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Table 3 All Alerts are on an annual basis unless specified otherwise

From: Developing public health clinical decision support systems (CDSS) for the outpatient community in New York City: our experience

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 intervention Stop smokers with medications or counseling
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 HTN Control BP < 140/90 with a diagnosis of IVD AND HTN without DM
  BP control in DM Control BP < 130/80 with a diagnosis of DM
  BP control in DM AND HTN Control BP < 130/80 with a diagnosis of DM AND 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 and drugs Alcohol use screening Screen for alcohol misuse
Get checked for cancer Colorectal cancer screening Screen 50-80 years old patients
  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 risk) Vaccinate high risk patients 5-49 years old
  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 assessment Assess 18-56 years old for asthma severity
  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