CQMs – What You Need To Know

Ask Joy: This Week – Clinical Quality Measures (CQM)

If you work in healthcare, you’re tuned to CMS updating the requirements for providers participating in incentive programs. We’ve talked about PQRS. We’ve touched on Meaningful Use Stage 2. This week, I’ll be answering questions about the 2014 CQM rules. Find out what you need to know to successfully report your clinical quality measures in 2013, 2014 and beyond.

Q: My practice is reporting Stage 1, year 1 in 2014. There have been so many changes. How do I keep up? 

A: If your first year of attesting Meaningful Use will be 2014, the Stage 1 core and menu objectives apply to your practice. Note that the final rule for Stage 2 made some changes to the Stage 1 requirements that will go into effect January 2014. You will need to electronically report on 9 Clinical Quality Measures. You will be able to do this in two ways: 1) through your EHR or 2) if your PQRS and CQMs are aligned, through the PQRS Medicare EHR Incentive Pilot. CMS has recommended core measures to report, but if those don’t apply to your specialty, you can choose to report on 9 measures that cover at least 3 of the 6 domains from the complete CQM Library.

Q: My practice has been reporting Meaningful Use since 2011. Is it true that in 2014, we report CQMs for 90 days and then in 2015 report a full calendar year? 

A: That is correct. For 2014, just make sure that your 90-day reporting period corresponds to a calendar year quarter.

Q: How will I report my CQMs electronically? 

A: CMS is introducing electronic reporting of the measures by aligning the PQRS and CQM reporting. Eligible Professionals who choose to report the same PQRS & CQM measures may participate in the PQRS-Medicare EHR Incentive Pilot where they can either use a PQRS EHR Data Submission Vendor to submit the measures on their behalf or they can report directly from their EHR, if they use one of these qualified EHRs. To help providers successfully report CQMs electronically for 2014 and beyond, CMS has outlined the functions that your EHR must be capable of performing to capture the required information for each CQM. If your EHR is not on the qualified list above, make sure your vendor has a copy of this specification list, so they will qualify in the future.

Q: Can CQMs be reported via attestation if the provider is in year 1 of Meaningful Use?

A: Unfortunately, no. 2013 is the last year that EPs will be able to report CQMs through attestation. The new requirements for electronic reporting of CQMs go into effect in 2014, regardless of the stage or year an EP is attesting.

Q: Do we need to meet a certain threshold for our CQM measures? 

A: Providers do not need to reach or exceed a specific threshold for CQMs. All that is required is that the provider’s performance is reported to CMS. It is possible that thresholds will be set sometime in the future, potentially as part of Stage 3. However, there is currently no documentation to guide EPs as to what the thresholds might be.

Q: What if my EHR is not included on the list of qualified EHRs that can report CQMs electronically? 

A:  Great question. You and/or your EHR vendor should check out the popHealth project. It’s a certified standalone CQM reporting module sponsored by the Office of the National Coordinator for Health IT. One of its main benefits is that it’s an open source software service that  automates the reporting of quality measures. popHealth integrates with EHRs using continuity of care records and helps providers meet the CQM requirements for Meaningful Use. It’s currently certified to meet Stage 1 Meaningful Use requirements (2013) and in process of being certified for Stage 2 (2014 and beyond).

Q: Can the standalone CQM reporting module satisfy PQRS reporting?

A: The short answer is no. The longer answer is that popHealth is aligned with the Meaningful Use program. There is non-trivial overlap between some of the PQRS measures and Meaningful Use measures, so there’s value to be extracted with popHealth being applied to PQRS. However, to categorize that the work required to fully align popHealth with PQRS as “non-trivial” would probably be an understatement. popHealth would be a great starting point to implement PQRS measures, but it would require a significant amount of engineering work to fully implement PQRS. Additionally, some of the PQRS measures have slightly different logic than what was stated for Meaningful Use. If this issue has not been resolved, that is another risk to using popHealth for PQRS.

About the Author: Joy Rios has worked directly with multiple EHRs to develop training programs for both trainers and practice staff. She has successfully attested to Meaningful Use for multiple ambulatory practices in both Medicare and Medicaid. She also authored the Certified Professional Meaningful Use course for www.4Medapproved.com. Joy holds an MBA with a focus in sustainability. She is Health IT certified with a specialty in Workflow Redesign, holds HIPAA security certification, and is a great resource for information regarding government incentive programs.Ask Joy is a regular column on 4Medapproved HIT Answers.