Effortless Mips Reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow.

  1. Minimal staff involvement, after set-up, for data collection and reporting to CMS
  2. EMR independent data collection - no more extra "clicks"!
  3. CMS audit management on your behalf
  4. Continually updated dashboard to monitor and optimize performance
  5. Proactive notification under-performing providers, to help focus your quality- improvement efforts
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5 reasons why you should choose OBERD for MIPS reporting

QCDR Supported Measures

All of the measures below qualify for MIPS credit. Those labeled "Non-MIPS" were developed by OBERD QCDR and approved by CMS for use in the 2018 MIPS reporting program.

OBERD allows you to collect and report patient-reported measures, independent of your EMR, to meet 55% of the MIPS Composite Performance Score. After set-up, data collection and reporting requires no staff involvement! We do it all for you, including managing CMS audits.

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NON-MIPS (OBERD) Measures


Non-MIPS (Oberd) Measures


NON-MIPS MEASURES All measures below were developed by OBERD QCDR and approved by CMS, and qualify for 2019 MIPS Reporting Program credit

OBERD22 Post Stroke Outcome & Follow-Up

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the “baseline” measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the “follow-up” measurement)

NUMERATOR: Number of patients counted in the denominator for whom a follow-up score is obtained which and has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Differences (MCID) of the questionnaire in use).

DENOMINATOR: Number of patients 18 or older, diagnosed with IS, ICH, or TIA, who received a baseline score, and who are eligible for a follow-up score during the measurement period.

DENOMINATOR EXCLUSIONS: Patients unable or unwilling to provide a follow-up

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD23 Health Related Quality of Life: Patient Defined Outcomes

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.

NUMERATOR: Number of p

ENOMINATOR: Number of patients 18 or older who are being treated for an impairment of the ability to perform a self-selected activity of importance to the patient's quality of life.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD25 Patient Satisfaction: Tracking Satisfaction Improvement with CG-CAHPS

RISK ADJUSTED: No

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.

NUMERATOR: Number of patients whose score did not go down between the last two

DENOMINATOR: Number of patients who have two or more CG-CAHPS scores

DENOMINATOR EXCLUSION: None

MEANINGFUL MEASURE AREA: Patient’s Experience of Care

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD28 Hip Functional Outcomes

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcomes

DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up patient-reported hip functional assessment (e.g. Harris Hip Score, HOOS, HOOS-PS, HOOS Jr, Oxford Hip, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

NUMERATOR: Number of patients whose follow-up hip score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR: Number of patients whose follow-up hip score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD31 Quality of Life-Mental Health Outcomes

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Patient Engagement/ Experience

HIGH PRIORITY: Yes, Outcomes

DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a mental component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

NUMERATOR: Number of patients whose follow-up QoL Mental Component Score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, at least one follow-up QoL assessment completed.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD32 Quality of Life – Physical Health Outcomes

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes TYPE: Patient Engagement/Experience

HIGH PRIORITY: Yes, Outcomes

DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

NUMERATOR: Number of patients whose follow-up QoL Physical Component Score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, at least one follow-up QoL assessment completed.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD33 Patient Acceptable Symptom State Outcomes

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes TYPE: Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients 18 years or older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up Patient Acceptable Symptoms State (PASS) assessment that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

NUMERATOR: Number of patients whose PASS score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, at least one PASS assessment completed.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

OBERD34 Upper Extremity Functional Outcomes

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Patient Reported Outcome

HIGH PRIORITY: No

DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, a follow-up patient-reported upper extremity functional assessment (e.g. PROMIS Upper Extremity, ASES, ASES - elbow, Oxford Shoulder Score, Oxford Instability Score, Penn Shoulder Score, Boston questionnaire, DASH, Quick DASH, PRWE, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

NUMERATOR: Number of patients whose follow-up upper extremity score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx in comparison to baseline.

DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx - Dec.31, 20xx, at least one follow-up upper extremity assessment completed.

DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

CCOME1 Patient-Reported Pain and/or Function Improvement after Total Knee arthroplasty

QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients 18 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include any validated measures of knee-related pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

NUMERATOR: Patients whose knee pain and/or function scores at 9-15 months post-op improved by at least 10% (e.g., 10 points on a 100-point scale) from baseline.

DENOMINATOR: All patients 18 years of age and older undergoing elective primary TKA surgery who completed knee-related PROMs (KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR or other validated measure) to measure knee pain and/or function up to 90 days prior to and 9-15 months after the surgery.

DENOMINATOR EXCLUSION: Patients under 18 years of age; emergent (non-elective) TKA; revision TKA surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

MEANINGFUL MEASURE AREA: Functional Outcomes

MEANINGFUL MEASURE AREA RATIONALE: This measure directly relates to patient-reported outcomes measures (PROMs).

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

CCOME4 Patient-Reported Pain and/or Function Improvement after ACLR Surgery

QUALITY DOMAIN: Person and Caregiver Centered Experience and Outcomes

TYPE: Patient Reported Outcome HIGH

PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

NUMERATOR: Patients whose knee pain and/or function scores at 9-15 months post-op improved by at least 10% (e.g., 10 points on a 100-point scale) from baseline.

DENOMINATOR: All patients 13 years of age and older undergoing elective primary ACLR surgery who completed knee-related PROMs (e.g., KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR) to measure knee pain/or function up to 90 days prior to and 9-15 months after the surgery.

DENOMINATOR EXCLUSION: Patients under 13 years of age; revision ACLR surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

CCOME6 Patient-Reported Pain and/or Function Improvement after APM Surgery

QUALITY DOMAIN: Person and Caregiver Centered Experience and Outcomes

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

NUMERATOR: All patients 13 years of age and older undergoing elective primary APM surgery who completed knee-related PROMs (e.g., KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR) to measure knee pain/or function up to 90 days prior to and 9-15 months after the surgery.

DENOMINATOR: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

DENOMINATOR EXCLUSION: Patients under 13 years of age; revision APM surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

IROMS11 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury patients treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.

NUMERATOR: The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their KOS change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

DENOMINATOR: The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 2

RISK ADJUSTED: Yes

IROMS13 Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome (PRO)

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

NUMERATOR: The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID ≥ 9) from their initial visit to their final visit in PT/OT practice or PT/OT group during the observation window.

DENOMINATOR: The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 2

RISK ADJUSTED: Yes

IROMS15 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

NUMERATOR: The total number of neck pain/injury patients evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

DENOMINATOR: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported. Additionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 2

RISK ADJUSTED: Yes

IROMS17 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

NUMERATOR: The total number of patients with low back pain to not achieve an MCID in their MDQ change score (MCID >6) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

DENOMINATOR: The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 2

RISK ADJUSTED: Yes

IROMS19 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported. Additionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).These measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

NUMERATOR: The total number of patients with arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID >10 for DASH, MCID>8 for QDASH) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

DENOMINATOR: The total number of surgical patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 2

RISK ADJUSTED: Yes

MEX4 Bunion Outcome - Adult and Adolescent

QUALITY DOMAIN: Effective Clinical Care TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain

NUMERATOR: Patients who were evaluated for hallux deformity Performance Met: Patient experienced less pain by pain scale 181A Denominator Exception: Clinician documented that the patient was not an eligible candidate for treatment of hallux deformity 181B Performance Not Met: Patient did not experience either improvement in pain scale or improvement in foot function index. 181C

DENOMINATOR: All patients with a contracted hallux or digit hallux valgus Denominator Criteria (Eligible Cases)Diagnosis for hallux deformity M20.11, M20.12, M20.21, M20.22, M20.5X2, M20.31, M20.32, Q74.2, Q66.6, Q66.3 and Patients who have had at least two visits during the reporting period WITHOUT Telehealth Modifier: GQ, GT

DENOMINATOR EXCLUSION: None

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

MEX5 Hammer Toe Outcome

QUALITY DOMAIN: Effective Clinical Care

TYPE: Patient Reported Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Percentage of patients who have a painful hammer toe, claw toe, mallet toe or other lesser toe deformity causing disability

NUMERATOR: Performance Met: Patient experienced less pain by pain scale 183A. Denominator Exception: Clinician documented that patient was not an eligible candidate for treatment of hammer toe 183B OR Performance Not Met: Patient did not experience either improvement in pain scale or improvement in foot function index. 183C

DENOMINATOR: All patients with a contracted lesser digit (Eligible Cases)

Diagnosis for contracted digit Q66.89, M20.41, M20.42, M20.51, M20.5x2, M20.61, M20.62 AND Patients who have had at least two visits during the reporting period WITHOUT Telehealth Modifier: GQ, GT

DENOMINATOR EXCLUSION: None

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

SPINETRACK4 Percent of patients meeting SCB thresholds for back or neck pain

QUALITY DOMAIN: Effective Clinical Care

TYPE: Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)

NUMERATOR: Number of patients who have a final value of 3.5 or less, have at least a 2.5 point improvement, or a at least a 41.4% improvement in back or at least a 3.5 point improvement in neck pain on NRS measures at least 6 months after the intervention.

DENOMINATOR: Any patient >18 years of age who underwent a spinal fusion procedure using any method.

DENOMINATOR EXCLUSION: Those patients who underwent a spinal fusion procedure without back or neck pain, measured as ≤3 on a numeric rating scale (e.g., patients being treated primarily for myelopathy). Those patients who had not yet reached the minimum 6-month follow-up time point.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

SPINETRACK6 Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)

QUALITY DOMAIN: Effective Clinical Care

TYPE: Outcome

HIGH PRIORITY: Yes, Outcome

DESCRIPTION: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)

NUMERATOR: Number of patients who have at least an 18.8 point improvement, at least a 36.8% improvement, or final disability value below 31.3 measured by ODI or at least a 9.5 point improvement on NDI questionnaires at least 6 months after the intervention.

DENOMINATOR: Any patient >18 years of age who underwent a spinal fusion procedure using any method.

DENOMINATOR EXCLUSION: Those patients who underwent a spinal fusion procedure without market disability, measured as ≤30 on Oswestry or neck disability questionnaires (e.g., patients being treated primarily for myelopathy). Those patients who had not yet reached the minimum 6-month follow-up time point.

MEANINGFUL MEASURE AREA: Functional Outcomes

PROPORTIONAL MEASURE: Yes

INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

PERFORMANCE RATE: 1

RISK ADJUSTED: No

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