The fact that the CMS FAQ website contains 7 questions on clinical quality measure (CQM) reporting is an indication of the confusion surrounding this core meaningful use measure.

Many specialists are concerned that very few, or none, of the CQMs are relevant to their practices. According to FAQ #10144, “In the event that none of the 44 clinical quality measures applies to an EP’s patient population, the EP is still required to report [but with] a zero for the denominators.” It would be logical, therefore, for physicians to conclude that they should report a zero denominator for quality measures related to problems or conditions they do not treat.

For the purpose of meaningful use, however, it is not the physician who determines whether a particular quality measure applies—it is the EHR.  In one of the final steps of the attestation process, physicians must confirm that “the information submitted for CQMs was generated as output from an identified certified EHR technology.”

This means that, in reality, physicians will rarely be able to report a zero denominator.  Any secondary problem documented in a patient’s chart will place the patient in the denominator of all measures related to that problem—even if the physician did not treat the patient for it. For example, an ENT specialist who records vital signs, (see “The “All 3” Vital Signs Dilemma”), will have to report on whether she documented a weight management plan for patients who have a body mass index outside of the norm, even though she only treated those patients for an earache or sinusitis. An orthopaedist will have to report on how many times he provided smoking cessation guidance to patients who presented with tennis elbow—and whether he documented the blood pressure of patients he diagnosed with a sprained ankle or broken wrist, who happen to have hypertension. Pediatricians who have even a few patients over age 18, (and most do), will have to report on the core CQMs designed for adult populations, rather than on the more relevant pediatric-focused alternate measures such as immunization status or childhood weight management.

The above has no effect on eligibility for incentives—physicians will qualify for the EHR incentives regardless of the numerators they report for these CQMs, since there are no thresholds that must be met. CMS acknowledges that for now, the clinical quality measure reporting requirement is simply that—a reporting requirement.

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.