I am starting the discussion of the individual meaningful use measures with “reporting on clinical quality measures (CQM)” for two reasons: It is one of the three pillars of meaningful use identified in the legislation, and it is a measure that appears to be causing a great deal of confusion.

Just one of the 15 core measures required of meaningful users, it sounds a lot like PQRI (now PQRS); and many of the measures are, in fact, taken from that program. However, unlike PQRS, meaningful use requires reporting only—it does not set required thresholds, at least not in Stage 1—and reporting is not limited to Medicare patients. Interestingly, physicians can earn both PQRS and EHR Incentives in the same reporting period (in contrast to ePrescribing and EHR incentives.)

While EPs cannot exclude this measure, providers can report “0”s (for denominators and numerators) if they cannot find measures that apply to their patient population.

The Final Rule shortened the list of quality measures contained in the Proposed Rule—eliminating the specialty-specific measure sets—and created a list of 44 CQMs from which EPS must choose. Some specialists perceived this change as good news, while others were disappointed.

Reporting Requirements:

Eligible professionals must report on 3 “Core CQMs” and 3 “Additional CQMs” as follows:

• There are 3 “Required Core CQMs” (Hypertension, Smoking Cessation, and Adult Weight Screening) and 3 “Alternate Core CQMs” (Weight Assessment for Children, Flu Vaccinations for Patients over 50, and Childhood Immunizations.) EPs must report on the 3 Required Core CQMs. If a physician reports “0”s for one or more of the 3 Required Core CQMs, he/she must then report on up to 3 Alternate Core CQMs. (Some specialists, therefore, may have to report on as many as 6 core CQMs.)
• There are 38 Additional CQMs from which physicians must also select 3. Again, there will be some specialists who find few measures, if any, that are relevant to their patient populations. They must still report on 3 of these measures with actual numerators and denominators where possible and “0”s for the others.

You can read more about the quality measures and their specifications in the Final Rule, pages 44398-44408, and on the CMS website.

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.