What are Clinical Quality Measures (CQMs)?
Electronic clinical quality measures, also called eCQMs, are tools that help us measure and monitor the quality of healthcare and the contribution of those healthcare services towards improved health outcomes. In the past, quality measures primarily used data that came from claims, but as technology has improved and become more prominent in the healthcare setting, many quality measures now use data that comes from a provider’s electronic health record (EHR). These electronic CQMs (eCQMs) use EHR data to measure health outcomes, clinical processes, patient safety, efficient use of healthcare resources, care coordination, patient engagement, and population and public health improvement.
The definitions below will help you better use this eCQM guide to measure and monitor the quality of care that you provide to your patients.
- Initial patient population (IPP) – The group of patients (or events/episodes of care) that the measure is designed to address.
- Denominator – Is a subset of the IPP for which the measure applies (may also be the same as the IPP).
- Numerator – Is a subset of the denominator and refers to the patients who meet the measure specified clinical requirements or the events/episodes of care from the denominator where the measure specific requirements have been performed.
- Denominator Exclusions – Is a subset of the denominator. Exclusion specifications remove patients/events from the denominator who meet specific criteria that make it clinically unnecessary for the patient to receive the numerator clinical action.
- Denominator Exception – Is a subset of the denominator. Exception specifications remove patients/events from the denominator only if the numerator criteria are not met. Exceptions are generally provider or patient determined reasons for refusing certain clinical actions.
- Measurement period – This is also known as the EHR reporting period and refers to the time frame for which the eCQMs will be calculated. For more information on determining your eCQM reporting period, refer to the reporting requirements at the end of this guide.
- United States Health Information Knowledgebase (USHIK) – For a one-stop shop, visit the USHIK meaningful use portal where you can readily view, easily download, and accurately compare the 2014 CQMs, data elements, value sets, and codes for each quality measure. This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical Language System® (UMLS) license, available from NLM, is required to access USHIK.
- National Quality Strategy (NQS) Domains – The NQS outlines the federal plan to improve the quality of healthcare delivered in the United States and was developed as a result of the Affordable Care Act.
The six NQS domains, one of which is assigned to each CMS eCQM, are: Patient and Family
Engagement, Patient Safety, Care Coordination, Population and Public Health, Efficient Use of Healthcare Resources, and Clinical Processes/Effectiveness
- National Quality Forum (NQF) – NQF reviews, endorses, and recommends use of standardized quality measures. Not all quality measures are “NQF-endorsed,” but those that are have an assigned NQF number.
- Value sets – Lists of specific values (terms and their codes) derived from single or multiple standard vocabularies used to define clinical concepts (e.g. patients with diabetes, clinical visit, reportable diseases) used in clinical quality measures and to support effective health information exchange. Although there are many uses for value sets, most of the value sets are used to define the patient populations that should be included in the denominators and in the numerators when computing a clinical quality measure.
- Quality Reporting Document Architecture (QRDA) – An HL7-based standard document format for the exchange of clinical quality measure data. QRDA reports contain data extracted from electronic health records (EHRs) and other information technology systems. QRDA reports are used for the exchange of CQM data between systems for a variety of quality measurement and reporting initiatives, including Meaningful Use and PQRS. These programs require the submission of QRDA Category I reports, which utilize patient-level data, or QRDA Category III reports, which utilize aggregated patient data.
eCQM Calculation Information
eCQM values can be monitored in the Practice Fusion Clinical Quality Measures Report, which can be accessed under the Reports section of the EHR. After selecting the “PQRS Clinical Quality Measures” link, you will need to select the correct provider and reporting period from the drop-down menus. These values will be retained until they are actively changed.
Below is information on each of the current Practice Fusion clinical quality measures, including the measure title, the CMS eMeasure ID number, the NQF number (if applicable), and the NQS Domain. The PF Suggested Workflow includes more details about the measure and information on how the measure can be fulfilled using the Practice Fusion EHR. For information on what codes are included in each numerator and denominator, please refer to the USHIK resource linked above.
CMS Quality Measure Reporting
Meaningful Use eCQM Reporting
- Providers can manually submit eCQM values during Meaningful Use attestation. This option is available to providers in any stage of Meaningful Use.
- Providers submitting eCQM values to CMS for attestation will need to report for at least 9 measures covering at least 3 of the NQS domains. Zero values are acceptable if you do not have 9 eCQMs in your Practice Fusion Clinical Quality Measures report with values.
- Providers who submit eCQMs via Meaningful Use attestation can still use electronic submission with Practice Fusion for the purposes of 2015 PQRS reporting in January/February 2016.
- Providers who choose to submit eCQMs electronically for the purposes of dual credit for PQRS and Meaningful Use will be able to do this via their EHR vendor, but will require a year’s worth of eCQM data.
PQRS eCQM Reporting
PQRS offers multiple reporting mechanisms including claims, registry, or EHR reporting. Providers who wish to report PQRS via their EHR will be required to report 9 measures covering at least 3 of the National Quality Strategy domains using CERHT that has been certified to the most recent version of the CMS electronic eCQMs.
- If a provider’s CEHRT does not contain patient data for at least 9 measures covering at least 3 NQS domains, then the provider will need to report the measures for which there is Medicare patient data.
- In order to use the EHR reporting option for PQRS, a provider must report on at least 1 measure for which there is Medicare patient data. Measures with a zero value denominator cannot be used for PQRS.
- The PQRS measurement period length is a full calendar year, so for 2015 it would run from January 1, 2015 through December 31, 2015.
Electronic Reporting of eCQMs
In the PQRS Clinical Quality Measures dashboard in early 2016, providers can click the orange “Attest” button to begin the process of generating a file to submit to CMS that meets the HL7 standards for the Quality Reporting Data Architecture (QRDA).
Making Quality Measurement and Monitoring Part of Your Workflow
As your prepare for quality reporting in 2015, you should become familiar with the eCQMs that are available in your certified EHR so that you can incorporate them into your daily workflow and make improvement to the care that you deliver, as needed. Quality measurement and reporting is a key part of improving our healthcare system and Practice Fusion is dedicated to making that easier for health care providers in 2015.
More Information on eCQMS
Providers who are interested in learning more about the detailed eCQM specifications can use USHIK to locate specific measures and to find the detailed codes and value sets that are included in the specifications of that measure. This site is produced by the Agency for Healthcare Research and Quality (AHRQ) in partnership with CMS and the National Library of Medicine (NLM). A free Unified Medical®(UMLS)license, available from NLM, is required to access USHIK.
From the USHIK website, click on the link for Clinical Quality Measures, select the measure or measures you want to know more about, and select the measure title link to get more information on the measure logic, included code lists, exclusions, and reference information. From this screen, you can also download the applicable codes as a PDF file, Excel File, or CSV File. Make sure you select the correct version of the measure (Practice Fusion’s CQMs utilize the July 2014 EP specifications.)