Centers for Medicare & Medicaid Services Quality Measurement and Program Alignment

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Centers for Medicare & Medicaid Services Quality Measurement and

Program Alignment



Conflict of Interest Disclosure

Deborah Krauss, MS, BSN, RN Maria Michaels, MBA, CCRP, PMP

Maria Harr, MBA, RHIA

Have no real or apparent

conflicts of interest to report.


Learning Objectives

This presentation will focus on alignment efforts across the Centers for Medicare & Medicaid

Services (CMS) for Clinical Quality Measures (CQMs), highlighting the incorporation of

meaningful use of EHRs in:

 CQM Selection

 Hospital Quality Reporting

 Eligible Professional (EP) Quality Reporting



CQM Selection


HHS, CMS, and National Quality Strategy



Care Coordination

Safety Clinical


Population &


Health Efficiency

& Cost Reduction

Person / Caregiver




Three levels of

measurement critical to achieving three aims of National Quality Strategy

Measure concepts should

“roll up” to align quality improvement objectives at all levels

Patient-centric, outcomes- oriented measures preferred at all three levels

The “six domains” can be measured at each of the three levels


Practice setting

Individual physician

• Population-based denominator

• Multiple ways to define

denominator, e.g., county, HRR

• Applicable to all providers

• Denominator based on practice

setting, e.g., hospital, group practice

• Denominator bound by patients cared for

• Applies to all physicians

• Greatest component of a physician’s total performance


Multi-level Measurement & Improvement


CMS CQM Alignment Objectives

Align with the National Quality Strategy and Six Measure Domains

Implement CQMs that fill critical gaps within the six domains

Align across programs whenever appropriate

Leverage opportunities to align with private sector (e.g., NQF MAP), and focus on patient-centered CQMs (patient outcomes and patient experience).



CMS CQM Alignment Objectives (continued)

Create parsimonious sets of CQMs — core sets and measure concepts

Maintain optional menu to apply to broad range of

specialties and clinical practice of medicine in programs seeking broad, diverse participation

Remove CQMs that are no longer appropriate (e.g., topped out)

Maximize improvement in quality and minimize

provider burden


NQS Interagency Work Group HHS Measurement

Policy Council

HHS Measure

Coordination Group CMS Quality Measures Task Force

CMS Measures Forum Work Groups

CMS Grand Rounds

CMS Quality Improvement


CMS Grand Rounds


Measurement Policy Work Groups



CMS Quality and Performance Programs

Medicare and Medicaid EHR Incentive Program

PPS-Exempt Cancer Hospitals

Inpatient Psychiatric Facilities

Inpatient Quality Reporting

HAC Payment Reduction Program

Readmission reduction program

Outpatient Quality Reporting

Ambulatory Surgical Centers

Medicare and Medicaid EHR Incentive Program


eRx quality reporting

Inpatient Rehabilitation Facility

Nursing Home Compare Measures

LTCH Quality Reporting

Hospice Quality Reporting

Home Health Quality Reporting

Medicare Shared Savings Program

Hospital Value- based Purchasing

Physician Feedback

Physician Value- based Modifier


Innovations Pilots

Medicaid Adult Quality Reporting

CHIPRA Quality Reporting

Health Insurance Exchange Quality Reporting

Medicare Part C

Medicare Part D Hospital Quality Physician Quality


PAC and OTHER Setting Quality


Payment Model

Reporting “Population”

Quality Reporting


 Measures should be patient-

centered and

outcome-oriented whenever possible

 Form a core set of measures from measure concepts in each of the six domains that are common across providers and settings

Person- and Caregiver-centered

Experience and Outcomes

Experience of care

Patient-reported outcomes

Efficiency and Cost Reduction

Annual spend measures (e.g., per capita spend)

Episode cost measures



Care transitions

Admission and readmission



Clinical Care

Acute care

Chronic care




Population / Community Health

Health behaviors

Access to care

Disparities in care (could also apply across domains)


Patient safety

Healthcare- acquired

infections and conditions

Provider safety

Greatest commonality of measure concepts across domains

CMS Measure Domains and Sub-domains



CMS Measure Selection Criteria

Core Criteria:

Measure addresses an important condition/topic with a

performance gap and has a strong scientific evidence base to demonstrate that the measure when implemented can lead to the desired outcomes and/or more appropriate costs (i.e., NQF’s

Importance criteria).

Measure addresses one or more of the six National Quality Strategy Priorities (safety, care coordination, clinical care,

population health, person- and family-centered care, making care more affordable).

Measure promotes alignment with specific program attributes and across CMS and HHS programs

Program measure set includes consideration for healthcare disparities

Measure reporting is feasible.


CMS Measure Selection Criteria (concluded)

Optional Criteria:

 Measure enables measurement using measure type not already measured well (e.g., outcome, cost, etc.).

 Measure enables measurement across the person-centered episode of care, demonstrated by assessment of the person’s trajectory across providers and settings

 Program measure set promotes parsimony



CMS Measure Selection Process

QMTF rulemaking Pre-

CQM List,

Dec 1st Pre-

rulemaking Feedback MAP

Feb 1st

NPRM for each applicable


Public comment on

CQMs implements CMS

CQMs in Final Rules Performance CQM

Review and Maintenance rulemaking Pre-

Assessment of Impact of


Program staff and Stakeholders

suggest CQMs




Electronic Clinical Quality Measures (eCQMs)

Retooled De Novo

Start with manual chart- abstracted, paper-based specifications and translate as closely as possible to Health Quality Measures Format (HQMF) for EHR automated abstraction.

Developed from newly created measure concept into HQMF for EHR

automated abstraction.

CQM Specifications

Paper Electronic

CQM Specifications




eCQMs: Improvements in Development

 Standardization efforts in eCQM specifications

 Health Quality Measures Format (HQMF)

 Quality Reporting Document Architecture (QRDA)

 Q/A Review Goals in Creation of e-specifications

 National Library of Medicine: appropriate terminologies, value sets, testing, etc.

 Logic Review: frequent

 Stewards are involved throughout development processes

 Stakeholder input: early in process


CMS Examples of Program and Measurement




Vision for CMS Quality Reporting Programs

Implement a unified set of

electronic clinical quality measures (eCQMs) and e-reporting requirements to synchronize

and integrate CMS quality programs and

reduce provider reporting burden.


Goals for CMS Quality Reporting Programs

Improve quality of care using robust CQMs, timely

feedback to hospitals and physicians, and meaningful use of EHRs.

Minimize burden by:

 Synchronizing performance and submission periods.

Allowing participating providers to make one submission of eCQM data for multiple programs.

 Using the same CQMs and electronic specifications across programs.

Maximize efficiency by using eCQM data submitted by providers for multiple quality programs.



Quality Improvement Goals: HHS, CMS, and National Quality Strategies

CQM Harmonization

Populations Measured / Sample Size

Program Performance / Reporting Periods

Program Submission Periods

Payment Adjustment Timelines


Rulemaking Vehicles and Timelines

Outreach, Communication, and Public Engagement

Program Ownership

Privacy and Security

Type and Format


Measure e-Specifications

Level (aggregate, patient, or hybrid)

Submission Pathway



Program Design Data and Systems

* Many of the elements are governed by statutory requirements

Alignment Elements*


Hospital Quality Programs



Transition to EHR Reporting for Hospitals

Transition to EHR Reporting

2011 2017

Other Hospital Quality Reporting Programs (HVBP, OQR, etc.):

Transition to eCQMs

IQR: Transition to eCQMs EHR Incentive Program

(Stage 1, 2, 3)

eCQM – Electronic Clinical Quality Measure

IQR – Inpatient Quality Reporting HVBP – Hospital Value-Based Purchasing OQR – Outpatient Quality Reporting


 Over 99% of hospitals participate in the IQR/HVBP programs.

 Statutory requirement: CQMs must be included in IQR and displayed on Hospital Compare for one year before an HVBP performance period starts.

 CMS obtains feedback from hospitals and associations to build on current IQR/HVBP approach when aligning with EHR

Incentive Program.

 CMS will continue to electronically specify CQMs, introduce them through the EHR Incentive Program, and then transition sets of measures over time to electronic reporting in IQR,

HVBP, and other hospital reporting programs.

Hospital Program Alignment:

Key Considerations



Hospital Program Alignment Using eCQMs




1. Meaningful Use 2. IQR


4. Other CMS Quality Reporting Programs eCQMs





Certified EHR Technology


Quality Reporting Data Architecture


Hospital Program Alignment: Timeline

By 2013:

 Complete alignment of HVBP and IQR CQMs reported on Hospital Compare.

 Implementation of the Medicare EHR Incentive Program Electronic Reporting Pilot for Eligible Hospitals and Critical Access Hospitals.

(Note: This electronic reporting pilot will be the basis for electronic reporting in other reporting programs.)

By 2014:

 IQR will introduce EHR-based reporting. Additional details will be included in the FY2014 Inpatient Prospective Payment Schedule proposed rule that is targeted for publication in Spring 2013.

Beyond 2014:

 CQMs will be transitioned to EHR-based reporting in the EHR Incentive Program and then to IQR and other hospital reporting




Eligible Professional (EP)*

Quality Programs

* NOTE: EP is a term used in the EHR Incentive

Program. Other programs may have other terms for

participants (e.g., ACOs).


Transition to EHR Reporting

2011 2017

Other EP Quality Reporting Programs (VBM, ACOs, etc.):

Transition to eCQMs PQRS: Transition to eCQMs

EHR Incentive Program (Stage 1, 2, 3)

eCQM – Electronic Clinical Quality Measure PQRS – Physician Quality Reporting System EP – Eligible Professionals

Transition to EHR Reporting for EPs



EP Program Alignment:

Key Considerations

Quality Measures Reported

 PQRS and EHR Programs are aligned on the same set of eCQMs (64 total) and the same electronic specifications beginning in 2014.

Data Origination

 If submitted electronically, the data submitted for both programs must originate from CEHRT.

Submission Methods

 Participating EPs have the option to submit patient-level data

(via QRDA I) or aggregate data (via QRDA III) using the same

reporting mechanism for electronic reporting.


EP Program Alignment Using eCQMs



Individual EPs/Groups

1. Meaningful Use

2. PQRS (including PROs) 3. ACOs

4. Value-Based Modifier 5. Other CMS Quality

Reporting Programs eCQMs





Certified EHR Technology


Quality Reporting Data Architecture



EP Program Alignment: Timeline

By 2013:

Individual EPs

Implementation of the PQRS-EHR Incentive Program Pilot (Note: Can fulfill the CQM component of meaningful use as well as PQRS if

reported using QRDA I).

Group Practices

 PQRS Group Practice Reporting Option (GPRO) web interface CQMs aligned with those in the ACO GPRO measure set and the VBM GPRO measure set.

 PQRS aligned with the Physician Value-Based Modifier (VBM), whereby

the quality component of the 2015 VBM for group practices with 100 or

more eligible professionals that elect quality tiering will be based on

the groups’ performance on PQRS measures.


EP Program Alignment: Timeline (concluded)

By 2014:

Individual EPs

 CMS previously finalized full alignment of PQRS EHR reporting options, including CQMs, reporting criteria, and reporting mechanism in the CY 2013 Physician Fee Schedule (PFS) and the Stage 2 rules.

Group Practices

 CMS also previously finalized in the CY 2013 PFS and Stage 2 rules that group practices participating in the PQRS GPRO or ACOs using CEHRT and reporting via the GPRO web interface fulfill the

requirement of the CQM component of meaningful use.



Electronic Reporting Pilots (2012 and 2013)

Pilot participation in 2012:

 EPs: 9700+ (as of last week of 2/2013)

 Hospitals: 4

Pilot participation in 2013:

 EPs

 MU CQMs + PQRS -> QRDA I using PQRS specifications

 Hospitals

 Both 2011 and 2014 e-specifications will be accepted



 Standards are key to building interoperability between EHRs

 Focus of alignment efforts is with EHR-based reporting of eCQMs

 Alignment with national, HHS, and CMS Quality Strategies

 Alignment across CMS programs, including:

 CQMs selected

 CQM specifications

 Reporting mechanisms

 Reporting schemas

 Reporting/performance and submission periods







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