Clinical Quality Measure
CMS117v2 (NQF 0038) - Pediatric Recommended Core Measure

Childhood Immunization Status

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio(IPV), one measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); 1 hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday.

NQS DOMAIN:   Population/Public Health




Description and Implementation within the EMR software

Denominator: All patients who turned 2 years of age during the meaningful-use reporting period and had at least 1 encounter during the period.

Numerator: Patients in the above mentioned list who had the appropriate number of vaccine doses administered by their second birthday. UniCharts looks at the HEALTH MAINTENANCE section on the HISTORY form to determine the vaccines and their administered date or status. The system identifies any particular vaccine by its CVX code that user provides in the customization area when defining that vaccine item in the HEALTH MAINTENANCE section. There are a total of 10 vaccines involved in this measure:
  1. DTaP (CVX 20, 50, 106, 110 or 120) - 4 doses
  2. IPV (CVX 10, 110 or 120) - 3 doses
  3. MMR (CVX 03 or 94) - 1 dose
  4. HiB (CVX 22, 46, 47, 48, 49, 50, 51 or 120) - 2 doses
  5. Hepatitis B (CVX 08, 42, 44, 51 or 110) - 3 doses
  6. VZV (CVX 21 or 94) - 1 dose
  7. Pneumococcal (CVX 33, 100 or 133) - 4 doses
  8. Hepatitis A (CVX 83 or 84) - 1 dose
  9. Rotavirus (CVX 116 or 119) - 2 doses
  10. Influenza (CVX 15, 111, 140 or 141) - 2 doses
Contraindications: The system will look at the KNOWN ALLERGIES section of the HISTORY form for any contraindications or exceptions. Medication allergies to any of the immunizations listed above should be recorded in KNOWN ALLERGIES section of the HISTORY form with allergy name exactly matching with the vaccine name. In addition, the system associates "bakers yeast" allergy with Hepatitis B, "neomycin" and "streptomycin" allergies with IPV, and "polymyxin" allergy with MMR vaccine.

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