"detail": "0.57.4",
"value": 19.27,
"parts": [
{
"name": "quality",
"title": "QUALITY component of total score",
"detail": "Scoring based on weight of 50%.",
"value": 19.27,
"original": {
"name": "quality",
"value": 38.5,
"detail": "Picked the highest scoring measurement set registry",
"parts": [
{
"name": "quality",
"value": 38.5,
"detail": "registry",
"parts": [
{
"name": "001",
"value": 3,
"detail": "Contributing 3",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-076",
"message": "Applied minimum decile score."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-093",
"message": "Default end to end bonus score of 0."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
}
],
"metadata": {
"performanceRate": 84.99,
"reportingRate": 100,
"measureClass": "Class 1",
"measureTitle": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)",
"highPriorityBonusEligible": true,
"endToEndBonusEligible": false,
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"highPriorityBonusIgnored": true,
"decileScore": 3,
"performanceDenominator": 473,
"performanceNumerator": 402,
"eligiblePopulation": 478,
"partialDecileScore": 0,
"partialPoints": 0,
"decile": -1,
"deciles": [
100,
57.89,
42.36,
31.58,
25.77,
20.93,
16.81,
12.77,
7.69
],
"processingStatus": "PICKED",
"totalMeasurementPoints": 3,
"totalBonusPoints": 0,
"messages": {
"benchmarkType": "Did not override registry benchmark because measure is missing EHR submission method or spec and not an eCQM measure",
"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"decileScore": "Applied minimum decile score",
"e2eBonusScore": "Default E2E bonus score",
"highPriorityBonus": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus",
"measurementPicker": "Picked at 1",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "registry",
"eMeasureId": "CMS122v6",
"cpcPlusGroup": "Outcome_Measure",
"toppedOut": false,
"isGhost": false,
"unroundedScoreValue": 3
}
},
{
"name": "110",
"value": 9.1,
"detail": "Contributing 9.1",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-078",
"message": "Applied default decile scoring."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-093",
"message": "Default end to end bonus score of 0."
},
{
"reasonCode": "QUALITY-105",
"message": "Measure eligible for high priority bonus with minimum performance rate and eligible populations reached."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
}
],
"metadata": {
"performanceRate": 84.57,
"reportingRate": 100,
"measureClass": "Class 1",
"measureTitle": "Preventive Care and Screening: Influenza Immunization",
"highPriorityBonusEligible": false,
"endToEndBonusEligible": false,
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"decileScore": 9.14,
"performanceDenominator": 473,
"performanceNumerator": 400,
"eligiblePopulation": 478,
"partialDecileScore": 0.1,
"partialPoints": 1.86,
"decile": 9,
"deciles": [
0,
26.89,
40.49,
50,
57.07,
64.79,
73.08,
82.71,
96.44
],
"processingStatus": "PICKED",
"totalMeasurementPoints": 9.14,
"totalBonusPoints": 0,
"messages": {
"benchmarkType": "Did not override registry benchmark because measure is missing EHR submission method or spec and not an eCQM measure",
"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"e2eBonusScore": "Default E2E bonus score",
"measurementPicker": "Picked at 2",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "registry",
"eMeasureId": "CMS147v7",
"cpcPlusGroup": "Other_Measure",
"toppedOut": false,
"isGhost": false,
"unroundedScoreValue": 9.14
}
},
{
"name": "109",
"value": 7.9,
"detail": "Contributing 7.9",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-078",
"message": "Applied default decile scoring."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-096",
"message": "If measure is end to end reported, then end to end bonus score is applied."
},
{
"reasonCode": "QUALITY-105",
"message": "Measure eligible for high priority bonus with minimum performance rate and eligible populations reached."
},
{
"reasonCode": "QUALITY-110",
"message": "Allotted high priority bonus point."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
}
],
"metadata": {
"performanceRate": 84.57,
"reportingRate": 100,
"measureClass": "Class 1",
"measureTitle": "Osteoarthritis (OA): Function and Pain Assessment",
"highPriorityBonusEligible": true,
"endToEndBonusEligible": true,
"endToEndBonus": 1,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 1,
"decileScore": 5.98,
"performanceDenominator": 473,
"performanceNumerator": 400,
"eligiblePopulation": 478,
"partialDecileScore": 0.9,
"partialPoints": 19.57,
"decile": 5,
"deciles": [
0,
15.38,
35.33,
65,
84.9,
95.19,
100,
100,
100
],
"processingStatus": "PICKED",
"totalMeasurementPoints": 7.98,
"totalBonusPoints": 2,
"messages": {
"benchmarkType": "Did not override registry benchmark as eHR benchmark was not found",
"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"e2eBonusScore": "Bonus from isEndToEndReported",
"highPriorityBonus": "Allotting 1 point to high priority bonus for measure type 'process'",
"measurementPicker": "Picked at 3",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "registry",
"eMeasureId": null,
"toppedOut": true,
"isGhost": false,
"unroundedScoreValue": 7.98
}
},
{
"name": "102",
"value": 3,
"detail": "Contributing 3",
"instrumentations": [
{
"reasonCode": "QUALITY-009",
"message": "Measurement meets the minimum reporting rate for this attestation year."
},
{
"reasonCode": "QUALITY-051",
"message": "Measure is a class 1 measure, Eligible population is >= 20 and reporting rate > 60 and has benchmarks"
},
{
"reasonCode": "QUALITY-076",
"message": "Applied minimum decile score."
},
{
"reasonCode": "QUALITY-091",
"message": "Class 1 measures receive a higher weight than the rest."
},
{
"reasonCode": "QUALITY-093",
"message": "Default end to end bonus score of 0."
},
{
"reasonCode": "QUALITY-105",
"message": "Measure eligible for high priority bonus with minimum performance rate and eligible populations reached."
},
{
"reasonCode": "QUALITY-111",
"message": "Measure contributed points to total score."
},
{
"reasonCode": "QUALITY-113",
"message": "Measure contributed bonus points to total score."
},
{
"reasonCode": "QUALITY-117",
"message": "Measurement points for PICKED measure include decile score with all bonus points."
},
{
"reasonCode": "QUALITY-005",
"message": "If measure is found to be in a clinical cluster the measure will be labeled with its EMA relationship"
}
],
"metadata": {
"performanceRate": 84.99,
"reportingRate": 100,
"measureClass": "Class 1",
"measureTitle": "Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients",
"highPriorityBonusEligible": false,
"endToEndBonusEligible": false,
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"decileScore": 3,
"performanceDenominator": 473,
"performanceNumerator": 402,
"eligiblePopulation": 478,
"partialDecileScore": 0,
"partialPoints": 0,
"decile": -1,
"deciles": [
0,
98.92,
100,
100,
100,
100,
100,
100,
100
],
"processingStatus": "PICKED",
"totalMeasurementPoints": 3,
"totalBonusPoints": 0,
"messages": {
"benchmarkType": "Did not override registry benchmark as eHR benchmark was not found",
"measurementClass": "Eligible population is greater than or equal to 20, reporting rate is greater than 60% and has benchmarks",
"decileScore": "Applied minimum decile score",
"e2eBonusScore": "Default E2E bonus score",
"measurementPicker": "Picked at 4",
"totalMeasurementPoints": "Measurement points for PICKED measure include decile score with all bonus points"
},
"noBenchmarks": false,
"benchmarkType": "registry",
"eMeasureId": "CMS129v7",
"toppedOut": true,
"isGhost": false,
"unroundedScoreValue": 3
}
}
],
"instrumentations": [
{
"reasonCode": "QUALITY-031",
"message": "EMA eligible specialty sets have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-032",
"message": "EMA eligible specialty sets do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-060",
"message": "Not EMA eligible because measurement set does not match a specialty set exactly"
},
{
"reasonCode": "QUALITY-025",
"message": "EMA eligible clinical clusters have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-026",
"message": "EMA eligible clinical clusters do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-027",
"message": "EMA eligible clinical clusters belong to a single clinical cluster"
},
{
"reasonCode": "QUALITY-071",
"message": "At least 1 high or outcome or patient experience measure available, so denominator is 60."
},
{
"reasonCode": "QUALITY-100",
"message": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus."
},
{
"reasonCode": "QUALITY-116",
"message": "Applicable measurement points summed."
}
],
"metadata": {
"messages": {
"denominator": "At least 1 high or outcome or patient experience measure available. So denominator is 60",
"totalDecileScore": "Decile score points for measurements included in measurement set score, excluding bonus points",
"totalBonusPoints": "Sum of measurement bonus points included in the measurement set score",
"totalMeasurementPoints": "Sum of applicable measurement points."
},
"maxContribution": 100,
"measuresPicked": [
"001",
"110",
"109",
"102"
],
"measuresSubmittedCount": 4,
"measuresSubmitted": [
"001",
"110",
"109",
"102"
],
"totalDecileScore": 21,
"totalBonusPoints": 2,
"totalMeasurementPoints": 23,
"denominator": 60,
"e2eBonusScore": 1,
"maxMeasurementsAllowed": 6,
"mergedWithCahps": false,
"processingStatus": "PICKED",
"unroundedScoreValue": 23.12,
"measurementSetPicked": true,
"reweightedScore": 23
}
}
],
"metadata": {
"unroundedScoreValue": 38.53333333333334
},
"instrumentations": [
{
"reasonCode": "QUALITY-031",
"message": "EMA eligible specialty sets have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-032",
"message": "EMA eligible specialty sets do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-060",
"message": "Not EMA eligible because measurement set does not match a specialty set exactly"
},
{
"reasonCode": "QUALITY-025",
"message": "EMA eligible clinical clusters have between one and five EMA eligible measures"
},
{
"reasonCode": "QUALITY-026",
"message": "EMA eligible clinical clusters do not contain QCDR measurements"
},
{
"reasonCode": "QUALITY-027",
"message": "EMA eligible clinical clusters belong to a single clinical cluster"
},
{
"reasonCode": "QUALITY-071",
"message": "At least 1 high or outcome or patient experience measure available, so denominator is 60."
},
{
"reasonCode": "QUALITY-100",
"message": "Measure having highest decile score (preference given to outcome, intermediate outcome, intermediate outcome and process) is not eligible for high priority bonus."
},
{
"reasonCode": "QUALITY-116",
"message": "Applicable measurement points summed."
}
]
},
"metadata": {
"maxContribution": 50,
"unroundedScoreValue": 19.26666666666667
}
},
{
"name": "feedback-quality",
"parts": [
{
"name": "001",
"detail": "Focus on improving measure 001"
},
{
"name": "102",
"detail": "Focus on improving measure 102"
},
{
"name": "109",
"detail": "Focus on improving measure 109"
}
]
}
],
"instrumentations": [],