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Step 5: Achieve Meaningful Use Stage 1

Clinical Quality Measures (CQMs)

Objective:

Report ambulatory clinical quality measures to CMS.

Measure:

Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS.

Note: Eligible professionals must report on 6 total clinical quality measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures (selected from a set of 38 clinical quality measures). See Clinical Quality Measures for more information.

Changes as of August 2012:

Beginning in 2013, there is no longer a separate objective for reporting ambulatory or hospital clinical quality measures as a part of meaningful use. It is important to note, however, that EPs, eligible hospitals, and CAHs are still required to report on clinical quality measures in order to achieve meaningful use. CMS simply removed the standalone objective that requires providers to attest that they plan to report on clinical quality measures because due to redundancy.

Clinical Importance

Over the last ten years Clinical Quality Measures (CQM) have become an integral component in the Centers for Medicare and Medicaid (CMS) strategy to understand and improve the quality of healthcare for their beneficiaries. Data from a wide variety of healthcare delivery settings are used for a variety of programs aimed at assuring the United States is delivering high-quality healthcare – care that is effective, safe, efficient, patient-centered, equitable, and timely. These quality initiatives are used by CMS in its quality improvement, public reporting, and pay-for-reporting programs for specific healthcare providers. Electronic health records assist in the collection of this data that has a direct correlation to the future of reimbursement for your service and the quality of healthcare processes implemented in your office.

CMS Resources

The following resources are available to help you meet the Report Ambulatory Clinical Quality Measures meaningful use core measure:

Related CMS EHR Incentive Program Frequently Asked Questions

Lessons from the Field

"The key to choosing the best clinical quality measures for your practice to report against is to step back and look at your patient population as a whole."

— Barbara Tergis, RN, BSN, Office Manager, Family Practice, Hastings on Hudson, N.Y

Zeroing in on which clinical quality measures your practice will report against for meaningful use can be a daunting task. It is suggested that you begin this process by looking at your patient population as a whole, and pulling out the top ten (10) to twenty (20) diagnoses that are typically seen. From there, you can match those diagnoses against the listing of clinical quality measures available, identify the best candidates that align with the most common diagnoses amongst your patients, and work with your vendor to ensure your EHR system has the ability to track the selected measures.

National Learning Consortium Resources

The NLC resources are examples of tools that are used in the field today, and that are recommended by “boots-on-the-ground” professionals. The NLC, in partnership with HealthIT.gov, shares this collective EHR implementation knowledge and resources throughout this site.

National Learning Consortium Resources
Resource Name Description Source

EHR Incentive Program Clinical Quality Measures (CQMs)

View

Webpage that provides information and resources on the CQMs and how to successfully report them in the Medicare and Medicaid EHR Incentive Programs.

Center for Medicare and Medicaid Services (CMS)

Clinical Quality Measure (CQM) Case for Quality Briefs

Download

[ZIP - 13.31 MB]

Vignettes intended to help providers contextualize clinical quality measures (CQMs) and what they mean for patients within their own practice. Download includes brief vignettes for the following conditions:

  • Childhood Obesity
  • Coronary Artery Disease
  • Diabetes
  • Heart Failure
  • Ischemic Vascular Disease
  • Smoking Cessation
  • Vaccination Status
  • Asthma
  • Adult Obesity
  • Hypertension
  • Breast Cancer
  • Colorectal Cancer
  • Women's Health

Health Information Technology Resource Center (HITRC)

Clinical Quality Measure (CQMs) Quick Reference Guides

Download

[ZIP/PDF - 22 MB]

Guides that provide a summary of key information about the EHR fields which must be complete in order for the EHR system to calculate CQMs accurately. Each also includes a Technical Supplement, which "defines" many of the codes used to calculate the measure. Intended to be shared with clinical staff implementing and using an EHR. Download includes Quick Reference Guides for all 44 CQMs.

Health Information Technology Resource Center (HITRC)

Electronic Health Record (EHR) Quality Measure Dataflow Tool #1: Understanding Clinical Quality Measure (CQM) Data Documentation in Your Practice

Download

[PDF - 362 KB]

Worksheet to determine how data elements that are captured before, during, or after the patient visit are entered into the EHR. Includes discussion questions to help providers think about how to modify their workflow, training, computer terminal locations, and CQM data documentation responsibilities as needed. To be used with EHR Quality Measure Dataflow Tool #2.

Health Information Technology Resource Center (HITRC)

Electronic Health Record (EHR) Quality Measure Dataflow Tool #2: Creating a Clinical Quality Measure (CQM) Data Documentation Plan in Your Practice

Download

[PDF - 1.4 MB]

Worksheet to help providers develop individual-specific or role-specific plans for training and implementing the appropriate workflow in order to capture the necessary data elements for selected CQMs. To be used with EHR Quality Measure Dataflow Tool #1.

Health Information Technology Resource Center (HITRC)

Clinical Quality Measure (CQM) Quality Improvement Briefs

Download

[ZIP - 6.9 MB]

Vignettes intended to help providers understand how they can use their EHR to improve their clinical quality measures. Download includes brief vignettes for the following conditions:

  • Asthma
  • Breast Cancer Screening
  • Coronary Artery Disease
  • Colorectal Cancer Screening
  • Diabetes
  • Heart Failure
  • Hypertension
  • Vaccinations

Health Information Technology Resource Center (HITRC)

Making Meaningful Use Meaningful

Download

[ZIP - 1.7 MB]

Resources that provide links between Meaningful Use Stage 1 EHR functions and quality improvement. They are intended to help providers select clinical quality measures for Meaningful Use, as well as improve selected measures. The series includes the following:

  • Clinical Quality: Measurement to Improvement
  • How Using and EHR Meaningfully Can Improve Quality of Care in Practices

Health Information Technology Resource Center (HITRC)

Meaningful Use Stage 1 to Stage 2 Factsheets

Download

[ZIP - 1.73 MB]

Fact sheets outline how requirements around clinical quality measurement will change for Meaningful Use Stage 2/2014. They are intended to help providers understand what the changes are, and how they might influence existing clinical quality measures, and selection of future clinical quality measures. These series includes:

  • Clinical Quality Measures: Core Set in Stage 1 and Recommended Core Set in Stage 2
  • Clinical Quality Measures: A Stage 1 and Stage 2 Comparison by Clinical Category

Health Information Technology Resource Center (HITRC)

US Health Information Knowledge Base (USHIK) for Clinical Quality Measurement

Download

[PDF - 4.77 MB]

Guide provides a summary of how to use the US Health Information Knowledgebase (USHIK) to access key information on Clinical Quality Measures.

Health Information Technology Resource Center (HITRC)

Clinical Quality Measures: Alignment Across Quality Initiatives

Download

[DOCX - 1.1 MB]

Factsheet describes how providers’ efforts to measure and improve quality using EHRs aligns with quality initiatives.

Health Information Technology Resource Center (HITRC)

* Persons using assistive technology may not be able to fully access information in this file. For assistance, contact ONC at onc.request@hhs.gov.

The material in these guides and tools represents the collective EHR implementation experiences and knowledge gained directly from the field of ONC’s outreach programs (REC, Beacon, State HIE) and through the Health Information Technology Research Center (HITRC) Communities of Practice (CoPs) in their performance of technical support and EHR implementation assistance to primary care providers. The information contained in these resources is not intended to serve as legal advice nor should it substitute for legal counsel. The resource list is not exhaustive, and readers are encouraged to seek additional detailed technical guidance to supplement the information contained herein.

Reference in this web site to any specific resources, tools, products, process, service, manufacturer, or company does not constitute its endorsement or recommendation by the U.S. Government or the U.S. Department of Health and Human Services.

Related CMS EHR Incentive Program Frequently Asked Questions

For additional questions around meaningful use, visit the CMS EHR Incentive Program Frequently Asked Questions (FAQs).

 

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Last updated: Tuesday, November 26, 2013