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What are Electronic Specifications? In order to report clinical quality measures (CQMs) from an electronic health record (EHR), electronic specifications must be developed that include the data elements, logic and definitions for that measure in a format that can be captured or stored in the EHR so that the data can be sent or shared electronically with other entities in a structured, standardized format, and unaltered. EHR Incentive Program Electronic Specifications Introduction to Electronic Specifications These electronic specifications are derived from certified EHRs. As part of the criteria for satisfying meaningful use, CQM results (numerators, denominators, and exclusions) must be reported to CMS. Specific details regarding the reporting of the specifications for EPs and eligible hospitals/CAHs are described below. Each electronic specification contains four main components: - Measure Overview/Description - This contains the measure title, description, number, measurement period, measure steward, and other relevant information to the measure.
- Measure Logic - This contains the population criteria and measure logic for the numerator, denominator and exclusion categories. The measure logic contains the algorithm used to calculate performance.
- Measure Code Lists - This contains all of the codes pertaining to the measure.
- QDS Elements - This lists and describes each Quality Data Set (QDS) data element associated with the measure. The QDS is a model of information that contains the standard element, the quality data element, and the data flow attributes. It is a way to describe clinical concepts in a standardized format so individuals (i.e., providers, researchers, measure developers) monitoring clinical performance and outcomes can clearly and concisely communicate necessary information. The QDS model also describes information in a manner that allows EHR and other clinical electronic system vendors to unambiguously interpret the data and clearly locate the data required.
Reporting Period: The reporting period for the EHR Incentive program using a certified EHR is any continuous 90 day period during the first payment year. Please note that although the measure specifications assume a full calendar year you should only calculate the denominator and numerator from the first day of the 90 day reporting period to the last day of the 90 day reporting period. Eligible Professionals (EPs) Eligible professionals must report from the table of 44 clinical quality measures which includes, 3 Core, 3 Alternate Core, and 38 additional CQMs. - Core CQMs - EPs must report on 3 required core CQMs, and if the denominator of 1 or more of the required core measures is 0, then EPs are required to report results for up to 3 alternate core measures.
- EPs also must also select 3 additional CQMs from a set of 38 CQMs (excluding the core/alternate core measures). It is acceptable to have a '0' denominator provided the EP does not have an applicable population.
In sum, EPs must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures. A maximum of 9 measures would be reported if the EP needed to attest to the 3 required core, the three alternate core, and the 3 additional measures. To view the 44 measure specifications, look at the EP Measure Specifications Zip file. You can also view the Eligible Professional Clinical Quality Measure document, which identifies the specific number of numerators, denominators, and exclusions reported for these measures. Reporting will require a numeric value for each numerator, denominator, and exclusion, if applicable. EP Implementation Guidance for EHR Incentive Program CQMs: By viewing the Guide to Reading the EHR Incentive Program for EP Measures, you can learn how to read and understand specific CQMs. You can also look at the EP CQM Supplemental Log and related EP Supplemental Measure Specifications for information on the supplemental CQMs for EPs. CMS is providing this information to assist implementers with technical updates and requested guidance. Eligible Hospitals and CAHs Eligible hospitals and CAHs must report all 15 CQMs. The HITSP Technical Note will allow you to view the electronic specifications for eligible hospitals. For the two Emergency Department (ED) Throughput measures, ED-1/NQF 0495 and ED-2/NQF 0497, there is information on the numerators/denominators/exclusions in the Emergency Department Throughput Measures Stratification document. The link for the HITSP Technical Note will take you to information for HITSP Technical Note 906 v1.1 and contain the HITSP eMeasure specifications. To note, these specifications include QRDA reporting requirements which are not used for ARRA HITECH reporting in 2011 and 2012. Use of both documents is required for numerator/denominator/exclusion reporting. Eligible Hospital and CAH Implementation Guidance for EHR Incentive Program CQMs: By viewing the HITSP Technical Note (TN)902 v1.2, partners can obtain information on the supplemental CQMs for Eligible Hospitals and CAHs. CMS is providing this information to assist implementers with technical updates and requested guidance. The HITSP TN906 v1.2 was created in order to address public comments about the previous version. The new version was developed with input from the measure stewards, with additional guidance statements added throughout the specifications for the benefit of the stakeholders implementing and needing to understand the measures. Version 1.2 is not required to be used for 2011 and 2012 nor is it meant to completely align with the current manual specifications for these measures, but alignment is a goal of future publications. In order to make it intuitive for the reader of the updated specifications, HITSP TN906 v1.2, we have published this version with the track changes displayed instead of a log. Information on the EHR Incentive Program Electronic Reporting Pilots for 2012 EPs, eligible hospitals and CAHs are required to submit CQM results as calculated by certified EHR technology. In 2012, there will be two options for CQM reporting: - Attestation
- Electronic Reporting Pilots
- EPs – through PQRS http://www.cms.gov/PQRS/20_AlternativeReportingMechanisms.asp
Note: EPs interested in the pilot should review documents posted to the Alternative Reporting Mechanism Page and the Educational Resources Page on the PQRS website, including the EHR Pilot Guide: http://www.cms.gov/PQRS/downloads/2012PQRS_MedicareEHR-IncentPilot_Final508_1-13-2012.pdf
- Eligible hospitals and CAHs – through Hospital IQR Program http://qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228771190900
Participation in the pilot is voluntary and enables EPs, eligible hospitals, and CAHs to satisfy the Medicare EHR Incentive Program requirements for reporting CQMs for the 2012 payment year. EPs, eligible hospitals, and CAHs that choose not to participate in the pilot will be able to continue to use an attestation methodology for reporting CQMs for payment year 2012. PQRS CMS accepts PQRS quality measures data extracted from a qualified EHR product for a limited subset of PQRS quality measures. Go to the PQRS page of the CMS website for the electronic specifications for those quality measures that have been developed for PQRS. For the electronic specifications for those quality measures that have been developed for other CMS programs, look at the PQRS page of the CMS website for EP measures, and the HITSP Technical Note for hospital measures. Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical Association (AMA) convened Physician Consortium for Performance Improvement® (PCPI ™) and /or the National Committee for Quality Assurance (NCQA). These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the PCPI) or NCQA. Neither the AMA, NCQA, PCPI nor its members shall be responsible for any use of the Measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. © 2010 American Medical Association and /or National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. CPT® contained in the Measure specifications is copyright 2004- 2010 American Medical Association. LOINC® copyright 2004 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms® (SNOMED CT®) copyright 2004-2010 International Health Terminology Standards Development Organisation. All Rights Reserved.
Page Last Modified: 02/06/2012 7:48:39 AM
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