Form 1 HIVQM Manual

RYAN WHITE HIV/AIDS PROGRAM

HIV Quality Measures (HIVQM) Module
Instruction Manual 2021-2022
Date: August 2021 | Version: 1

Public Burden Statement: An agency may not conduct or
sponsor, and a person is not required to respond to, a collection
of information unless it displays a currently valid OMB control
number. The OMB control number for this project is 0906- 0022
with an expiration date of Dec. 31, 2022. Public reporting burden
for this collection of information is estimated to average six
hours per response, including the time for reviewing instructions,
searching existing data sources, and completing and reviewing
the collection of information. Send comments regarding this
burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to
HRSA Reports Clearance Officer, 5600 Fishers Lane, Room
14N39, Rockville, Maryland, 20857.

HIV/AIDS Bureau
Division of Policy and Data
Health Resources and Services Administration
U.S. Department of Health and Human Services
5600 Fishers Lane, Room 9N164
Rockville, MD 20857

Table of Contents
Background
The HIV Quality Measures Module
What’s new?
What are the components of the HIVQM Module?
Which clients can be included in the HIVQM Module?
Who enters data in the HIVQM Module?
How do you access the HIVQM Module?
When can you enter data?

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How are the HIVQM Module data submitted to HAB?
Instructions for Completing the HIVQM Module
Step One: Access the most recent RSR deliverable
Step Two: Access the HIVQM Module
Step Three: Completing the Provider Information Page
Step Four: Entering Performance Measures Data

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Access prior reports during the March submission period

Uploading Performance Measures Data
Manually Entering Performance Measures Data
Select measures
Enter performance data
Entering Demographic Data NEW

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Step Five: Generate HIVQM Reports

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Appendix A
HIVQM Upload – Field Definitions
Performance Measure IDs
Gender Codes
Race/Ethnicity Codes
HIV Risk Factor Codes
HIVQM Data Validations
Appendix B - HIVQM Validation Rules
HIVQM File Upload Validations

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Summary report
Comparison trend report
Program Parts Comparison Report

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

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Background
The The Ryan White HIV/AIDS Treatment
Extension Act of 2009 (Public Law 111-87,
October 30, 2009) provides the federal
HIV programs in the Public Health Service
Act under Title XXVI, flexibility to respond
effectively to the changing epidemic. It
emphasizes providing life-saving and lifeextending services for people with HIV
across the country and providing resources
to targeted areas with the greatest need.
All Program Parts of the Ryan White
HIV/AIDS Program (RWHAP) specify
the Health Resources and Services
Administration’s (HRSA’s) responsibilities
in the allocation and administration of
grant funds, as well as the evaluation of
programs for the population served, and
the improvement of the quality of care.
The provision of accurate records of the
recipients receiving RWHAP funding, the
services provided, and the clients served
continue to be critical to the implementation
of the statute and thus are necessary for
HRSA to fulfill its responsibilities.
The RWHAP statute authorizes the use
of grant funds to improve the quality,
availability, and organization of HIV health

care and support services. Specifically,
recipients are required to establish a clinical
quality management program (CQM) to:
— assess the extent to which HIV
services are consistent with the
most recent Public Health Service
guidelines (otherwise known as the
HHS guidelines) for the treatment of
HIV disease and related opportunistic
infections; and
— develop strategies for ensuring that
such services are consistent with the
guidelines for improvement in the
access to, and quality of HIV services.
Since 2007, the HIV/AIDS Bureau (HAB)
has released performance measures for
recipients to use as guidance for their
CQM program; however, recipients are
not required to use the HAB-developed
measures nor are they required to submit
performance measure data. Recipients
do report on some clinical data elements
through the required Ryan White HIV/
AIDS Program Services Report (RSR) on
an annual basis; however, these data give
HAB only a snapshot of the quality of HIV
services provided by recipients.

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

In 2013, HAB introduced new HIV
performance measures, located at: https://
hab.hrsa.gov/clinical-quality-management/
performance-measure-portfolio with the
goals of:
— Identifying core performance
measures that are most critical to the
care and treatment of people with HIV;
— Combining measures to address
people with HIV of all ages;
— Aligning measures with U.S.
Department of Health and Human
Services priorities, guidelines, and
initiatives;
— Promoting relevant performance
measures used in other federal
programs;
— Archiving performance measures;
and
— Monitoring progress toward achieving
the goals identified in the National
HIV/AIDS Strategy: Updated to 2020.

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The HIV Quality Measures Module
HAB developed the HIV Quality
Measures (HIVQM) Module, a tool within
the existing RSR portal, to allow recipients
to voluntarily enter aggregate data on the
HAB performance measures. This tool
offers recipients and their subrecipients
an easy-to-use and structured platform
to continually monitor their performance
in serving clients, particularly in providing
access to care and quality HIV services.
Recipients and subrecipients may find
the tool helpful as they set goals for

performance measures and quality
improvement projects. Finally, the HIVQM
Module allows recipients to obtain reports
that compare providers within their state,
regionally, nationally, as well as by Ryan
White Program Part. HRSA expects the
HIVQM Module will better support CQM,
performance measurement, service
delivery, and client monitoring at both the
recipient and client levels, enhancing the
submitted data’s quality and utility.

Recipients and service providers who
participate in a Centers for Medicare and
Medicaid Incentive program, such as
the Medicare and Medicaid Electronic
Health Records Incentive Program
and the Physician Quality Reporting
System, may also find the HIVQM
Module helpful because data submitted
qualify and comply with these programs’
requirements.

What’s new?
— Recipients and subrecipients can now enter demographic data along with performance
measures. Below is the list of demographics you can enter. You can upload your
demographic data from a CSV file along with your performance measure data or
manually enter them in the Module under “Enter Performance Data.” For more
information, see Step Four: Entering Performance Measures Data.
New Demographics Data:
— Age: minimum and max age
— Gender: Male, Female,
Transgender (All), Transgender
Male to Female, Transgender
Female to Male, Transgender
Other

— Race/Ethnicity: American Indian/
Alaska Native, Asian, Black/African
American, Hispanic/Latino, Native
Hawaiian/Pacific Islander, White,
Multiple races

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

— HIV Risk Factor: Male to Male
sexual contact (MSM), Injection
drug use (IDU), MSM and IDU,
Heterosexual contact, Perinatal
Transmission, Other

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The HIV Quality Measure Module

— HRSA HAB has also added a new core performance measure, “Annual Retention in
Care.” For more information on this new core performance measure, go to
https://hab.hrsa.gov/clinical-quality-management/performance-measure-portfolio.
— Finally, CAREWare users can now also upload performance measures data via
CAREWare. For more information, contact the CAREWare Help Desk at
[email protected] or (877) 294-3571.

What are the components of the HIVQM Module?
The HIVQM Module comprises three parts:
— The Provider Information page
consists of four prepopulated data
points about the provider (generated
from the latest RSR).

For more detailed information on
these clinical measures, visit the
HAB webpage at: https://hab.hrsa.
gov/clinical-quality-management/
performance-measure-portfolio.

— The Performance Measures section
is where recipients can choose and
enter aggregate data on up to 44
clinical measures under these nine
main categories:
•
•
•
•
•
•
•
•
•

Core
All Ages
Adolescent and Adult
Children
HIV-Exposed Children
Medical Case Management
Oral Health
ADAP
Systems-Level

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

— The HIVQM Reports are where
recipients can generate reports
based on their own data as well as
compare their data to other recipients
and/or subrecipients who have
entered data into the Module. The
comparison reports do not include
the identity of the other recipients or
subrecipients.

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The HIV Quality Measure Module

Which clients can be included in the HIVQM Module?
All clients who receive HIV services, regardless of funding source, can be included in the
HIVQM Module.

Who enters data in the HIVQM Module?
The use of the HIVQM Module is voluntary, but it is strongly encouraged. The HIVQM
Module is available for each recipient and subrecipient who provides HIV care services
and can enter their own data. Recipients can complete the data entry in the Module for
any of their subrecipients.

How do you access the HIVQM Module?
Access the Module through the existing RSR web system (you must be able to access
your RSR with a login and password). To learn how to access the Module from the RSR
Inbox, go to Step Two: Access the HIVQM Module.

When can you enter data?
The Module is available to recipients and subrecipients four times a year—March,
June, September, and December—to submit performance measure data for a specified
12-month period. These reporting periods are outlined in the table below.

HIVQM Module Opens

HIVQM Module Closes

Reporting Period

Sept. 1, 2021

Sept. 30, 2021

July 1, 2020–June 30, 2021

Dec. 1, 2021

Dec. 31, 2021

Oct. 1, 2020–Sept. 30, 2021

March 1, 2022

March 31, 2022

Jan. 1, 2021–Dec. 31, 2020

June 1, 2022

June 30, 2022

April 1, 2021–March 31, 2022

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

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The HIV Quality Measure Module

Access prior reports during the March submission period
Once a year, during the March submission period, recipients and subrecipients are able
to enter and update data for the previous four reporting periods. These reporting periods
will be listed in the HIVQM Report Inbox. See Figure 2b for a screenshot of the HIVQM
Inbox during March Reporting Period. To enter and update data for a reporting period,
click the envelope icon on the right under the “Action” column. Note that for reporting
periods with no previous data, the comment under the “Status” column will display “Not
Started,” but you will still be able to enter data by clicking the envelope icon.
Figure 2b. HIVQM Inbox during March Reporting Period

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

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The HIV Quality Measure Module

How are the HIVQM Module data submitted to HAB?
Once you have entered and saved data in the Provider Information and the Performance
Measures sections, you have submitted your data. HAB will have access to the data at
the conclusion of each submission period.

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Instructions for Completing the HIVQM Module
Each recipient and its subrecipients have access to the HIVQM Module. Those
that receive funding from multiple parts only need to access the Module once
to enter data. For example: If an agency receives Part A and C funding, it will
only need to enter data once per submission period. The Part A and C grant
recipients of record will have access to those data.

!

Enter data for all clients who receive HIV
services, regardless of funding source.

Step One: Access the most recent RSR deliverable
There are two ways that you can access the most recent RSR deliverable, depending on
whether you are a recipient/recipient-provider or a provider:
1. Recipients/recipient-providers only: Log in to the EHBs at
https://grants.hrsa.gov/webexternal and navigate to the RSR Inbox.
— Hover over the “Grants” tab at the top of the page, and on the drop-down menu,
click on “Work on Performance Reports.”
— Locate your most recent RSR deliverable and click “Start” or “Edit” in the Action
column on the far right.
2. Providers only: Log in to the RSR web system at: https://performance.hrsa.
gov/hab/regloginapp/admin/login.aspx?application=rsrApp and navigate to
the RSR Inbox.

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

If you need help navigating the EHBs to
find your annual RSR, contact Ryan White
Data Support at 1-888-640-9356 or e-mail
[email protected].

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Instructions for Completing the HIVQM Module

Step Two: Access the HIVQM Module
Once in the RSR Inbox, click the “HIVQM Inbox” link under the “Performance Measures”
heading on the Navigation panel on the left side of the screen. See Figure 1 for a
screenshot of the RSR Recipient Report Inbox.
Figure 1. RSR Recipient Report Inbox

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Instructions for Completing the HIVQM Module

In the HIVQM Report Inbox, find the provider name you want to enter data for and click
the envelope icon on the right under the “Action” column. See Figure 2a for a screenshot
of the HIVQM Inbox. This will take you to the first section of the HIVQM Module, the
Provider Information page.
Figure 2a. HIVQM Inbox

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Instructions for Completing the HIVQM Module

Step Three: Completing the Provider Information Page
The Provider Information page will be prepopulated with data from your last RSR and
consists of four items. Check the information already captured on the page and update
any incorrect data. Below are the items and option responses. See Figures 3a–b for
screenshots of the Provider Information page.
1. Provider Caseload: Total number of unduplicated clients enrolled at the end of the
reporting period. Enter a number up to seven characters; it must be greater than zero
2. Funding Source: Indicate all your agency’s funding sources received during the HIVQM
reporting period by clicking the corresponding checkboxes. You must select at least one
funding source, and you can select more than one if applicable to your agency.
— Part A
— Part B
— Part B Supplemental
— Part C EIS
— Part D
3. Provider Type: Indicate the agency type that best describes your agency by
clicking the appropriate radio button. If you choose Other facility, please specify a
description. You must indicate at least one provider type.
— Hospital or university-based clinic
— Publicly-funded community health center
— Publicly-funded community mental health center
— Other community-based service organization (CBO)
— Health department
— Substance abuse treatment center
— Solo/group private medical practice
— Agency reporting for multiple fee-for-service providers
— People Living with HIV/AIDS (PLWH) Coalition
— VA facility
— Other facility (Please specify)
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Instructions for Completing the HIVQM Module

Figure 3a. HIVQM: Provider Information Page

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4. Data Collection: This item consists of three (a–c) entries regarding your data
collection system(s). You must enter data for 4a and 4b. You must enter data for 4c
only if you selected Other in 4b.
a. Does your organization use a computerized data collection system? Click the
appropriate radio button.
— Yes, all electronic
— Yes, part paper and part electronic
— No
— Unknown
b. What is the name of your current data collection system(s)? Indicate all systems
that your agency uses by clicking the corresponding checkboxes.
— AIRES
— Allscripts
— AVIGA
— CAREWare
— Casewatch Millenium
— Cerner
— eClinicalWorks

— eCOMPAS
— EHS CareRevolution
— Epic
— ETO Software
— FutureBridge
— GE/Centricity
— Sage/Vitera

— NextGen
— Provide Enterprise
— SCOUT
— Other
— Unknown

c. If you selected Other in 4b, enter in the text field any data collection system(s)
used to run performance measures that are not listed in 4b. Use a semicolon to
separate multiple items.
Once you have completed the Provider Information page, save your data by clicking
“Save” on the bottom right of the screen. If you did not enter data for all items, you will
receive an error message to return to the item with missing data and correct it. You will
not be able to save your data until you have addressed all error messages.

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Instructions for Completing the HIVQM Module

Figure 3b. HIVQM: Provider Information Page

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Instructions for Completing the HIVQM Module

Step Four: Entering Performance Measures Data
Recipients and subrecipients can now enter performance measures data in
three ways: 1) via data upload from a CSV file into the Module, 2) manually
entering the data into the Module performance measures pages or 3) via
CAREWare upload for CAREWare users. Below you will find instructions for
the first two ways. CAREWare users can contact the CAREWare Help Desk
at [email protected] or (877) 294-3571.

Uploading Performance Measures Data

Instructions on how to create a CSV
file can be found in Appendix A. These
instructions have been updated to
include demographic data.

Recipients and subrecipients can import performance measures data into the
HIVQM Module from a CSV file. In the Navigation panel on the top left side of
the screen, click on the link, “Upload HIVQM Data” to bring you to the HIVQM
Data Upload page. See Figure 4a for a screenshot of the Data Upload page.

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Instructions for Completing the HIVQM Module

Figure 4a. HIVQM Data Upload Page and Provider Selection

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Instructions for Completing the HIVQM Module

On the Data Upload page, you will be able to select the provider name through
a drop-down menu. Once you select the provider name, click on the “Select”
button. Two new buttons for importing your file will appear. First, click on the
“Choose File” button to search for the CSV file on your computer. Then click
the “Upload File” button to upload the file. See Figure 4b for a screenshot of
the upload buttons.
A validation process will automatically begin to ensure that data in your
file passes system requirements. The Upload Summary table will appear
to provide you information of the validation results. See Figure 4b for a
screenshot of the Upload Summary table. The Upload Summary table
will include information on the number of records in the file, the number of
records that failed validation and the number of alerts. Alerts tell you to check
your data to make sure that they are correct. Some alerts are also errors that
you must correct before successfully uploading your file. To view your list of
validations, click on the link, “Validation Result” in the Upload Summary table
and an Excel document will appear that can also be downloaded to your
computer.

A list of validations can be found in
Appendix B.

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Instructions for Completing the HIVQM Module

Figure 4b. Uploading Your File

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After you have checked the alerts and fixed the errors in your file, you can begin
the upload process again by clicking on the “Choose File” button to search for
the CSV file on your computer and then clicking the “Upload File” button. When
your file has passed the validation process, you will see at the top of the page,
“The file is processed successfully.”

Manually Entering Performance Measures Data

!

The Data Summary table located below
the Upload Summary table contains
information on the reporting period and
the number of records uploaded. This
information can especially be helpful if
you have multiple file uploads.

!

You will still see the alerts that ask you
to check your data even though you have
successfully uploaded your file and are
ready to generate reports.

Select measures
Recipients and subrecipients can also manually enter data into the HIVQM
Module. First you must select the performance measures that you want to enter.
To select performance measures, click the “Select Measures” link under the
“HIVQM Report Navigation” heading in Navigation pane on the left side of the
screen. See Figure 5 for a screenshot on selecting performance measures.

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Instructions for Completing the HIVQM Module

Figure 5. HIVQM: Performance Measure Selection Page

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The page will refresh to a list of the nine main performance measure categories. To see
the performance measures under each main category, click the expand icon on the left
to expand your selections. Then click the checkbox for the performance measures you
will be entering data for. If you want more information about the performance measure,
click the information icon to the right, and a pop-up window will display additional
information. Once you have selected all the performance measures your agency wants
to submit data on, click “Save” in the lower right corner of the screen.
Enter performance data
After saving your performance measures, you are ready to enter your data. On the left
side of the screen, under the Navigation pane, click the “Enter Performance Data” link,
and the screen will refresh to the Data Entry page containing a list of all the performance
measures that you selected. Click on the “View/Edit” link for the performance measure
you want to begin entering data for. See Figure 6 for a screenshot on entering
performance measures.

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Figure 6. HIVQM: Performance Measure Data Entry Page

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Once you have clicked on the “View/Edit” link, the screen will refresh to the chosen
performance measure page to enter three main numbers: Records Reviewed,
Numerator, and Denominator. Note that the other fields on this page are grayed out
and you will not be able to enter any other numbers. See Figure 7 for a screenshot
on entering these numbers. The Numerator and Denominator numbers are required
numbers to enter. Below are the guidance to determining the three main numbers:
— Records reviewed is the number of
records that were assessed for the
performance measure under review.

— Denominator includes clients who
should receive the care or service
under review.

— Numerator includes those clients who
should and did receive the care or
service under review.

In addition, for more program-related guidance on these numbers, click the information
icon to the right of the performance measure, and a pop-up window will display
additional information.
Try these tips to avoid receiving error messages when entering your data.
— For Records Reviewed, you must enter a number less than or equal to your caseload
number entered in the Provider Information page.
— The Records Reviewed number must be greater than or equal to the Denominator.
— The Numerator must be less than or equal to the Denominator.
— If your Numerator is less than 20 percent of the Denominator, you will receive an alert
to make sure this number is correct. Correct the Numerator or ignore the alert if the
Numerator is correct.

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Instructions for Completing the HIVQM Module

Figure 7. HIVQM: Entering Records Reviewed, Numerator, and Denominator

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Once you have entered all your data, save your data by clicking “Update” on the lower
right corner of the screen. The numbers will appear as Row 1 of your performance
measure data. See Figure 8 for an example of Row 1. Row 1 includes all client records
that were uploaded for that specific performance measure. A dash in any of the columns
indicates that the measure includes all clients in that category and is not restricted to
any specific sub groups (e.g., males only or 25 – 44 year olds only). If you have entered
invalid data (valid data is described above) in any of the fields, you will receive an error
message. Go back to your data entries and correct the errors by clicking on “Edit” on the
right side of the screen. You will not be able to save your data until you have addressed
all error messages.

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Instructions for Completing the HIVQM Module

Figure 8. HIVQM: Row 1
In this example, dashes appear in age min, age max, gender, race/ethnicity, and HIV risk
factor columns. The dashes indicate that you uploaded for all 125 records and did not
restrict your data to any specific sub group.

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Instructions for Completing the HIVQM Module

Entering Demographic Data NEW
After your main numbers are saved, you can now enter demographic data for that
performance measure. To enter demographic data, click on the plus icon, “Add new
record,” and the page will refresh to allow you to enter demographic data. See Figure 9
for an example of entering demographic data. The Gender, Race/Ethnicity and HIV Risk
Factor fields include drop-down options that you can choose from. See below for dropdown options.
— Age: minimum and max age
— Gender: Male, Female, Transgender
(All), Transgender Male to Female,
Transgender Female to Male,
Transgender Other

— Race/Ethnicity: American Indian/
Alaska Native, Asian, Black/African
American, Hispanic/Latino, Native
Hawaiian/Pacific Islander, White,
Multiple races

— HIV Risk Factor: Male to Male
sexual contact (MSM), Injection
drug use (IDU), MSM and IDU,
Heterosexual contact, Perinatal
Transmission, Other

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Instructions for Completing the HIVQM Module

Figure 9. HIVQM: Entering Demographic Data

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The demographics data will allow you to enter the denominator and numerator for
various characteristics of your population. You can enter the numbers for one particular
demographic or a set of demographic data. In the Module, this is called a Row. For
example, a Row can include the numbers for only one demographic data, such as
“males,” or a Row can include the numbers for African American males who are 24 – 50
years of age. See Figure 10 for an example of different Rows.
Once you have chosen your demographic preferences for a Row and entered the
numbers, click on the “Insert” link at the bottom left to submit the data. At the top of the
page, you will either get a message that the submission was a “success” or an “error”
message if your numbers do not make sense. You can correct your numbers by clicking
on “Edit” on the right side of the screen. You can also review the previous guidance on
determining the denominator and numerator. When you get the “success” message, the
Module will generate a table showing you the data you entered along with the calculated
percentage.
To add another Row, click on the plus icon, “Add new record” at the top left of the table.
Remember to click on the “Insert” link at the bottom left once you are finished with a
Row.
Figure 9 is an example of the generated table with various Rows. You can also sort your
data by clicking on column title. Figure 9 shows that table sorted by Race/Ethnicity. For
now, demographic data will only be reported in this table. Demographic data will
not appear in any of the HIVQM reports.

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Instructions for Completing the HIVQM Module

Figure 10. HIVQM: Demographic Data Report

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Step Five: Generate HIVQM Reports
The HIVQM Module can generate three types of reports: a summary report, a
comparison trend report and a program parts comparison report. These reports allow
recipients to compare their performance measures data with that of others:
— The Summary Report is a report
that will allow recipients to compare
their performance data at the
organization, state, regional, and
national level.

— The Comparison Trend Report
will allow recipients to compare
their performance data at the
organizational, state, regional, and
national level over a five-year period.

— The Program Parts Comparison
Report will allow recipients to
compare performance measures
data by RWHAP Part.

To view a report, click the “Summary Report,” “Comparison Trend Report,” or “Program
Parts Comparison Report” link under HIVQM Reports in the Navigation panel on the left
side of the screen.

Summary report
Once you click “Summary Report,” select
the performance measure(s) that you
want to view from the pull-down menu
at the top of the page. You can select all
performance measures, a main category,
or individual performance measure. See
Figure 11 for a screenshot on selecting
performance measures.

Note that the reports will only represent
data of organizations that submitted data
into the HIVQM Module.

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Instructions for Completing the HIVQM Module

Figure 11. HIVQM: Selecting Performance Measure for Reports
(Same for Summary and Comparison Trend Reports)

Once you select the performance measure(s), click “View Report” on the upper right and
the report will be generated in a different tab. You can export your summary report via
multiple formats (including PDF, Microsoft Excel, and CSV format) by clicking the floppy
disk icon for a pull-down menu of options. This summary report reflects data that were
submitted during the reporting period. Note that the state and regional columns will be
hidden if fewer than four organizations submit data for that state or region. See Figure 12
for an example of the Summary Report.

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Instructions for Completing the HIVQM Module

Figure 12. HIVQM: Summary Report

!

Note that the reports will only represent
data from organizations that submitted
data into the HIVQM Module.

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Comparison trend
report

Figure 13. HIVQM: Comparison Trend Report

Once you click the
“Comparison Trend Report”
link, select the performance
measure(s) that you want to
view from the pull-down menu
at the top of the page. You
can select all performance
measures, a main category,
or individual performance
measure. In the “Reporting
Period” field, select a yearlong reporting period from the
pull-down menu, starting from
January 2016. Click “View
Report,” and the report will
be generated in a different
tab. You can export your
Comparison Trend Report via
multiple formats (including
PDF, Microsoft Excel, and
CSV format) by clicking the
floppy disk icon for a pull-down
menu of options. If fewer than
four organizations report data
under a performance measure,
asterisks will be displayed in
the corresponding cell of the
data table. See Figure 13 for
an example of the Comparison
Trend Report.

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Instructions for Completing the HIVQM Module

Program Parts Comparison Report
Once you click the “Program Parts
Comparison Report” link, select the
performance measure(s) that you want
to view from the pull-down menu at
the top of the page. You can select all
performance measures, a main category,
or individual performance measure. See
Figure 11. HIVQM: Selecting Performance
Measures for Reports. Once you select
the performance measure(s), click “View
Report” on the right and the report will
be generated in a different tab. You can
export your summary report via multiple
formats (including PDF, Microsoft Excel,
and CSV format) by clicking the floppy
disk icon for a pull-down menu of options.
This summary report reflects data that
were submitted during the reporting
period. See Figure 14 for an example of
the Program Parts Comparison Report.

Figure 14. HIVQM: Program Parts Comparison Report

For further assistance on completing the
HIVQM Module or generating reports, contact
Data Support at (888) 640-9356 or e-mail
[email protected].

36

Appendix A
HIVQM Upload – Field Definitions
This document outlines the procedure to create a CSV file to upload HIVQM data. The
first row of the file contains the column headers separated by commas. The HIVQM data
for various performance measures should be populated starting from the second row of
the file and each entry should be separated by commas. A screenshot of the sample file
is shown below.

The description of each column is defined in the table below.

Field
#

Field
Name

Description

Field
Type

Length

Coding

Required
Yes

1.

Provider ID

Provider ID of the provider

Numeric

5

Provider ID is a unique five-digit
identifier assigned to your organization.
Please contact Data Support if you do
not have this information.

2.

Provider
Name

Name of the provider
corresponding to the Provider ID

Character

250

No
The Provider Name should be entered
in double quotations. e.g. “UNIVERSITY
OF CALIFORNIA, SAN DIEGO”

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

37

Appendix A

Field
#

Field
Name

Description

Field
Type

Length

Coding

Required

3.

Software
Name

Name of the software being used
to populate the HIVQM data

Character

250

The Software Name should be entered
in double quotations. e.g. “CAREWare”

No

4.

Measure ID

Measure code corresponding to
the performance measure under
review

Character

250

The Measure ID should be entered in
double quotations. e.g. “Core01”
Please refer to the Appendix for a list of
valid Measure IDs.

Yes

5.

Measure
name

Name of the performance
measure under review

Character

250

The Measure Name should be entered
in double quotations. e.g. “Viral Load
Suppression”
Please refer to the Appendix for a list of
valid Measures corresponding to each
Measure ID

No

6.

Report Start
Date

Start date of the reporting period

Date

NA

The Report Start Date should be
entered in “MM/DD/YYYY” format.

Yes

7.

Report End
Date

End date of the reporting period

Date

NA

The Report End Date should be entered Yes
in “MM/DD/YYYY” format.

8.

Report
Date when the report was created
creation date

Date

NA

The Report Creation Date should be
entered in “MM/DD/YYYY” format.

9.

Records
Reviewed

The number of records that were
assessed for the performance
measure under review

Numeric

9

10.

Numerator

Total number of patients from the
denominator

Numeric

9

11.

Denominator Total number of patients under
review for the corresponding
performance measure

Numeric

9

12.

Age Min

Numeric

3

Minimum Age within the group
under review

HIV Quality Measures (HIVQM) Module Instruction Manual 2020-2021

NA
NA
NA
NA

No
Yes

Yes
Yes

No

38

Appendix A

Field
#

Field
Name

Field
Type

Description

Length

Coding

Required

13.

Age Max

Maximum Age within the group
under review

Numeric

3

No

14.

Gender

Gender code corresponding to the Numeric
Gender value under review

3

Please refer to the Appendix for a list of
valid Gender codes.

No

15.

Race/
Ethnicity

Race/Ethnicity code
corresponding to the Race/
Ethnicity value under review

Numeric

3

Please refer to the Appendix for a list of
valid Race/Ethnicity codes.

No

16.

HIV Risk
Factor

HIV Risk Factor code
corresponding to the HIV Risk
Factor value under review

Numeric

3

Please refer to the Appendix for a list of
valid HIV Risk Factor codes.

No

NA

Performance Measure IDs
The HIVQM Performance Measures are each assigned a unique Measure ID. The
following table depicts the category and the Measure ID for each performance measure.

Performance Measure Category
Core Measures
Core Measures
Core Measures
Core Measures
Core Measures
Core Measures
All Ages Measures
All Ages Measures
All Ages Measures

Performance Measure Name
Viral Load Suppression
Prescribed Antiretroviral Therapy
Medical Visits Frequency
Gap in Medical Visits
PCP Prophylaxis
Annual Retention in Care
HIV Drug Resistance Testing Before Initiation of Therapy
Influenza Vaccination
Lipids Screening

Measure ID
Core01
Core02
Core03
Core04
HAB03
Core05
HAB35
HAB19
HAB11
39

Appendix A

Performance Measure Category

Performance Measure Name

Measure ID

All Ages Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures
Adolescent and Adult Measures

TB Screening
Cervical Cancer Screening
Chlamydia Screening
Gonorrhea Screening
Hepatitis B Screening
Hepatitis B Vaccination
Hepatitis C Screening
HIV Risk Counseling
Oral Exam

HAB14
HAB07
HAB15
HAB16
HAB17
HAB08
HAB09
HAB10
HAB12

Adolescent and Adult Measures

Pneumococcal Vaccination

HAB22

Adolescent and Adult Measures

Preventive Care and Screening: Screening for Clinical Depression and
Follow-Up Plan

HAB21

Adolescent and Adult Measures

Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention

HAB36

Adolescent and Adult Measures

Substance Use Screening

HAB23

Adolescent and Adult Measures

Syphilis Screening

HAB13

HIV Infected Children Measures

MMR Vaccination

HAB37

HIV Exposed Children Measures

Diagnostic Testing to Exclude HIV Infection in Exposed Infants

HAB38

HIV Exposed Children Measures

Neonatal Zidovudine Prophylaxis

HAB39

HIV Exposed Children Measures

PCP Prophylaxis for HIV-Exposed Infants

HAB40

Medical Case Management (MCM) Measures

Care Plan

HAB41

Medical Case Management (MCM) Measures

Gap in Medical Visits

HAB57

Medical Case Management (MCM) Measures

Medical Visit Frequency

HAB58

Oral Health Measures

Dental and Medical History

HAB42

Oral Health Measures

Dental Treatment Plan

HAB43
40

Appendix A

Performance Measure Category
Oral Health Measures
Oral Health Measures
Oral Health Measures
ADAP Measures
ADAP Measures
ADAP Measures
ADAP Measures
Systems-Level Measures
Systems-Level Measures
Systems-Level Measures
Systems-Level Measures
Systems-Level Measures
Systems-Level Measures

Performance Measure Name
Oral Health Education
Periodontal Screening or Examination
Phase I Treatment Plan Completion
Application Determination
Eligibility Recertification
Formulary
Inappropriate Antiretroviral Regimen
Waiting Time for Initial Access to Outpatient/Ambulatory Medical Care
HIV Test Results for PLWHA
HIV Positivity
Late HIV Diagnosis
Linkage to HIV Medical Care
Housing Status

Measure ID
HAB44
HAB45
HAB46
HAB47
HAB48
HAB49
HAB50
HAB51
HAB52
HAB53
HAB54
HAB55
HAB56

Gender Codes
The valid Gender values are each assigned a unique Gender Code.
The following table depicts the Gender codes for each Gender value.

Gender Code
1
2
3
4
5
6

Gender
Male
Female
Transgender (all)
Transgender Male to Female
Transgender Female to Male
Transgender Other
41

Appendix A

Race/Ethnicity Codes
The valid Race/Ethnicity values are each assigned a unique Race/Ethnicity Code.
The following table depicts the Race/Ethnicity codes for each Race/Ethnicity value.

Race/Ethnicity Code
1
2
3
4
5
6
7

Race/Ethnicity
American Indian/Alaska Native
Asian
Black/African America
Hispanic/Latino
Native Hawaiian/Pacific
Islander
White
Multiple races

HIV Risk Factor Codes
The valid HIV Risk Factor values are each assigned a unique HIV Risk Factor Code.
The following table depicts the HIV Risk Factor codes for each HIV Risk Factor value.

HIV Risk Factor Code
1
2
3
4
5
6

HIV Risk Factor
Male to Male sexual contact
(MSM)
Injection drug use (IDU)
MSM and IDU
Heterosexual contact
Perinatal transmission
Other

42

Appendix A

HIVQM Data Validations
Field Name

Validation Rule Logic (Validation
will fire when the condition is met)

Validation
Type

Error message text on UI

Numerator,
Denominator

Measure’s Numerator = blank

Error

[Performance Measure]: A whole number greater than or
equal to zero must be reported in the numerator field.

Records Reviewed

Measure’s Records Reviewed <= 0 or
blank

Error

[Performance Measure]: A whole number greater than
zero must be reported in the records reviewed field.

Denominator

Measure’s Denominator <= 0 or blank

Error

[Performance Measure]: A whole number greater than
zero must be reported in the denominator field.

Numerator,
Denominator

Measure’s Numerator is greater than the
Denominator

Error

[Performance Measure]: The Numerator must be less than
or equal to the Denominator.

Records Reviewed,
Denominator

Measure’s Denominator is greater than
the number of Records Reviewed

Error

[Performance Measure]: The Records Reviewed must be
greater than or equal to the Denominator.

Records Reviewed,
Provider Caseload

Measure’s Records Reviewed > Provider
Caseload (in Provider Information page)

Error

[Performance Measure]: The Records Reviewed must be
less than or equal to the Caseload.

Numerator,
Denominator

Measure (except for Gap in Medical
Visits)’s Numerator < 20 percent of the
Denominator

Alert

The numerator is less than 20 percent of the Denominator.
Please check the values to make sure they are accurate.

Numerator,
Denominator

Gap in Medical Visits’ Numerator > 20
percent of the Denominator

Alert

The numerator is greater than 20 percent of the
Denominator. Please check the values to make sure they
are accurate.

Report Start Date

Report Start Date = blank OR an invalid
date OR not matching Report Period
Start Date Open for Editing

Error

A valid date is required for Report Start Date. Acceptable
value(s):

43

Appendix B - HIVQM Validation Rules
HIVQM File Upload Validations
Field Name

Validation Rule Logic (Validation
will fire when the condition is met)

Validation
Type

Error message text on UI

File to Upload

If field is empty

Error

You did not select a file to upload. Please click “Browse” to
select a file before clicking “Upload File.”

File to Upload

If a file selected is not an CSV file

Error

Only file with .csv extension is allowed.

File to Upload

If file size is > 29 MB

Error

The file you uploaded is larger than 29 MB. Please upload
a file smaller than 29 MB and complete the remaining data
directly on the form.

File to Upload

If the file directory given in the path does
not exists

Error

File directory does not exist, please enter a valid directory
path.

File to Upload

If the column name is missing in the file

Error

The column name ‘’ is missing from the
data file.

File to Upload

If the file has wrong column name

Error

The column name ‘’ is unknown for the
data file.

File to Upload

If a column is repeated in the file.

Error

Repeated columns found for ‘’. Please
remove extra columns.

File to Upload

File does not contain data

Error

File cannot be uploaded because it does not contain data.

File to Upload

File Status = Processed AND Total #
errors encountered > 0

Error

File is processed with validation errors. Data will not be
populated in the HIVQM forms until all errors are fixed.

HIV Quality Measures (HIVQM) Module Instruction Manual 2021-2022

44

Appendix A

Field Name

Validation Rule Logic (Validation
will fire when the condition is met)

Validation
Type

Error message text on UI

Report End Date

Report End Date = blank OR an invalid
date OR not matching Report Period End
Date Open for Editing

Error

Report Start Date;
Report End Date

Report Start Date and Report End Date
do not correspond to the same report
period
Provider ID <> Reg Code of the Provider
in Provider Name field

Error
Error

Provider ID is invalid.

Provider ID

Provider ID is blank

Error

Provider ID is required.

Measure ID

Measure ID is blank

Error

Measure ID is required.

Measure ID

Measure ID <> HIVQM Performance
Measure ID

Error

Measure ID is invalid. Refer to the HIVQM field definition
file for the list of Measurement Codes.

Error**

Measure ID is duplicate.

Error

Report Creation Date must be prior to today’s date.

Provider ID

Measure ID

Duplicate Measure IDs are provided in
the CSV file for the same Provider and
Reporting Period
Report Creation Date Report Creation Date > today’s date OR
an invalid date

A valid date is required for Report End Date. Acceptable
value(s):
Report Start Date and Report End Date do not belong to
the same reporting period.

** Please note, when there are duplicate Measure IDs populated all the records shall be errored out and displayed as a part of the validation
results document.

45