Diabetic Retinopathy: Document Macular Edema CE Kidd 1 0 0.00% 0%CQM-169 Bipolar & Depression: AOD Appraisal CE Kidd 24 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Kidd 1 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Kidd 6 5 83.33% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Kidd 6 4 66.67% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Lathrop 789 357 54.59% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Lathrop 686 161 35.38% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Lathrop 264 148 56.06% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Lathrop 102 88 87.13% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Lathrop 192 98 51.04% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Lathrop 341 125 37.88% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Lathrop 89 37 42.05% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Lathrop 98 64 65.31% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Lathrop 129 114 91.20% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Lathrop 69 9 13.04% 28%CQM-68 Documentation of Current Medications PS Lathrop 1398 1319 94.35% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Lathrop 15 8 53.33% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Lathrop 681 291 43.56% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Lathrop 78 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Lathrop 104 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Lathrop 117 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Lathrop 299 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Lathrop 299 1 0.33% 0%CQM-82 Maternal Depression Screening PH Lathrop 2 0 0.00% 0%CQM-90 FSA for Complex Chronic Conditions PE Lathrop 1 0 0.00% 0%CQM-117 Childhood Immunization Status PH Lathrop 14 3 21.43% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Lathrop 85 24 28.24% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Lathrop 85 15 17.65% 55% 55%CQM-124 Cervical Cancer Screening CE Lathrop 356 169 59.09% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Lathrop 200 82 41.21% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Lathrop 7 5 71.43% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Lathrop 5 5 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Lathrop 9 9 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Lathrop 5 4 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Lathrop 26 23 92.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Lathrop 13 0 0.00% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Lathrop 30 15 88.24% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Lathrop 30 11 64.71% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Lathrop 232 84 36.36% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Lathrop 85 6 7.06% 18% 18%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-134 Diabetes: Urine Screening CE Lathrop 85 83 97.65% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Lathrop 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Lathrop 11 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Lathrop 9 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Lathrop 368 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Lathrop 368 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Lathrop 28 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Lathrop 28 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Lathrop 340 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Lathrop 340 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Lathrop 319 316 99.06% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Lathrop 13 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Lathrop 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Lathrop 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Lathrop 1 1 100.00% 80%CQM-146 Testing for Children with Pharyngitis ER Lathrop 24 2 9.09% 39%CQM-147 Influenza Immunization PH Lathrop 21 4 21.05% 10% 10%CQM-149 Dementia: Cognitive Assessment CE Lathrop 1 1 100.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Lathrop 31 7 22.58% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Lathrop 19 1 5.26% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Lathrop 50 8 16.00% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Lathrop 12 1 20.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Lathrop 214 213 99.53% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Lathrop 214 32 14.95% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Lathrop 214 21 9.81% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Lathrop 133 132 99.25% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Lathrop 133 25 18.80% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Lathrop 133 16 12.03% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Lathrop 81 81 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Lathrop 81 7 8.64% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Lathrop 81 5 6.17% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Lathrop 11 1 9.09% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Lathrop 11 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Lathrop 42 24 57.14% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Lathrop 21 11 61.11% Not Set -- 58%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Lathrop 21 10 50.00% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Lathrop 14 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Lathrop 85 33 38.82% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Lathrop 20 12 60.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Lathrop 221 116 52.49% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Lathrop 16 16 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Lathrop 15 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Lathrop 7 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Lathrop 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Lathrop 20 15 75.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Lathrop 20 6 30.00% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Laughlin 1202 475 47.36% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Laughlin 1019 266 37.62% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Laughlin 387 169 43.67% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Laughlin 132 77 59.23% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Laughlin 267 86 32.45% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Laughlin 538 132 25.24% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Laughlin 77 28 36.36% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Laughlin 86 56 65.12% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Laughlin 133 123 93.18% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Laughlin 102 36 35.29% 28%CQM-68 Documentation of Current Medications PS Laughlin 2104 2080 98.86% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Laughlin 20 14 70.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Laughlin 1020 418 41.88% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Laughlin 239 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Laughlin 185 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Laughlin 218 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Laughlin 642 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Laughlin 642 1 0.16% 0%CQM-82 Maternal Depression Screening PH Laughlin 21 0 0.00% 0%CQM-117 Childhood Immunization Status PH Laughlin 54 3 5.56% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Laughlin 116 34 29.31% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Laughlin 116 58 50.00% 55% 55%CQM-124 Cervical Cancer Screening CE Laughlin 564 269 59.38% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Laughlin 296 121 41.02% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Laughlin 10 10 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Laughlin 2 2 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Laughlin 9 7 77.78% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Laughlin 2 2 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Laughlin 23 21 91.30% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Laughlin 18 3 16.67% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Laughlin 40 23 79.31% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Laughlin 40 17 58.62% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Laughlin 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Laughlin 288 90 31.25% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Laughlin 116 5 4.31% 18% 18%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-134 Diabetes: Urine Screening CE Laughlin 116 105 90.52% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Laughlin 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Laughlin 6 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Laughlin 5 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Laughlin 844 5 0.66% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Laughlin 844 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Laughlin 82 1 1.35% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Laughlin 82 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Laughlin 762 4 0.58% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Laughlin 762 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Laughlin 473 458 96.83% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Laughlin 18 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Laughlin 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Laughlin 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Laughlin 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Laughlin 47 30 76.92% 39%CQM-147 Influenza Immunization PH Laughlin 277 24 8.79% 10% 10%CQM-149 Dementia: Cognitive Assessment CE Laughlin 1 1 100.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Laughlin 58 11 18.97% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Laughlin 37 6 16.22% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Laughlin 95 17 17.89% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Laughlin 166 14 36.84% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Laughlin 397 397 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Laughlin 397 232 58.44% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Laughlin 397 226 56.93% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Laughlin 252 252 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Laughlin 252 159 63.10% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Laughlin 252 157 62.30% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Laughlin 145 145 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Laughlin 145 73 50.34% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Laughlin 145 69 47.59% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Laughlin 16 3 18.75% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Laughlin 16 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Laughlin 37 20 55.56% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Laughlin 48 28 63.64% Not Set -- 58%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Laughlin 40 23 57.50% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Laughlin 10 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Laughlin 116 25 21.55% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Laughlin 16 11 68.75% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Laughlin 324 173 53.40% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Laughlin 48 44 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Laughlin 33 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Laughlin 9 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Laughlin 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Laughlin 16 5 31.25% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Laughlin 16 3 18.75% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Lyons 1291 509 45.41% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Lyons 1144 329 39.31% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Lyons 400 231 57.75% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Lyons 126 82 66.13% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Lyons 272 80 29.52% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Lyons 640 172 27.43% 27% 26%CQM-62 HIV/AIDS: Medical Visit CE Lyons 1 1 100.00% 33%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Lyons 83 35 42.68% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Lyons 80 56 70.00% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Lyons 173 157 91.28% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Lyons 94 29 30.85% 28%CQM-68 Documentation of Current Medications PS Lyons 1888 1877 99.42% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Lyons 28 20 71.43% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Lyons 1140 440 39.32% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Lyons 129 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Lyons 135 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Lyons 194 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Lyons 458 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Lyons 458 2 0.44% 0%CQM-77 HIV/AIDS: RNA Control for HIV Patients CE Lyons 1 0 0.00% 0%CQM-82 Maternal Depression Screening PH Lyons 4 0 0.00% 0%CQM-117 Childhood Immunization Status PH Lyons 18 3 16.67% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Lyons 105 28 26.67% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Lyons 105 27 25.71% 55% 55%CQM-124 Cervical Cancer Screening CE Lyons 592 295 61.72% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Lyons 323 125 39.06% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Lyons 6 4 66.67% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Lyons 4 4 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Lyons 11 10 90.91% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Lyons 21 18 85.71% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Lyons 26 4 15.38% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Lyons 35 19 90.48% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Lyons 35 16 76.19% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Lyons 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Lyons 352 100 28.41% 5% 31 34% 33%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-131 Diabetes: Eye Exam CE Lyons 105 5 4.76% 18% 18%CQM-134 Diabetes: Urine Screening CE Lyons 105 100 95.24% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Lyons 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Lyons 8 3 100.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Lyons 7 3 100.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Lyons 407 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Lyons 407 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Lyons 35 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Lyons 35 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Lyons 372 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Lyons 372 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Lyons 417 411 98.56% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Lyons 26 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Lyons 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Lyons 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Lyons 1 1 100.00% 80%CQM-146 Testing for Children with Pharyngitis ER Lyons 70 31 49.21% 39%CQM-147 Influenza Immunization PH Lyons 145 16 11.68% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Lyons 73 12 16.44% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Lyons 35 6 17.14% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Lyons 108 18 16.67% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Lyons 31 1 12.50% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Lyons 268 268 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Lyons 268 150 55.97% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Lyons 268 146 54.48% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Lyons 166 166 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Lyons 166 98 59.04% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Lyons 166 95 57.23% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Lyons 102 102 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Lyons 102 52 50.98% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Lyons 102 51 50.00% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Lyons 22 2 9.09% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Lyons 22 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Lyons 48 31 65.96% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Lyons 41 28 71.79% Not Set -- 58%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Lyons 46 36 78.26% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Lyons 10 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Lyons 105 28 26.67% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Lyons 28 20 71.43% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Lyons 342 169 49.56% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Lyons 52 49 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Lyons 45 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Lyons 19 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Lyons 28 18 64.29% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Lyons 28 8 28.57% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Miller 7 6 100.00% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Miller 7 4 57.14% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Miller 3 0 0.00% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Miller 1 1 100.00% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Miller 2 0 0.00% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Miller 3 0 0.00% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Miller 1 1 100.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Miller 0 0 0.00% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Miller 0 0 0.00% 92% 92%CQM-68 Documentation of Current Medications PS Miller 7 6 85.71% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Miller 2 2 100.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Miller 5 4 80.00% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Miller 1 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Miller 1 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Miller 2 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Miller 2 0 0.00% 0%CQM-117 Childhood Immunization Status PH Miller 1 0 0.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Miller 1 0 0.00% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Miller 1 0 0.00% 55% 55%CQM-124 Cervical Cancer Screening CE Miller 3 0 0.00% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Miller 2 2 100.00% 50% 17 42% 42%CQM-127 Pneumonia Vaccination Status for Older Adults CE Miller 2 0 0.00% 20% 20%CQM-129 Prostate Cancer: Bone Scans ER Miller 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Miller 2 0 0.00% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Miller 1 0 0.00% 18% 18%CQM-134 Diabetes: Urine Screening CE Miller 1 0 0.00% 88% 88%CQM-139 Falls: Screening for Future Fall Risk PS Miller 2 0 0.00% 0% 0%CQM-154 Appropriate Treatment for Children with URI ER Miller 1 0 0.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Miller 1 1 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Miller 1 1 100.00% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Miller 1 1 100.00% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Miller 1 1 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Miller 1 1 100.00% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Miller 1 1 100.00% 95% 97-98 51%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Miller 2 0 0.00% 15% 15%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Miller 2 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Miller 1 1 100.00% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Miller 1 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Miller 1 1 100.00% 24% 24%CQM-165 Controlling High Blood Pressure CE Miller 1 0 0.00% 70% 35 54% 54%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Randall 811 451 65.08% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Randall 707 174 32.28% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Randall 245 141 57.55% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Randall 81 65 80.25% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Randall 189 78 41.27% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Randall 375 113 30.79% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Randall 65 32 49.23% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Randall 78 50 64.10% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Randall 116 102 90.27% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Randall 68 23 33.82% 28%CQM-68 Documentation of Current Medications PS Randall 1099 1076 97.91% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Randall 16 9 56.25% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Randall 717 340 48.16% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Randall 99 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Randall 101 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Randall 136 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Randall 336 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Randall 336 1 0.30% 0%CQM-82 Maternal Depression Screening PH Randall 3 0 0.00% 0%CQM-90 FSA for Complex Chronic Conditions PE Randall 1 0 0.00% 0%CQM-117 Childhood Immunization Status PH Randall 18 3 16.67% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Randall 73 21 28.77% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Randall 73 28 38.36% 55% 55%CQM-124 Cervical Cancer Screening CE Randall 388 218 70.55% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Randall 219 116 53.46% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Randall 4 4 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Randall 4 4 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Randall 10 9 90.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Randall 2 2 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Randall 20 19 95.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Randall 14 2 14.29% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Randall 23 15 83.33% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Randall 23 10 55.56% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Randall 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Randall 218 101 46.54% 5% 31 34% 33%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-131 Diabetes: Eye Exam CE Randall 73 4 5.48% 18% 18%CQM-134 Diabetes: Urine Screening CE Randall 73 65 89.04% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Randall 0 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Randall 2 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Randall 2 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Randall 389 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Randall 389 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Randall 38 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Randall 38 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Randall 351 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Randall 351 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Randall 226 217 96.02% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Randall 14 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Randall 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Randall 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Randall 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Randall 36 10 33.33% 39%CQM-147 Influenza Immunization PH Randall 125 19 16.67% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Randall 43 4 9.30% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Randall 26 3 11.54% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Randall 69 7 10.14% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Randall 41 2 25.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Randall 204 194 95.10% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Randall 204 90 44.12% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Randall 204 86 42.16% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Randall 139 134 96.40% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Randall 139 73 52.52% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Randall 139 70 50.36% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Randall 65 60 92.31% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Randall 65 17 26.15% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Randall 65 16 24.62% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Randall 14 3 21.43% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Randall 14 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Randall 38 19 50.00% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Randall 30 22 78.57% Not Set -- 58%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Randall 28 17 65.38% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Randall 27 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Randall 73 29 39.73% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Randall 10 6 60.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Randall 173 76 43.93% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Randall 17 17 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Randall 34 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Randall 1 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Randall 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Randall 10 9 90.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Randall 10 3 30.00% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Reece 913 513 71.65% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Reece 807 207 41.57% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Reece 413 286 69.25% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Reece 136 108 79.41% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Reece 248 128 52.03% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Reece 364 172 48.59% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Reece 108 52 48.15% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Reece 129 89 69.53% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Reece 178 156 90.70% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Reece 80 26 32.91% 28%CQM-68 Documentation of Current Medications PS Reece 1852 1851 99.95% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Reece 24 24 100.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Reece 791 680 87.29% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Reece 73 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Reece 116 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Reece 110 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Reece 299 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Reece 299 3 1.00% 0%CQM-82 Maternal Depression Screening PH Reece 2 0 0.00% 0%CQM-117 Childhood Immunization Status PH Reece 7 1 14.29% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Reece 112 29 25.89% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Reece 112 79 70.54% 55% 55%CQM-124 Cervical Cancer Screening CE Reece 464 213 63.20% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Reece 313 166 53.55% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Reece 3 3 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Reece 1 1 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Reece 8 7 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Reece 4 4 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Reece 16 15 100.00% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Reece 24 7 29.17% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Reece 48 30 78.95% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Reece 48 24 63.16% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Reece 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Reece 318 147 46.37% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Reece 112 27 24.11% 18% 18%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-134 Diabetes: Urine Screening CE Reece 112 107 95.54% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Reece 2 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Reece 11 0 0.00% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Reece 10 0 0.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Reece 488 2 0.55% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Reece 488 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Reece 43 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Reece 43 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Reece 445 2 0.61% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Reece 445 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Reece 436 424 97.25% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Reece 24 0 0.00% 0% 0%CQM-142 Diabetic Retinopathy: Managing Diabetes Care CE Reece 0 0 0.00% 0%CQM-143 POAG: Optic Nerve Evaluation CE Reece 1 0 0.00% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Reece 2 2 100.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Reece 1 1 100.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Reece 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Reece 7 4 57.14% 39%CQM-147 Influenza Immunization PH Reece 364 74 20.67% 10% 10%CQM-148 Diabetes: HbA1c Test for Children CE Reece 1 1 100.00% 100%CQM-149 Dementia: Cognitive Assessment CE Reece 2 2 100.00% 77%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Reece 25 5 20.00% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Reece 16 4 25.00% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Reece 41 9 21.95% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Reece 38 3 50.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Reece 220 219 99.55% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Reece 220 174 79.09% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Reece 220 169 76.82% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Reece 130 129 99.23% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Reece 130 109 83.85% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Reece 130 106 81.54% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Reece 90 90 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Reece 90 65 72.22% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Reece 90 63 70.00% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Reece 19 2 10.53% 15% 15%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Reece 19 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Reece 5 0 0.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Reece 36 20 60.61% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Reece 21 16 80.00% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Reece 16 10 66.67% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Reece 37 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Reece 112 42 37.50% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Reece 30 27 90.00% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Reece 318 215 67.82% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Reece 5 5 100.00% 100%CQM-167 Diabetic Retinopathy: Document Macular Edema CE Reece 1 0 0.00% 0%CQM-169 Bipolar & Depression: AOD Appraisal CE Reece 34 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Reece 13 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Reece 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Reece 30 24 80.00% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Reece 30 14 46.67% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Tuley 265 184 88.46% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Tuley 251 55 33.13% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Tuley 128 63 49.22% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Tuley 54 42 77.78% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Tuley 75 24 32.00% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Tuley 106 38 36.89% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Tuley 42 14 33.33% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Tuley 24 17 70.83% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Tuley 40 36 94.74% 92% 92%CQM-68 Documentation of Current Medications PS Tuley 352 351 99.72% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Tuley 16 13 81.25% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Tuley 241 144 60.76% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Tuley 19 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Tuley 19 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Tuley 19 0 0.00% 0%CQM-122 Diabetes: HbA1c Poor Control PH Tuley 43 16 37.21% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Tuley 43 24 55.81% 55% 55%CQM-124 Cervical Cancer Screening CE Tuley 133 65 67.71% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Tuley 97 52 53.61% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Tuley 4 3 75.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications 4. Age 51-64 CE Tuley 2 2 100.00% 85% 13-14 100%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Tuley 6 5 83.33% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Tuley 13 6 46.15% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Tuley 9 6 75.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Tuley 9 6 75.00% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Tuley 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Tuley 109 49 44.95% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Tuley 43 4 9.30% 18% 18%CQM-134 Diabetes: Urine Screening CE Tuley 43 41 95.35% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Tuley 0 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Tuley 190 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Tuley 190 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Tuley 9 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Tuley 9 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Tuley 181 0 0.00% 0%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Tuley 181 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Tuley 67 67 100.00% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Tuley 13 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Tuley 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Tuley 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Tuley 0 0 0.00% 80%CQM-147 Influenza Immunization PH Tuley 0 0 0.00% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Tuley 8 2 25.00% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Tuley 3 1 33.33% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Tuley 11 3 27.27% 17% 16%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Tuley 7 7 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Tuley 7 1 14.29% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Tuley 7 1 14.29% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Tuley 7 7 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Tuley 7 1 14.29% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Tuley 7 1 14.29% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Tuley 10 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Tuley 10 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Tuley 12 7 58.33% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Tuley 12 6 54.55% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Tuley 23 12 54.55% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Tuley 6 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Tuley 43 10 23.26% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Tuley 14 10 71.43% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Tuley 88 46 52.27% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Tuley 8 8 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Tuley 7 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Tuley 14 11 78.57% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Tuley 14 4 28.57% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Williams 580 250 53.42% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Williams 444 145 41.91% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Williams 291 149 51.20% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Williams 48 40 85.11% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Williams 95 41 43.62% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Williams 262 83 32.81% 27% 26%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Williams 41 20 50.00% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Williams 41 31 75.61% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Williams 89 77 92.77% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Williams 16 2 12.50% 28%CQM-68 Documentation of Current Medications PS Williams 702 695 99.00% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Williams 6 4 66.67% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Williams 457 245 55.06% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Williams 219 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Williams 176 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Williams 139 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Williams 534 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Williams 534 3 0.56% 0%CQM-82 Maternal Depression Screening PH Williams 12 0 0.00% 0%CQM-117 Childhood Immunization Status PH Williams 41 7 17.07% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Williams 39 14 35.90% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Williams 39 26 66.67% 55% 55%CQM-124 Cervical Cancer Screening CE Williams 285 148 65.20% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Williams 132 49 37.12% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Williams 11 8 72.73% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Williams 6 6 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Williams 5 5 100.00% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Williams 22 19 86.36% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Williams 3 2 66.67% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Williams 11 6 75.00% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Williams 11 5 62.50% Not Set -- 71%CQM-130 Colorectal Cancer Screening CE Williams 109 36 33.03% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Williams 39 6 15.38% 18% 18%CQM-134 Diabetes: Urine Screening CE Williams 39 36 92.31% 88% 88%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Williams 22 1 25.00% Not Set -- 40%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Williams 20 1 33.33% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Williams 270 9 4.07% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Williams 270 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Williams 44 6 16.67% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Williams 44 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Williams 226 3 1.62% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Williams 226 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Williams 146 144 98.63% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Williams 3 0 0.00% 0% 0%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Williams 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Williams 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Williams 73 40 58.82% 39%CQM-147 Influenza Immunization PH Williams 0 0 0.00% 10% 10%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Williams 45 7 15.56% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Williams 21 5 23.81% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Williams 66 12 18.18% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Williams 21 0 0.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Williams 374 373 99.73% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Williams 374 128 34.22% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Williams 374 95 25.40% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Williams 260 259 99.62% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Williams 260 94 36.15% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Williams 260 72 27.69% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Williams 114 114 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Williams 114 34 29.82% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Williams 114 23 20.18% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Williams 1 0 0.00% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Williams 1 0 0.00% 1% 1%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Williams 22 10 45.45% Not Set -- 52%CQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Williams 27 18 69.23% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Williams 34 21 65.63% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Williams 12 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Williams 39 16 41.03% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Williams 9 6 66.67% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Williams 95 54 56.84% 70% 35 54% 54%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-166 Low Back Pain: Use of Imaging Studies ER Williams 16 16 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Williams 19 2 10.53% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Williams 17 0 0.00% Not Set -- 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Williams 9 7 77.78% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Williams 9 4 44.44% 31%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-2 Clinical Depression and Follow-Up Plan PH Workman 558 309 65.88% 75% 24-26 70% 69%CQM-22 High Blood Pressure Screening and Follow-Up PH Workman 488 112 40.00% 37% 36%CQM-50 Closing the Referral Loop: Receipt of Report CC Workman 239 167 69.87% 70% 28-30 54% 54%CQM-61 Preventive Care: Fasting LDL-C Test Performed 1. High Risk CE Workman 85 61 73.49% 62% 62%CQM-61 Preventive Care: Fasting LDL-C Test Performed 2. Moderate Risk CE Workman 145 91 63.64% 33% 33%CQM-61 Preventive Care: Fasting LDL-C Test Performed 3. Low Risk CE Workman 228 114 50.89% 27% 26%CQM-62 HIV/AIDS: Medical Visit CE Workman 1 0 0.00% 33%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 1. High Risk CE Workman 62 29 47.54% 40% 40%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 2. Moderate Risk CE Workman 92 70 76.92% 66%CQM-64 Preventive Care: Risk-Stratified Fasting LDL-C 3. Low Risk CE Workman 116 105 92.11% 92% 92%CQM-65 Hypertension: Improvement in Blood Pressure CE Workman 56 28 50.00% 28%CQM-68 Documentation of Current Medications PS Workman 1056 1045 98.96% Not Set -- 98% 96%CQM-69 BMI Screening and Follow-Up 1. Age 65+ PH Workman 20 17 85.00% 95% 15-16 72% 71%CQM-69 BMI Screening and Follow-Up 2. Age 18-64 PH Workman 475 337 72.16% 95% 15-16 57% 57%CQM-74 Primary Caries Prevention Intervention 1. Age 0-5 CE Workman 61 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 2. Age 6-12 CE Workman 86 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention 3. Age 13-20 CE Workman 67 0 0.00% 0%CQM-74 Primary Caries Prevention Intervention All Ages (0-20) CE Workman 214 0 0.00% 0%CQM-75 Children Who Have Dental Decay or Cavities CE Workman 214 3 1.40% 0%CQM-82 Maternal Depression Screening PH Workman 2 0 0.00% 0%CQM-117 Childhood Immunization Status PH Workman 8 2 25.00% 10% 22-23 6%CQM-122 Diabetes: HbA1c Poor Control PH Workman 77 20 25.97% 20% 36 30% 30%CQM-123 Diabetes: Foot Exam CE Workman 77 55 71.43% 55% 55%CQM-124 Cervical Cancer Screening CE Workman 293 160 73.73% 50% 21 59% 58%CQM-125 Breast Cancer Screening CE Workman 193 112 58.33% 50% 17 42% 42%CQM-126 Asthma: Use of Appropriate Medications 1. Age 5-11 CE Workman 2 2 100.00% 85% 13-14 82%CQM-126 Asthma: Use of Appropriate Medications 2. Age 12-18 CE Workman 1 1 100.00% 85% 13-14 87%CQM-126 Asthma: Use of Appropriate Medications 3. Age 19-50 CE Workman 7 5 83.33% 85% 13-14 90%CQM-126 Asthma: Use of Appropriate Medications All Ages (5-64) CE Workman 10 8 88.89% 85% 13-14 100%CQM-127 Pneumonia Vaccination Status for Older Adults CE Workman 19 12 63.16% 20% 20%CQM-128 Antidepressant Medication Management 1. At Least 84 Days of Meds CE Workman 20 15 88.24% Not Set -- 85%CQM-128 Antidepressant Medication Management 2. At Least 180 Days of Meds CE Workman 20 14 82.35% Not Set -- 71%CQM-129 Prostate Cancer: Bone Scans ER Workman 0 0 0.00% #DIV/0!CQM-130 Colorectal Cancer Screening CE Workman 216 127 58.80% 5% 31 34% 33%CQM-131 Diabetes: Eye Exam CE Workman 77 51 66.23% 18% 18%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-134 Diabetes: Urine Screening CE Workman 77 72 93.51% 88% 88%CQM-135 Heart Failure: ACE/ARB for LVSD CE Workman 1 0 0.00% 0%CQM-136 ADHD: Follow-Up Care for Children a. Initiation Phase CE Workman 15 1 16.67% Not Set -- 40%CQM-136 ADHD: Follow-Up Care for Children b. Maintenance Phase CE Workman 13 1 20.00% Not Set -- 41%CQM-137 Alcohol and Drug Dependence Treatment All N1. Age 13+ 1st Visit CE Workman 275 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment All N2. Age 13+ 2 Visits CE Workman 275 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P1 N1. Age 13-17 1st Visit CE Workman 20 0 0.00% 2%CQM-137 Alcohol and Drug Dependence Treatment P1 N2. Age 13-17 2 Visits CE Workman 20 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N1. Age 18+ 1st Visit CE Workman 255 0 0.00% 0%CQM-137 Alcohol and Drug Dependence Treatment P2 N2. Age 18+ 2 Visits CE Workman 255 0 0.00% 0%CQM-138 Tobacco Use Screening and Cessation PH Workman 236 227 96.19% 90% 90-91 92% 91%CQM-139 Falls: Screening for Future Fall Risk PS Workman 19 0 0.00% 0% 0%CQM-144 Heart Failure: Beta-Blocker Therapy for LVSD CE Workman 1 1 100.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 1. LVSD CE Workman 0 0 0.00% 100%CQM-145 CAD: Beta-Blocker Therapy for Prior MI or LVSD 2. Prior MI CE Workman 0 0 0.00% 80%CQM-146 Testing for Children with Pharyngitis ER Workman 14 5 35.71% 39%CQM-147 Influenza Immunization PH Workman 224 77 35.00% 10% 10%CQM-148 Diabetes: HbA1c Test for Children CE Workman 1 1 100.00% 100%CQM-153 Chlamydia Screening for Women 1. Age 16-20 PH Workman 16 7 43.75% 16%CQM-153 Chlamydia Screening for Women 2. Age 21-24 PH Workman 10 2 20.00% 17% 17%CQM-153 Chlamydia Screening for Women All Ages (16-24) PH Workman 26 9 34.62% 17% 16%CQM-154 Appropriate Treatment for Children with URI ER Workman 33 3 75.00% 43%CQM-155 Weight Assessment for Children & Adolescents All N1. Age 3-17 BMI PH Workman 156 156 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents All N2. Age 3-17 Nutrition Ed PH Workman 156 123 78.85% 95% 97-98 49%CQM-155 Weight Assessment for Children & Adolescents All N3. Age 3-17 Physical Ed PH Workman 156 118 75.64% 95% 97-98 47%CQM-155 Weight Assessment for Children & Adolescents P1 N1. Age 3-11 BMI PH Workman 105 105 100.00% 95% 97-98 98%CQM-155 Weight Assessment for Children & Adolescents P1 N2. Age 3-11 Nutrition Ed PH Workman 105 86 81.90% 95% 97-98 53%CQM-155 Weight Assessment for Children & Adolescents P1 N3. Age 3-11 Physical Ed PH Workman 105 82 78.10% 95% 97-98 51%CQM-155 Weight Assessment for Children & Adolescents P2 N1. Age 12-17 BMI PH Workman 51 51 100.00% 95% 97-98 99%CQM-155 Weight Assessment for Children & Adolescents P2 N2. Age 12-17 Nutrition Ed PH Workman 51 37 72.55% 95% 97-98 42%CQM-155 Weight Assessment for Children & Adolescents P2 N3. Age 12-17 Physical Ed PH Workman 51 36 70.59% 95% 97-98 39%CQM-156 High-Risk Medications in the Elderly 1. At least 1 High-Risk Drug PS Workman 19 1 5.26% 15% 15%CQM-156 High-Risk Medications in the Elderly 2. At least 2 High-Risk Drugs PS Workman 19 0 0.00% 1% 1%CQM-159 Depression Remission at Twelve Months CE Workman 6 0 0.00% 2%CQM-160 Depression Utilization of the PHQ-9 Tool 1. First Four Months CE Workman 30 19 67.86% Not Set -- 52%


01/01/2016 - 12/31/2016


ProvidersOverall

ProvidersCQM-160 Depression Utilization of the PHQ-9 Tool 2. Middle Four Months CE Workman 27 20 74.07% Not Set -- 58%CQM-160 Depression Utilization of the PHQ-9 Tool 3. Last Four Months CE Workman 12 4 33.33% Not Set -- 55%CQM-161 Adult MDD: Suicide Risk Assessment CE Workman 12 0 0.00% Not Set -- 0%CQM-163 Diabetes: LDL Management CE Workman 77 27 35.06% 24% 24%CQM-164 IVD: Aspirin/Antithrombotic Therapy CE Workman 19 17 89.47% 90% 51 75%CQM-165 Controlling High Blood Pressure CE Workman 217 129 59.45% 70% 35 54% 54%CQM-166 Low Back Pain: Use of Imaging Studies ER Workman 13 11 100.00% 100%CQM-169 Bipolar & Depression: AOD Appraisal CE Workman 28 0 0.00% Not Set -- 0%CQM-177 Child/Adolescent MDD: Suicide Risk Assessment PS Workman 7 0 0.00% Not Set -- 0%CQM-179 ADE Prevention and Monitoring: Warfarin TTR PS Workman 1 0 0.00% 0%CQM-182 IVD: Complete Lipid Panel and LDL Control 1. LDL Test Performed CE Workman 19 16 84.21% 60%CQM-182 IVD: Complete Lipid Panel and LDL Control 2. Qualifying LDL Results CE Workman 19 7 36.84% 31%

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