Clinical Quality Measures for Providers

posted by Kevin Heubusch

Feb 17, 2010 01:25 pm

AHIMA Meaningful Use White Paper Series
Paper no. 6a

Papers 5a and 5b in this series reviewed the functionality measures for providers and hospitals described in the notice of proposed rulemaking on meaningful use, published by the Centers for Medicare and Medicaid Services on January 13, 2010. This paper offers an overview of the requirements for reporting clinical quality measures for eligible providers. A companion paper (6b) provides an overview of the requirements for hospitals.

When Congress developed the meaningful use EHR incentive program, one of its goals was to improve the quality and efficiency of care for the Medicare and Medicaid populations. Accordingly, hospitals and providers that participate in the program will be required to capture and report clinical quality measures using certified EHR technology, in addition to the functionality measures they must report to prove they are using EHR technology in a meaningful way.

For purposes of the incentive program, CMS defines clinical quality measures as the “processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care” (p. 1871).

Many of the clinical quality measures identified for eligible providers (EPs) have been pulled from CMS’s Physician Quality Reporting Initiative (PQRI), a quality reporting initiative currently in use. CMS intends to create an added incentive for EPs to adopt EHRs by leveraging the PQRI measures.

Proposed Clinical Quality Measures

The NPRM is not intended to be used a means to update or modify clinical quality measure specifications. This is accomplished through a consensuses-based process guided by the National Quality Forum (NQF), an organization that ensures clinical quality measures are developed and maintained through a consistent and collaborative process.

However, CMS will supplement the clinical quality measures proposed for 2011 and 2012 payment years with technical specification for EHR submission. It will post the measures on its Web site to solicit comments (p. 1873).

The measures appear in table 3, including title, description, developer, links to existing electronic specification where applicable, and whether the measure belongs in the core or specialty group (pp. 1874–89).

As part of the public comment process, CMS is requesting input on each measure’s readiness for use in the incentive programs.

Clinical Quality Measure Priorities

The top clinical quality measure priorities are PQRI measure numbers 1, 2, 3, 5, and 7. These address the high priority chronic conditions of diabetes, coronary artery disease, and heart disease.

The next area of importance include the preventive care measures: PQRI numbers 110–15 and 128.

In addition, CMS also proposes clinical quality measures that were not included in recommendations from the Health IT Standards Committee but which it believes are of high importance to the overall population, including (p. 1890):

  • IVD: Use of Aspirin or Another Antithrombotic (PQRI 204)
  • IVD: Complete Lipid Profile (PQRI 202)
  • IVD: Low Density Lipoprotein (LDL–C) Control (PQRI 203)
  • IVD: Blood Pressure Management Control (PQRI 201)

Finally, CMS included a variety of other measures which it believes address important aspects of clinical quality. CMS concludes that the set of clinical quality measures is expansive enough to allow for reporting for all EPs and addresses high priority conditions.

CMS recognizes the work required to integrate the measures into certified EHR products and that not all measures may be ready in time for the 2011 payment year. It is requesting comment on the advisability of deferring some or all clinical quality reporting until the 2012 payment year (p. 1895).

CMS expects to expand the set of clinical quality measures in future years. Clinical quality measure considerations and potential topics for 2013 and beyond are addressed on pp. 1900–1. CMS welcomes comment on the potential topics as well as specific clinical quality measures.

Measures to Report for 2011 and 2012 Reporting Years

For the 2011 and 2012 reporting periods, CMS proposes that each EP submit information on two measures groups-core measures and specialty measures. CMS believes the core measures are sufficiently general and of such importance to population health that all EPs treating Medicare and Medicaid patients in the ambulatory setting should report on them, as applicable for their patients.

The core measures are listed in table 4 (p. 1890), summarized below:

  • PQRI 114 and NQF 0028: Preventive Care and Screening: Inquiry Regarding Tobacco Use
  • NQF 0013: Blood pressure measurement
  • NQF 0022: Drugs to be avoided in the elderly: (a) Patients who receive at least one drug to be avoided; (b) Patients who receive at least two different drugs to be avoided

CMS proposes the following specialty groups:

  • Cardiology
  • Pulmonology
  • Endocrinology
  • Oncology
  • Proceduralist/Surgery
  • Primary Care 
  • Pediatrics
  • Obstetrics and gynecology
  • Neurology
  • Psychiatry
  • Ophthalmology
  • Podiatry
  • Radiology
  • Gastroenterology
  • Nephrology

The clinical quality measures for each specialty group are listed in tables 5–19 (pp. 1891–95).

Each EP will select for itself the specialty group it will report, and it must submit all measures within that group. EPs must report on the same specialty group of measures for the first two payment years of the program.

CMS recognizes that the second set of quality measures are not necessarily specialty specific. The denominator of the measure is determined by the patient population to whom the measure applies and the services rendered by the particular EP. However, CMS has grouped the measures according to the type of patients commonly treated and services rendered by EPs of various specialties.

This is the way measure groups are used in PQRI-they are based on conditions rather than specialty types. Grouping measures by condition provides EPs with a standard set of measures. CMS anticipates reducing the number of proposed measures per group down to 3 to 5 measures based on the availability of electronic measure specification and comments received.

Exempt EPs

In the final rule, CMS will specify which EP specialties will be exempt from reporting on a specialty measure group. EPs seeking exemption will be required to attest to the inapplicability of any of the specialty groups. They will not be required to report on measures from a specialty group, but they will still be required to report information on all of the core measures (p.1891).

No Electronic Reporting until 2012

CMS proposes that electronic reporting of clinical quality measure begin in 2012. It acknowledges that it is not prepared to receive electronic reports in 2011 and, further, that HHS must first provide EHR vendors with technical specifications for the transmission of measurement data.

If these pieces are in place for 2012, CMS will require EPs to electronically submit quality measure information directly to CMS and the states using certified EHR technology. If electronic reporting is not viable for 2012, CMS will extend the attestation process it proposes for 2011 (see below).

Within the NPRM CMS requests comments on its proposed  reporting criteria-particularly on the requirement that all EPs would report all core measures. CMS is also interested in reasons why an EP would be unable to meet a proposed reporting requirement and if there are other alternatives.

Reporting via Attestations for 2011

CMS proposes that for 2011 Medicare EPs attest to their use of a certified EHR system to capture the data elements and calculate the results for the clinical quality measures. EPs must also attest to the accuracy and completeness of the measures submitted. The attestation for clinical quality measures will utilize the same system as attestation for meaningful use.

The NPRM lists the following elements for attestation in 2011 (p.1901):

Elements for EPs submitting measures:

  • The information submitted with respect to clinical quality measures was generated as output of an identified certified electronic health record.
  • The information submitted is accurate to the best of the knowledge and belief of the EP.
  • The information submitted includes information on all patients to whom the clinical quality measure applies.
  • The national provider identifier (NPI) and tax identification number (TIN) of the EP submitting the information, and the specialty group of clinical quality measures that are being submitted.
  • The numerators, denominators, and exclusions for each clinical quality measure result reported, providing separate information for each clinical quality measure including the numerators, denominators, and exclusions for all patients.
  • The beginning and end dates for which the numerators, denominators, and exclusions apply.

Elements for EPs submitting their exclusionary status:

  • For an EP who is exempt from reporting each of the core measures, an attestation that one or more of the core measures do not apply to the scope of practice of the EP.
  • For an EP who is exempt from reporting on a specialty group, an attestation that none of the specialty groups applies to the scope of practice of the EP.
  • For an EP who does report on a specialty group, but is exempt from reporting on each of the clinical quality measures in the group, an attestation that the clinical quality measures not reported do not apply to any patients treated by the EP.

Duplicate Reporting

CMS recognizes the possibility that some EPs could be required to report the same measures to multiple Medicare initiatives.

In instances in which a particular clinical quality measure is included in the Medicare EHR incentive program and another Medicare quality reporting incentive program, CMS proposes that an EP would only report under the Medicare EHR incentive program. A single reporting would satisfy parallel reporting requirements under all other applicable Medicare programs.

Other Reporting Methods

EPs participating in the Medicaid incentive program will report their clinical quality measures data to the states. The states will propose to CMS how they plan to accept and validate the measures in their state Medicaid health IT plans, which are subject to CMS review and approval (p.1902).

CMS proposes allowing EPs several alternatives to submitting data from EHRs. The primary method would enable EPs to log on to a CMS-designated portal and upload data based on specified structures, such as Clinical Document Architecture and accompanying templates produced as output from the certified EHR.

Alternately, an EP could submit the required measures using certified EHR technology through a health information exchange or health information organization. CMS acknowledges that this option would be dependent on the ability to collect information through such networks.

The third option proposed is to submit data through registries using certified EHR technology.

Reporting Period

The reporting year period for clinical quality measures is aligned with the period for the functionality measures-any continuous 90-day period within the first payment year. Subsequent years, however, would require reporting for the entire year.

CMS encourages comment on the option of fixed reporting periods: either four quarterly periods or two six-month periods.

The next paper in this series will finalize coverage of the NPRM and discuss the processes for demonstrating meaningful use.

AHIMA. "Clinical Quality Measures for Providers." (AHIMA report, February 17, 2010).