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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).

1. Public comment of the retooling of Severe Sepsis and Septic Shock: Management Bundle”, as an electronic clinical quality measure (eCQM)

The Centers for Medicare & Medicaid Services (CMS) has contracted for the retooling of NQF #500, “Severe Sepsis and Septic Shock: Management Bundle”, as an electronic clinical quality measure (eCQM), to be derived from electronic health record data. Abt Associates, in collaboration with the Oklahoma Foundation for Medical Quality (OFMQ), are the measure developers leading the retooling of NQF 500.

The measure has been specified using the Measure Authoring Tool (MAT).  Abt is requesting stakeholder review and public comment on the draft specifications. This email serves as a call for public comment on these specifications. The 30-day public comment period will begin April 14, 2014 and end May 14, 2014.

We are particularly interested in feedback in the following areas:

• Representation of the legacy measure constructs in the logic
• Value sets
• Implementation considerations

Please note that comments should be limited to those related to the eSpecification of the measure, and not the measure construct itself.

There are three sets of files included in this posting for public comment, which include:

• The Measure Information Form (MIF), which outlines the specifications for the NQF-endorsed legacy measure
• A description of differences between the paper-based specifications and the eSpecifications
• The eCQM Health Quality Measures Format (HQMF) MAT generated artifacts:

• An XML Stylesheet for Transformation (XSLT):  The XSLT file allows the eCQM XML file to open directly in a web browser. When opened this way, the eMeasure XML file displays in the same human-readable format as the eMeasure human-readable HTML file.
• An XML file:  An XML document (.xml) based on the HQMF. Its major components include a Header and a Body. The Header identifies and classifies the document and provides important metadata about the measure. The HQMF Body contains eMeasure sections, e.g., data criteria, population criteria, and supplemental data elements.
• The “Human Readable” Rendition:  A HyperText Markup Language (HTML) file (.html) that displays the eCQM content in a human‐readable format directly in a web browser. This file does not include the underlying HQMF syntax.
• Two spreadsheets listing all value sets for the measure, including supplemental value sets

Questions and comments regarding the specifications may be submitted through http://jira.oncprojectracking.org/browse/PCQM until May 14, 2014.

Severe Sepsis Septic Shock eMeasure, Severe Sepsis Septic Shock Management Bundle, Sepsis Bundle Supplemental Value Sets, Sepsis Bundle Measure Information Form, Sepsis Bundle CQM Differences, eMeasure and Severe Sepsis Septic Shock Value Sets are included in the zip file “ Downloads” Section.

Please contact Sara Galantowicz (CMS_Hospital_eMeasures@abtassoc.com or 617-520-2510) should you have any questions.

Thank you for your support and participation

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

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. 

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

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.

The public comment period begins at 9:00 A.M. EDT on Friday, April 4, and ends at 5:00 P.M. EDT on Friday, April 25. All comments on the measures must be received by 5:00 P.M. EDT on Friday, April 25. 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.

3. Development of Total Hip and/or Total Knee Arthroplasty (THA/TKA) Patient-Reported Outcome Measures(s)

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 one to two patient-reported outcome-based performance measures following total hip and/or knee arthroplasty (THA/TKA, either a single combined or two procedure-specific measures) that can be used for hospital-level performance measurement. 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). At this time, the measure development process is not complete and we are seeking interim public comment on the preliminary measure specifications to help guide remaining development decisions and testing. CMS will hold a second public comment period at a later date.

Specific Project Objectives:

• The primary goal of this project is to develop either two separate or one combined THA/TKA patient-reported outcome measures to measure hospital-level performance.

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.
• Obtaining evaluation of proposed measures by technical expert panels.
• Posting for public comment.
• Testing measures for reliability, validity, and feasibility.

To Provide Public Comments, Note the Following:

• The public is encouraged to submit comments on the preliminary measure specifications of the measure(s) still under development.
• 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:

• 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 the measures on which you are providing comments.
• Email your comments to: cmshipkneeprom@yale.edu. Comments are due by close of business Friday, April 18, 2014.

The following information for the measure is included in the zip file in the Downloads section:

• Introduction to Public Comment on Preliminary Measure Specifications for Patient-Reported Outcome-Based Hospital Performance Measure(s) for Total Hip and/or Knee Arthroplasty Patients
• DRAFT Measure Methodology Report for Patient-Reported Outcome-Based Hospital Performance Measure(s) for Total Hip and/or Knee Arthroplasty Patients
• 2013-2014 TEP Summary Report for Patient-Reported Outcome-Based Hospital Performance Measure(s) for Total Hip and/or Knee Arthroplasty Patients

4. Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

February 2014

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation — Center for Outcomes Research and Evaluation (CORE) to solicit Public Comments on 7-Day risk-standardized hospital visit rate after outpatient colonoscopy procedure. A summary of the Public Comments is posted in the “Downloads” section below.

Rehospitalization during the First 30 Days of Home Health & Emergency Department without Hospital Readmission during the First 30 Days of Home Health

The Centers for Medicare & Medicaid Services (CMS) has contracted with Acumen, LLC to solicit Public Comments on Rehospitalization during the first 30 days of Home Health and Emergency Department without Hospital Readmission during the first 30 days of Home Health. A summary of the Public Comments is posted in the “downloads” section below.

Instructions/Information:

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