Form 1 2024 HIVQM Instrument Highlighted Changes

Updated November 20, 2025

HIVQM Instrument
Provider Information Page
1.

Contact Information:
a. Name _____________________________
b. Title ______________________________
c. Phone number _____________________
d. Address ___________________________
e. City ______________________________
f. State _____________________________
g. Zip Code __________________________
h. Congressional District _______________

2.

Provider Caseload Number: Total number of unduplicated clients
enrolled at your provider agency at the end of the reporting period.
_____________

3.

Funding Source (Select all that apply): Indicate all your agency’s funding sources
received during the HIVQM reporting period. You must select at least one
funding source, and you can select more than one if applicable to your agency.

4.

▪

Part A

▪

Part B

▪

Part B Supplemental

▪

Part C EIS

▪

Part D

▪

EHE

Provider Type: Indicate the organization type that best describes
your agency. If you choose ‘Other’ facility, please specify a
description. You must indicate only 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)
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Updated November 20, 2025
▪

Health department

▪

Substance abuse treatment center

▪

Solo/group private medical practice

▪

Agency reporting for multiple fee-for-service providers

▪

People Living with HIV/AIDS ( Coalition

▪

VA facility

▪

Other facility (Please specify) _______________

5. Data Collection:
a. Does your organization use a computerized data collection

system?
▪

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.
▪

ARIES

▪

Allscripts

▪

AVIGA

▪

CAREWare

▪

Casewatch Millennium

▪

Cerner

▪
▪

eClinicalWorks
eCOMPAS

▪

EHS CareRevolution

▪

Epic

▪

ETO Software

▪

FutureBridge

▪

GE/Centricity

▪

Sage/Vitera

▪

NextGen

▪

Provide Enterprise

▪

SCOUT

▪

Other
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▪
6.

Unknown

If you selected Other in 4b, report any data collection system(s) used to run
performance measures: __________________________________

Entering Performance Measures Data
7.

Select Measures: Select all the performance measures on which you will report.
Core Measures
▪ Viral Load Suppression
▪ Prescribed Antiretroviral Therapy
▪ Medical Visits Frequency
▪ Gap in Medical Visits
▪ PCP Prophylaxis
▪ Annual Retention in Care
All Ages Measures
▪ HIV Drug Resistance Testing Before Initiation of Therapy
▪ Influenza Vaccination
▪ Lipids Screening
▪ TB Screening
Adolescent and Adult Measures
▪ Cervical Cancer Screening
▪ Chlamydia Screening
▪ Gonorrhea Screening
▪ Hepatitis B Screening
▪ Hepatitis B Vaccination
▪ Hepatitis C Screening
▪ HIV Risk Counseling
▪ Oral Exam
▪ Pneumococcal Vaccination
▪
Preventative Care and Screening: Screening for Clinical Depression and Follow-up
Plan
▪ Preventative Care and Screening: Tobacco Use: Screening and Cessation
Intervention
▪ Substance Use Screening
▪ Syphilis Screening
HIV Infected Children Measures
▪ MMR Vaccination
HIV-Exposed Children Measures
▪ Diagnostic Testing to Exclude HIV Infection in Exposed Infants
▪ Neonatal Zidovudine Prophylaxis
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Updated November 20, 2025

PCP Prophylaxis for HIV Exposed Infants
Medical Case Management (MCM) Measures
▪ Care Plan
▪ Gap in HIV Medical Visits Medical Visit Frequency
Oral Health Measures
▪ Dental and Medical History
▪ Dental Treatment Plan
▪ Oral Health Education
▪ Periodontal Screening or Examination
▪ Phase I Treatment Plan Completion
ADAP Measures
▪ ADAP Application Determination
▪ Loss of ADAP Services due to Failure to Confirm Eligibility
▪ ADAP Inappropriate Anti-Retroviral Regimen Components
Resolved by ADAP
▪ Enrollment in Health Care Coverage (including Medicaid,
Medicare Part D and private health insurance)
▪ Timely Payment of Health Insurance Premiums
▪ Viral Suppression for Clients Who Receive ADAP Services
Systems-Level Measures
▪ Waiting Time for Initial Access to Outpatient/Ambulatory Medical
Care
▪ HIV Test Results for People with HIV
▪ HIV Positivity
▪ Late HIV Diagnosis
▪ Linkage to HIV Medical Care
▪ Housing Status
▪

8.

Enter data for the performance data you chose in #6.

Presentation Option 1:
Performance Measure (See list in #6)
▪ Records Reviewed ________________
▪ Numerator ______________________
▪ Denominator ____________________
Presentation Option 2:
Performance Measure

Records Reviewed

Core Measures
Viral Suppression
4

Numerator

Denominator

Updated November 20, 2025

Prescribed Antiretroviral Therapy
Medical Visits Frequency
Gap in Medical Visits
PCP Prophylaxis
Annual Retention in Care
All Ages Measures
HIV Drug Resistance Testing
Before Initiation of Therapy
Influenza Vaccination
Lipids Screening
TB Screening
Adolescent and Adult Measures
Cervical Cancer Screening
Chlamydia Screening
Gonorrhea Screening
Hepatitis B Screening
Hepatitis B Vaccination
Hepatitis C Screening
HIV Risk Counseling
Oral Exam
Pneumococcal Vaccination
Preventative Care and Screening:
Screening for Clinical Depression
and Follow-up Plan
Preventative Care and Screening:
Tobacco Use: Screening and
Cessation Intervention
Substance Use Screening
Syphilis Screening
HIV Infected Children Measures
MMR Vaccination
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Updated November 20, 2025

HIV-Exposed Children Measures
Diagnostic Testing to Exclude HIV
Infection in Exposed Infants
Neonatal Zidovudine Prophylaxis
PCP Prophylaxis for HIV Exposed
Infants
Medical Case Management Measures
Medical Case Management: Care
Plan
Gap in HIV Medical Visits
(Medical Case Management)
HIV Medical Visit Frequence
(Medical Case Management)
Oral Health Measures
Dental and Medical History
Dental Treatment Plan
Oral Health Education
Periodontal Screening or
Examination
Phase I Treatment Plan
Completion
ADAP Measures
AIDS Drug Assistance Program
(ADAP) Application
Determination
ADAP Inappropriate
Antiretroviral Regimen
Components Resolved by ADAP
Viral Suppression for Clients Who
Receive ADAP Services
Loss of ADAP Services due to
Failure to Confirm Eligibility
Timely Payment of Health
Insurance Premiums
Enrollment in Health Care
Coverage (Including Medicaid,
Medicare Part D and Private
Health Insurance)
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Updated November 20, 2025

Systems-Level Measures
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

9. Optional Demographics. You can include demographic data for the performance measure(s) you

chose in #6. You may also choose which demographic data elements you want to complete for that
performance measure(s).

Presentation Option 1
Age Min ________________
Age Max _______________
Sex at Birth
▪ Male
▪ Female
▪ Unknown
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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Updated November 20, 2025

Presentation Option 2
Performance Measure

Age
Min

Age
Max

Sex at Birth
(Male,
Female,
Unknown)

Core Measures
Viral Suppression
Prescribed
Antiretroviral Therapy
Medical Visits
Frequency
Gap in Medical Visits
PCP Prophylaxis
Annual Retention in
Care
All Ages Measures
HIV Drug Resistance
Testing Before Initiation
of Therapy
Influenza Vaccination
Lipids Screening
TB Screening
Adolescent and Adult Measures
Cervical Cancer
Screening
Chlamydia Screening
Gonorrhea Screening
Hepatitis B Screening
Hepatitis B Vaccination
8

Race/Ethnicity
HIV Risk Factor
(American
Male to Male sexual
Indian/Alaska Native,
contact (MSM,
Asian, Black/African
Injection drug use
American, Hispanic/
(IDU), MSM and IDU,
Latino, Native
Heterosexual
Hawaiian/ Islander,
contact, Perinatal
White, Multiple races)
transmission, Other

Updated November 20, 2025

Hepatitis C Screening
HIV Risk Counseling
Oral Exam
Pneumococcal
Vaccination
Preventative Care and
Screening: Screening for
Clinical Depression and
Follow-up Plan
Preventative Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention
Substance Use
Screening
Syphilis Screening
HIV Infected Children Measures
MMR Vaccination
HIV-Exposed Children Measures
Diagnostic Testing to
Exclude HIV Infection in
Exposed Infants
Neonatal Zidovudine
Prophylaxis
PCP Prophylaxis for HIV
Exposed Infants
Medical Case Management Measures
Medical Case
Management: Care Plan
Gap in HIV Medical
Visits (Medical Case
Management)
HIV Medical Visit
Frequence (Medical
Case Management)
Oral Health Measures
Dental and Medical
History
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Updated November 20, 2025

Dental Treatment Plan
Oral Health Education
Periodontal Screening
or Examination
Phase I Treatment Plan
Completion
ADAP Measures
AIDS Drug Assistance
Program (ADAP)
Application
Determination
ADAP Inappropriate
Antiretroviral Regimen
Components Resolved
by ADAP
Viral Suppression for
Clients Who Receive
ADAP Services
Loss of ADAP Services
due to Failure to
Confirm Eligibility
Timely Payment of
Health Insurance
Premiums
Enrollment in Health
Care Coverage
(Including Medicaid,
Medicare Part D and
Private Health
Insurance)
Systems-Level Measures
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
10

Updated November 20, 2025

Housing Status

11