SOAPware Learning CenterClinical Quality Measures User Guide (for 2011) Additional Measures (Choose 3 Additional Measures)NQF 0387 - (Additional) Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen

NQF 0387 - (Additional) Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen

Measure: NQF 0387 (Additional Measurement)

Measure Title:   Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen

Measure Description:  Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer.

Quality Measure Documentation Workflow

In order for the Clinical Quality Measure report to generate, the following must be documented in the relevant patient's chart:

1. The patient must be at least 18 years or older at the start of the reporting period and have at least one face-to-face encounter with the provider during the reporting period.

2. Documentation that the patient has stage IC-IIIC estrogen receptor/progesterone receptor positive breast cancer.  Inserting the shortcut code "PQRIbreCan" in the encounter Plan field will allow the user to select from a group of specific SMARText codes that can be used to document for this measure.  The encounter Plan field must include the following codes to document estrogen receptor or progesterone recptor positive breast cancer: 3315F.  

3.  Documentation that patient has stage IC-IIIC breast cancer.  Inserting the shortcut code "PQRIbreCan" in the encounter Plan field will allow the user to select from a group of specific SMARText codes that can be used to document for this measure.  The encounter Plan field must include one of the following codes to document breast cancer: 3372F, 3374F, 3376F or 3378F.  

4.  Documentation that the patient was prescribed tamoxifen or aromatase inhibitor.  Inserting the shortcut code "PQRIbreCan" in the encounter Plan field will allow the user to select from a group of specfic SMARText codes that can be used to document for this measure.  The encounter Plan field must include the following code to document that tamoxifen or aromatase inhibitor was prescribed: 4179F.  

*If the above is documented appropriately, this should increase the numerator and denominator for this measure to indicate that the patient is over the age of 18, has been seen at least once in the reporting period, has a diagnosis of Breast Cancer and Tamoxifen or aromatase inhibitor was not prescribed.

Measure Calculation Details

Numerator Calculation:

The numerator for this measure is calculated based on the following:

1.  The number of patients in the denominator who have documentation that the patient was prescribed tamoxifen or aromatase inhibitor using the SMARText code 4179F in the encounter Plan field.  

Denominator Calculation:

The denominator for this measure is calculated based on the following:

1.  The number of patients who are age 18 and older and have at least one face-to-face encounter with the provider during the reporting period;

2   And have a documentation of breast cancer estrogen receptor or progesterone positive using SMARText code 3315F in the encounter Plan field. *Note:  3316F and 3316F-8P will not increase the denominator.  

3.  And have documentation of Stage IC-IIIC breast cancer using one of the following SMARText codes in the encounter Plan field: 3372F, 3374F, 3376F or 3378F. *Note:  3370F, 3380F and 3370F-8P will not increase the denominator.

Report Clinical Quality Measures to CMS/Status

All of the items listed in the above steps need to be documented as structured data (as detailed above) in order to allow the user to capture the numerator, denominator and percentage for this quality measure.

For information on how to export the numerator, denominator and percentage for each Clinical Quality Measure, click here.

For more information on reporting clinical quality measures, click here.