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Washington Health Al iance Specification Document
January 2014

About the Technical Specifications
The medical group and clinic measures used by the Washington Health Alliance (the Alliance) for the Community Checkup report are based primarily on the Healthcare Effectiveness Data and Information Set (HEDIS®) specifications developed by the National Committee for Quality Assurance (NCQA). HEDIS® is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the health care quality. Reported measures that are NOT derived from NCQA HEDIS® specifications include the fol owing: the measure for the use of cholesterol-lowering medication for heart disease was developed by the American College of Cardiology and the American Heart Association and the five generic prescribing measures were developed by the Alliance in response to the significant potential for cost savings associated with fil ing prescriptions using generic rather than brand name drugs. All other reported measures are adhering to or are slight derivatives of the NCQA HEDIS® specifications. The results for many of the measures that the Alliance produces are reported at the clinic level. In order to report at this level, the Alliance must assign or “attribute” the care of a patient to an individual clinician. This document includes the methodology used for the attribution process. The results in the report are based on administrative claims data with a measurement year of July 1, 2012 through June 30, 2013. This differs from the typical HEDIS® measurement year which runs on a calendar cycle (January 1 through December 31). To obtain detailed specifications regarding HEDIS® measures including eligibility definitions, age ranges, procedure codes, diagnosis codes, specified dates of service, exclusions, continuous eligibility requirements, etc. please reference HEDIS® 2013 Volume 2: Technical Specifications, Reprinted with permission from the HEDIS 2013 Volume 2: Technical Specifications by the National Committee for Quality Assurance (NCQA). To purchase copies of this publication, contact NCQA Customer Support at 888-275-7585 or HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Access: Adults’
Eligible adults are defined as:
Adults 20 years and older as of the last date in the two years prior to the measurement year* (for Commercial) Access: Children and
Children who had a visit with a PCP during Eligible children are defined as:
Children 12 months to 19 years as of the last date in the measurement year* (7 to 19 years of age). Adolescent Well-Care
Adolescents who had at least one well-care Eligible adolescents are defined as:
visit with a PCP or an OB/GYN during the People 12-21 years as of the last date in the measurement Antibiotics:
Children who received a diagnosis of upper Eligible children are defined as:
respiratory infection (URI) and were Children 3 months as of the first day of the seventh month dispensed an antibiotic prescription on or 3 of the year prior to the measurement year* to 18 years as days after the index episode start date. of the 30th day of the sixth month of the measurement year* who had an outpatient or emergency department visit with rate so a higher score indicates appropriate testing for children with upper respiratory Exclusions:
Children who received more than one diagnosis on the episode date. Children who were dispensed a new or refill antibiotic prescription within the 30 days prior to the episode date, or still had an active antibiotics prescription on the episode date. Children with a competing diagnosis on or three days after the episode date. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 2: Technical Specifications, NCQA, Copyright 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Antibiotics:
Adults who received a diagnosis of acute Adults with Acute Bronchitis are defined as:
Patients 18 years as of the first day of the year prior to the antibiotic prescription on or 3 days after the measurement year* to 64 years of age as of the last day of the measurement year* who had an outpatient or emergency department visit with a diagnosis of acute rate so a higher score indicates appropriate treatment for adults with acute bronchitis. Exclusions:
Patients who had a diagnosis for a comorbid condition
during the 12 months prior to or on the episode date.
Patients where a new or refill prescription for an antibiotic
medication was filled 30 days prior to or on the episode
date. Patients with a competing diagnosis 30 days prior to
the episode date through 7 days after the episode date.
Asthma: Use of
Dispensed at least one prescription for a Eligible People with Asthma are defined as:
preferred therapy during the measurement Patients 5–50 years of age during the measurement year* who were identified as having persistent asthma because of at least four asthma medication dispensing events***, at least one emergency department visit with asthma as the primary diagnosis, at least one acute patient discharge with leukotriene modifiers, mast cell stabilizers, asthma as the principal diagnosis, or at least four outpatient asthma visits and dispensed at least two asthma medications. Exclusions: Exclude from the eligible population all
members diagnosed with emphysema, COPD, cystic
fibrosis, or acute respiratory failure at anytime in the
patient’s history up through the last day of the
measurement year.
***A member identified as having persistent asthma because of at least four asthma medication events, where leukotriene modifiers were the sole asthma medication dispensed in that year, must also have at least one diagnosis of asthma in the same year as the leukotriene modifier. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Breast Cancer
Women who had a mammogram during the Women eligible for breast cancer screening include:
Screening
Women 42-69 years of age as of the last day of the
Exclusions: Women who had a bilateral mastectomy or 2
separate unilateral mastectomies at anytime in the patient’s
history up through the last day of the measurement year.
Cardiology:
Adults with Cardiovascular conditions are defined as:
1. Patients 18-75 years discharged alive for AMI, CABG, or PTCA year prior to the measurement year*; or 2. Patients 18-75 years who had a diagnosis of any ischemic vascular disease (IVD) as an outpatient or as an acute inpatient during both the measurement year* and the Note: AMI and CABG are from inpatient claims only.
The NCQA Cholesterol Management for Patients with Cardiovascular Conditions measure also has an indicator for LDL-C control (<100 mg/dL) The Alliance is not reporting this indicator due to limited clinical results data. Cardiology:
Patients who had a prescription filled for a Adults with Coronary artery disease are defined as:
Patients 18-75 years of age with at least one outpatient, HEDIS® measure.
nonacute inpatient, acute inpatient or ED visit with any diagnosis of coronary artery disease on or between the first day of the first month and the first day of the eleventh month of the year prior to the measurement period. HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Cardiology:
Adults who have had a Heart Attack are defined as:
Patients 18 years of age and older as of the last day of the measurement year* who were discharged alive from an acute inpatient setting with an acute myocardial infarction
(AMI) between the first day of the seventh month of the
year prior the measurement year through the 30th day of the
sixth month of the measurement year.
Exclusions: Exclude members of the eligible population
that have a contra-indication to beta-blocker therapy
anytime in the member’s history including patients with a
history of asthma, hypotension, heart block > 1 degree,
sinus bradycardia, and/or COPD.
Cervical cancer
Women eligible for a Pap test include:
screening
Women 24-64 years as of the last day of the measurement Exclusions: Women who had a hysterectomy with no
residual cervix that occurred anytime in the patient’s history up through the last day of the measurement year. LOINC (lab test) codes are not being used. Chlamydia screening
Women eligible for a Chlamydia screen include:
Sexually active women 16-24 years of age as of the last day of the measurement year*. Sexually active women are identified by either having filled a prescription for
contraceptives during the measurement year* or had at
least 1 claim with a code to identify sexually active women.
Exclusions: Women who had a pregnancy test during the
measurement year followed within 7 days by either a
prescription for Accutane or an x-ray are excluded.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Colorectal Cancer
Patients who had a screening for colorectal Patients eligible for a Colorectal screen include:
Screening
Patients 51-58 years of age as of the last day of the Exclusions: Patients with a diagnosis of colorectal cancer
or total colectomy that occurred anytime in the patient’s history up through the last day of the measurement year. Claims (administrative) data only is being used to calculate the measure. Claims data looks back through 2004 for colonoscopies instead of looking back nine years. LOINC (lab test) codes are not being used. Depression:
Patients with Depression are defined as:
antidepressant medication for at least 84 Patients aged 18 and older as of the last day of the fourth month of the measurement year* diagnosed with a new episode of major depression during the measurement year* and prescribed antidepressant medication. Depression:
Exclusions: Patients who had a claim/encounter for any
antidepressant medication for at least 180 diagnosis of major depression or prior episodes of depression during the 120 days prior to the episode start Exclude patients who did not fill a prescription for an antidepressant medication 30 days prior to the prescription start date through 14 days after the episode start date. Exclude patients who filled a prescription for an antidepressant medication 90 days prior to the episode start date. Diabetes -
Patients who had at least one HbA1c test Patients with Diabetes are defined as:
Comprehensive
1. Patients 18-75 years of age as of the last day of the Diabetes Care:
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Diabetes -
Comprehensive
hypoglycemic/anti-hyperglycemic on an ambulatory Diabetes Care: LDL-C measurement year*.
basis during the measurement year or year prior; Diabetes -
b. who had two face-to-face encounters with Comprehensive
different dates of service in an outpatient setting or Diabetes Care: Eye
those diabetics who had a retinal or dilated non-acute inpatient setting with a diagnosis of diabetes during the measurement year or year (optometrist or ophthalmologist) during the c. with one face-to-face encounter in an acute inpatient or emergency department setting with a Diabetes -
diagnosis of diabetes during the measurement year Comprehensive
Diabetes Care:
during the measurement year*. Evidence of nephropathy includes a nephrologist visit, a Exclusions: Patients with gestational diabetes, steroid-
induced diabetes, or polycystic ovaries who did not have any face-to-face encounters with a diagnosis of diabetes. For gestational and steroid-induced diabetes, the diagnosis can occur during the measurement year or the year prior to the measurement year. For patients with polycystic ovaries, the diagnosis can come at any point in the patient’s history. All diagnoses must have occurred by the last day of the measurement year. Prescribing:
Prescribing event is defined by:
inhibitor or ARB prescriptions identified as A prescription for at least a 30-day supply of ACE inhibitors HEDIS® measure.
or ARBs, both brand-name and generic, during the 12- blockers (ARBs).
Prescribing:
Prescribing event is defined by:
A prescription for at least a 30-day supply of ADHD drugs, HEDIS® measure.
both brand-name and generic, during the 12-month HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012. Measure Name
Numerator: Definition for Compliance of
Denominator: Definition of Eligible Population and
Modifications to
Exclusions
NCQA HEDIS®
Specifications**
Prescribing:
Prescribing event is defined by:
A prescription for at least a 30-day supply of PPIs, both HEDIS® measure.
brand-name and generic, during the 12-month Prescribing:
Prescribing event is defined by:
A prescription for at least a 30-day supply of second and HEDIS® measure.
third generation antidepressants, both brand-name and generic, during the 12-month measurement year*. Generation
Antidepressants
Prescribing:
Number of prescribing events for statins Prescribing event is defined by:
A prescription for at least a 30-day supply of statins, both HEDIS® measure.
brand-name and generic, during the 12-month measurement year*. Details can be found in Appendix D. Use of Imaging
Patients with Low back pain are defined as:
Studies for Low Back
Patients aged 18-50 during the measurement year* who had an outpatient or emergency department encounter with rate so a higher score indicates appropriate Exclusions:
treatment of low back pain.
Patients with a low back pain diagnosis during the 180 days (6 months) prior to the episode date. Patients for whom an imaging study in the presence of low back pain is clinically indicated: cancer anytime in the patient’s medical history; recent trauma, intravenous drug use, or neurological impairment within 12 months of the episode date. Use of Spirometry
Patients with at least one medical claim for Adults with COPD are defined as:
Testing in the
spirometry testing in the 2 years before the Patients 40 years of age and older with a new diagnosis of Assessment and
diagnosis of COPD or up to 180 days after Diagnosis of COPD

Exclusions:
Members who had an outpatient, ED or acute inpatient visit
with a COPD diagnosis during the 2 years prior to the
episode date.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA) *The results are based on administrative claims data with a measurement year of July 1, 2012 – June 30, 2013. **HEDIS® 2013 Volume 3: Technical Specifications, NCQA, 2012.

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