Amirfar et al. BMC Public Health 2011, 11:753 http://www.biomedcentral.com/1471-2458/11/753 Page 5 of 8 Table 3 All Alerts are on an annual basis unless specified otherwise TCNY Domain Measure Name Brief Description of Measure Have a regular doctor Patients see assigned PCG See assigned PCG at least once Be tobacco free Smoking status Update smoking status Smoking cessation Stop smokers with medications or counseling intervention Keep your heart healthy BP control in HTN Control BP < 140/90 in patients with HTN without DM or IVD Antithrombic Provide Patients with IVD or DM with antithrombic therapy Body Mass Index Measure the height and weight for BMI Cholesterol screen Screen patients without DM or IVD for cholesterol/HDL Cholesterol control Control patients without DM or IVD to a total cholesterol < 240 or LDL < 160 LDL control (high risk) Control patients without DM or IVD to an LDL < 100 LDL testing (high risk) LDL screen for patients with DM or IVD A1C testing Measure at least one HbA1c in DM patients every 6 months A1C control (< 7%) Control HbA1c below 7.0% in DM patients BP control in IVD Control BP < 140/90 with a diagnosis of IVD without DM BP control in IVD AND Control BP < 140/90 with a diagnosis of IVD AND HTN without DM HTN BP control in DM Control BP < 130/80 with a diagnosis of DM BP control in DM AND Control BP < 130/80 with a diagnosis of DM AND HTN HTN Know your HIV status HIV screening Screen for HIV HIV viral load and CD4 Monitor HIV patients’ viral load and CD4 every 3 months Get help for depression Depression screening Screen patients for depression Depression follow-up Monitor patients with depression every 3 months Depression control Lower depressed patients PHQ-9 score Live free of dependence on alcohol Alcohol use screening Screen for alcohol misuse and drugs Get checked for cancer Colorectal cancer Screen 50-80 years old patients screening Breast cancer screening Screen female ≥ 40 years old Cervical cancer screening Screen female 18-64 years old Get the immunizations you need Influenza vaccine (child) Vaccinate children 7 months to 5 years old Influenza vaccine (high Vaccinate high risk patients 5-49 years old risk) Influenza vaccine Vaccinate > 50 years old Pneumococcal vaccine Vaccinate ≥ 65 years old or ( ≥ 60 months AND in a high risk group) Make your home safe and healthy Lead testing (1 year) Screen one-year old with a blood lead test Lead testing (2 years) Screen two-year old with a blood lead test Asthma symptom Assess 18-56 years old for asthma severity assessment Asthma control Assess 5-56 years old with persistent asthma who were prescribed appropriate medications Have a healthy baby Chlamydia screening Screen eligible female patients Sexual history Update > 18 years old sexual history Sexual history taken Update 12-17 years old sexual history binary counts is that it allows a quantitative assessment of each patients’ compliance to a particular CDSS alert and allows for comparison of providers’ performance to city or zip code averages. In order to provide some lag time between the time the provider orders a lab and the result return from the commercial laboratory, we also introduced the concept of snoozing alerts. It is a transition phase allowing the patients a certain amount of time (usually one month) to get their labs drawn and for the result to return to the provider’s EHR. A snoozed alert disappears from a provider’s CDSS menu but will return as an alert if the lab result does not appear in the time window. Once measures had been defined and we had agreed on how the DOHMH and our providers would use them to monitor and improve important quality