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Public Comment

Welcome to CMS Quality Measures Public Comment Page

This page serves as the designated site for CMS to solicit public comments on proposed quality measures that are included in the individual project pages. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Details of the Public Comment Period:

  • The public is encouraged to submit general comments relevant to both measures or comments specific to certain measures
  • Information about each measure is found in the Downloads section below
  • Do not include personal health information in your comments
  • At the end of the public comment period, all public comments will be posted on the website along with a public comment summary report

Instructions for Providing Comments:

  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information
  • If you are commenting as an individual, submit identifying or contact information
  • Please indicate which measure(s) you are commenting on
  • You may submit general comments on the entire set of measures or you may provide comments specific to individual measures

 

Project Title: 

Days in Acute Care after Hospitalization for Heart Failure, Pneumonia, or Acute Myocardial Infarction (AMI)

Dates: 

The public comment period closed on July 31, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, heart failure, and pneumonia. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure reevaluation, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, HF, and pneumonia.
  • The public comment period provided an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).
  • At that stage of measure reevaluation and testing, we were seeking feedback on the preliminary measure specifications of the three revised measures of post-discharge acute care utilization, for patients hospitalized with heart failure, pneumonia, and AMI.

Comment Summary: 

The following document is found below in the Download section:

1.  Public Comment Summary Report and Verbatim Comments

 

Project Title:

Hospital Visits after Hospital Outpatient Surgery

Dates:

The call for public comment period closed on August 3, 2014.

Project Overview:
The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop quality measures that use patient outcomes to assess the quality of outpatient care. The contract name is Development of Ambulatory Care Outcomes Measures and the contract number is HHSM-500-2012-00025I. As part of this project, CORE is developing a quality measure for outpatient surgeries. Specifically, CORE is developing a measure of hospital visits after outpatient surgery conducted in hospital outpatient departments (HOPDs). As part of its measure development process, CMS invited interested parties to submit comments on the draft measure specifications.

Project Objectives:

  • The primary goal of this project is to develop an administrative claims-based, risk-standardized measure of hospital visits after hospital outpatient surgery.
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on the measure under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary:

The following documents are found below in the Download section:

1. Measure technical report for public comment
2. Technical expert panel (TEP) summary report
3. Public comment summary report, including verbatim comments

 

Project Title:

Clinical Quality Measure for Human Immunodeficiency Virus (HIV) Infection Screening

Dates:

The public comment period begins at 9:00 a.m. EST on September 22, 2014, and ends at 5:00 p.m. EST on October 20, 2014.

Project Overview

The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) is seeking public comment on a newly developed draft clinical quality measure for human immunodeficiency virus (HIV) infection screening.  The measure aligns with the recently released U.S. Preventive Services Task Force (USPSTF) recommendations that all individuals between the ages of 15 and 65 be screened for HIV. The measure was developed in collaboration with clinicians and quality experts. The goal is to develop a measure that will be nationally endorsed through the National Quality Forum (NQF) and included in the Centers for Medicare & Medicaid Services (CMS) programs.

To Provide Public Comments, Note the Following:

CDC is seeking public comment on this draft measure, with particular interest in feedback on relevance, usefulness, and feasibility of the measure. Based on the comments it receives through this process, CDC will revise and refine the measure as needed.

Documents and Measures for Comment:

A zip file containing the Measure Information and Measure Justification forms for the measure can be found in the Downloads area below.

Instructions for Providing Comments:

Please email your comments to hivscreening1565@cdc.gov . All comments on the measures must be received by 5:00 p.m. EST.

 

Project Title: 

Risk-Standardized Acute Admission Rates for Patients with Diabetes

Risk-Standardized Acute Admission Rates for Patients with Heart Failure

Dates: 

The call for public comment period closed on May 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with diabetes and heart failure. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (diabetes and heart failure).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Diabetes and Heart Failure Admission Measures
  2. Diabetes and Heart Failure Draft Measures Technical Report
  3. Diabetes and Heart Failure Measures TEP Summary Report

 

Project Title: 

Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions

Dates: 

The call for public comment period closed on June 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with multiple chronic conditions. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (multiple chronic conditions).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Multiple Chronic Conditions Admission Measure
  2. Multiple Chronic Conditions Draft Measure Technical Report
  3. Multiple Chronic Conditions Measure TEP Summary Report

 

Project Title:

2015 Draft PQRS #181 Elder Maltreatment Screening and Follow-Up Plan 

Dates:

The public comment period begins at 9:00 a.m. EST on September 11, 2014, and ends at 5:00 p.m. EST on October 22, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Physician Quality Measures Management (PQMM) and Quality Insights of Pennsylvania (Quality Insights) to develop and maintain quality measures for the Physician Quality Reporting System (PQRS). Measure 181 - Elder Maltreatment Screening and Follow-Up Plan has undergone substantive changes as part of its measure development process and CMS requests interested parties to submit comments on this measure.

Project Objectives:

  • Because most cases of elder abuse are underreported by health care providers, in concert with a lack of strong evidence in the literature to support screening for elder maltreatment, CMS convened a national Elder Maltreatment & Care Symposium for all relevant stakeholders on March 8, 2013.  The aim of this symposium was to assess the value of continuing the implementation and development of PQRS #181 Elder Maltreatment Screening and Follow-Up Plan.
  • Feedback from the Elder Maltreatment & Care Symposium was incorporated into the comprehensive review of the 2014 Elder Maltreatment Screening and Follow-Up Plan measure for use in PQRS. This comprehensive review also included a literature review, measure specifications review and an evaluation of the measure code sets.

Measures for Comment:

  • 2015 Draft PQRS #181 Elder Maltreatment Screening and Follow-Up Plan

Commenting Information:

  • The public is encouraged to submit general comments on the entire measure or comments specific to certain aspects of the measure.
  • Information about Measure 181- Elder Maltreatment Screening and Follow-Up Plan is found in the Downloads section below.
  • Do not include personal health information in your comments.
  • At the end of the comment period, all public comments will be posted on the Web site.

Instructions:

  • Comments are due by close of business October 9, 2014.
  • Submit comments to measures@wvmi.org
  • Please indicate the name of the measure you are commenting on. You may submit general comments on the entire measure or you may provide specific comments to individual aspects of the measure.
  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.

Project Title:

Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data

Dates:

The Public Comment period ran from July 14, 2014 to August 8, 2014

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop a hospital-wide all-cause unplanned readmission hybrid electronic clinical quality measure (HWR eMeasure). This is a hybrid measure in that it includes a combination of claims data describing patient’s conditions and clinical data from electronic health records. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The purpose of the HWR eMeasure was to enhance the original hospital-wide readmission measure by including clinical data elements captured at the start of an episode of care in electronic health records (EHR). This enhancement was in response to stakeholder feedback expressing a need for clinical information in risk adjustment models.

The measure uses the methodology from the original HWR measure but adds clinical data to the risk adjustment strategy. We only included clinical data elements that were found to be consistently captured under current clinical practice and feasibly retrieved from EHRs by a 2013 TEP. This measure has been tested in a dataset from an integrated hospital system consisting of 21 hospitals. At that stage of measure development and testing, we were seeking feedback on the measure concept and clinical data elements used in the risk adjustment models for each specialty cohort.

Further measure testing in a larger, more diverse data set will occur once such data is available. Similarly, the value sets and logic surrounding those value sets will be available for public comment in 2015.

Comment Summary:

The following documents, including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Public Comment Summary Report.

 

Measure of Hospital Visits after Hospital Outpatient Surgery

Dates:

The public comment period ends at 11:59 P.M. EDT on August 3, 2014

Project Overview

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop quality measures that use patient outcomes to assess the quality of outpatient care. As part of this project, CORE is developing a quality measure for outpatient surgeries. Specifically, CORE is developing a measure of hospital visits following outpatient surgery conducted in hospital outpatient departments (HOPDs).

The purpose of the project is to develop quality measures that can be used to improve the quality of care for Medicare beneficiaries. The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Specific project objectives: CORE and CMS are requesting public comment on an administrative claims-based, risk-adjusted measure of hospital visits following outpatient surgery conducted at HOPDs.

The Measure Development Process Includes:

  • Identifying important quality goals related to a topic/condition or setting of focus.
  • Conducting literature reviews and environmental scans.
  • Defining and developing specifications for the quality measure.
  • Obtaining evaluation of proposed measure by TEP.
  • Posting for public comment.
  • Testing measure for reliability, validity, and feasibility.

To Provide Public Comments, Note the Following:

Documents and Measures for Comment:

The following documents are provided for your review and comment, and are found in the Downloads section of this site:

  • Technical Report
  • TEP Summary Report

Instructions for Providing Comments:

 

Hospital-Wide All-Cause Unplanned Readmission Hybrid Electronic Clinical Quality Measure

Dates:

The public comment period begins at 8:00 A.M. EDT on July 14, 2014 and ends at 5:00 P.M. EDT on August 8, 2014

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop a hospital-wide all-cause unplanned readmission hybrid electronic clinical quality measure (HWR eMeasure). This is a hybrid measure in that it includes a combination of claims data describing patient’s conditions and clinical data from electronic health records. The purpose of the project is to develop quality measures that can be used to provide quality care to Medicare beneficiaries. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP)1.

1Since this measure builds off of the measure methodology of the hospital-wide readmission measure that is already in public reporting, a TEP was convened just to identify feasible data elements that we could include in risk model development and testing. A TEP has not been reconvened to review the eMeasure.

Specific Project Objectives:

The purpose of the HWR eMeasure is to enhance the original hospital-wide readmission measure by including clinical data elements captured at the start of an episode of care in electronic health records (EHR). This enhancement is in response to stakeholder feedback expressing a need for clinical information in risk adjustment models.

The measure uses the methodology from the original HWR measure but adds clinical data to the risk adjustment strategy. We only included clinical data elements that were found to be consistently captured under current clinical practice and feasibly retrieved from EHRs by a 2013 TEP. This measure has been tested in a dataset from an integrated hospital system consisting of 21 hospitals. At this stage of measure development and testing, we are seeking feedback on the measure concept and clinical data elements used in the risk adjustment models for each specialty cohort.

Further measure testing in a larger, more diverse data set will occur once such data is available. Similarly, the value sets and logic surrounding those value sets will be available for public comment in 2015.

The Development Process Includes:

  • Identifying important quality goals related to a topic/condition or setting of focus.
  • Conducting literature reviews and grading evidence.
  • Defining and developing specifications for each quality measure.
  • Posting for public comment.
  • Testing measures for reliability, validity, and feasibility.

To Provide Public Comments, Note the Following:

  • The public is encouraged to submit general comments on the entire measure set or comments specific to certain measures.
  • At the end of the public comment period, all public comments will be posted on the Web site.
  • Do not include personal health information in your comments.

Instructions for Providing Comments:

Please follow the instructions at the top of this webpage and email your comments to: HybridHWReMeasure@yale.edu. Comments are due by close of business August 8, 2014.

 

All-Cause Acute Admission Rates For Patients With Heart Failure and Diabetes

Dates:

The public comment period ended on May 19, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with heart failure, diabetes, and multiple chronic conditions. We are developing claims-based risk-adjusted admission measures for patients in Accountable Care Organizations (ACOs). The purpose of this project is to assess the quality of care to Medicare beneficiaries and promote improvement.

This public comment period is for the heart failure and diabetes admission measures. We will hold a separate public comment period for the multiple chronic conditions measure later this spring.

Project Objectives:

• Identifying important quality goals related to these chronic conditions

• Conducting literature reviews and exploratory analyses

• Defining and developing specifications for each quality measure

• Convening a technical expert panel to provide input during development and evaluate the proposed measures

• Posting measures for public comment to solicit the widest possible array of input on the measures

• Testing measures for reliability, validity, and feasibility

• Refining measures as needed

Documents and Measures for Comment:

The following documents are provided for your review and comment and are found in the Downloads section of this site:

  • Heart Failure and Diabetes Draft Measures Technical Report
  •  Technical Expert Panel Summary Report

 

Public Comment for ARRA HITECH EP Annual Wellness Assessment (AWA) and Functional Status Assessment (FSA) Measures

Dates:

The public comment period ended at 5:00 P.M. EDT on Friday, April 25

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research to develop new clinical quality measures for potential use by eligible professionals (EPs) in the EHR Incentive Program (HHS Contract: HHSM-500-2008-00020I; Task Order HHSM-500-TO003). Mathematica and its subcontractor, the National Committee for Quality Assurance (NCQA), are developing these clinical quality measures for future stages of the EHR Incentive Program. The measures under consideration are based on literature reviews of the evidence and reviews by a technical expert panel that includes clinicians, quality experts, EHR vendors, consumers, and other stakeholders.

Project Objectives:

CMS is requesting that stakeholders review these measures and provide feedback on them. All comments are welcome, but we are particularly interested in feedback in the following areas:

  • Relevance of the measures to the mission of public reporting under the EHR Incentive Program component for Eps
  • Usefulness of the measures to improve quality of care for Medicare patients
  • Feasibility of data collection via EHRs for the purposes of public reporting under the EHR Incentive Program component for Eps
  • For the three Functional Status Assessment and Goal Setting measures, types or examples of functional status assessment tools that should be regularly used in used in clinical care for patients with COPD, asthma, or RA
  • For the two Annual Wellness Assessment measures, the appropriateness of using defined goals for health and wellness to assess EP performance

The specifications for these measures (PDF of the eCQM Health Quality Measures Format, or HQMF, MAT generated artifact) have been included in this posting for public comment.

Documents and Measures for Comment:

The proposed measures assess key components of many health care aspects deemed important to evaluate and measure. The measures are:

  • Functional Status Assessment and Goal Setting for Patients with Chronic Obstructive Pulmonary Disease (COPD)
  • Functional Status Assessment and Goal Setting for Patients with Asthma
  • Functional Status Assessment and Goal Setting in Patients with Rheumatoid Arthritis (RA)
  • Annual Wellness Assessment: Goal-Setting to Reduce Identified Risks
  • Annual Wellness Assessment: Reduction of Health Risks

The following document is provided for your review and comment and is found in the Downloads section of this site:

  • ARRA HITECH EP AWA and FSA Measures.zip

Instructions for Providing Comments:

The JIRA comment tool will be used for collecting comments on the measure specifications listed above. Please use the following links to submit your comments:

If you are a current JIRA user with an active account: http://jira.oncprojectracking.org/browse/MUCD (Select ‘log in’ at the top right corner)

If you are new to JIRA and do NOT have an account: http://jira.oncprojectracking.org/login.jsp (Select ‘sign up’ to set up a new account and log into the JIRA tool)

Once logged into the JIRA tool:

  1. Select “Projects” at the top middle of the home screen.
  2. Select “Comments on eCQM’s under development” project.
  3. Select “Create issue” (orange button) at the top middle of the screen to enter comments.
  4. Please fill out the fields labeled: ‘Summary’, ‘Contact name’, ‘Contact email’ and ‘Contact phone’
  5. Enter your comments in the ‘Description’ field
  6. Select the measure name that you are commenting on from the ‘Draft measures’ drop down box:
    1. The Functional Status Assessment and Goal Setting for Patients with COPD measure
    2. The Functional Status Assessment and Goal Setting for Patients with Asthma measure
    3. The Functional Status Assessment and Goal Setting for Patients with RA measure
    4. The Annual Wellness Assessment: Goal-Setting to Reduce Identified Risks measure
    5. The Annual Wellness Assessment: Goal-Setting to Reduce Identified Risks measure
  7. Select ‘Create’ at the bottom left to submit your comments. If you would like to enter more comments, select ‘Create another’ and then ‘Create’.

For more information on using JIRA, please visit click here for instructions.

Thank you for your support and participation.

Instructions/Information:

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