Skip to site content

Indian Health Service The Federal Health Program for American Indians and Alaska Natives

Share This Page:

CQM Reporting in 2014

Regardless of whether they are in Stage 1 or Stage 2, beginning in 2014, EPs and EHs will be required to report on CQMs using the new criteria determined by the Centers for Medicare and Medicaid Services (CMS). Although many quality measures exist, CMS has selected 64 ambulatory and 44 inpatient measures that can be used to demonstrate MU. While CQM reporting is no longer categorized as a performance measure in 2014, all providers are still required to report on CQMs in order to demonstrate MU. These CQMs must be chosen from at least three of the six National Quality Strategy domains (see 2014 Requirements).

The certified 2014 RPMS EHR will include 16 inpatient and 18 (nine adult and nine pediatric) ambulatory CQMs. See below for the CQMs available in the 2014 RPMS EHR or print the RPMS 2014 CQM List [PDF - 88 KB].

Inpatient CQMs in the RPMS EHR include:

  • ED-3 – Median time from ED arrival to ED departure for discharged ED patients
  • Stroke-2 Ischemic stroke – Discharged on anti-thrombotic therapy
  • Stroke-3 Ischemic stroke – Anticoagulation therapy for atrial fibrillation/flutter
  • Stroke-4 Ischemic stroke – Thrombolytic therapy
  • Stroke-5 Ischemic stroke – Antithrombotic therapy by end of hospital day two
  • VTE-3 VTE Patients with anticoagulation overlap therapy
  • AMI-7a- Fibrinolytic therapy received within 30 minutes of hospital arrival
  • AMI-10 statin prescribed at discharge
  • Exclusive breast milk feeding
  • EHDI-1a - Hearing screening prior to hospital discharge
  • Stroke-8 Ischemic or hemorrhagic stroke – Stroke education
  • Home Management Plan of Care (HMPC) document given to patient/caregiver
  • Emergency Department (ED) -1 Emergency Department Throughput – Median time from ED arrival to ED departure for admitted ED patients
  • ED-2 Emergency Department Throughput – admitted patients – Admit decision time to ED departure time for admitted patients
  • VTE-5 VTE discharge instructions
  • Healthy-term newborn

Pediatric ambulatory CQMs in the RPMS EHR include:

  • Appropriate testing for children with pharyngitis
  • Weight assessment and counseling for nutrition and physical activity for children and ado
  • Chlamydia screening for women
  • Use of appropriate medications for asthma
  • Childhood immunization status
  • Appropriate treatment for children with upper respiratory infection (URI)
  • Follow-up care for children prescribed attention-deficit/hyperactivity disorder (ADHD) medication
  • Preventive care and screening for clinical depression and follow-up plan
  • Children who have dental decay or cavities

Adult ambulatory CQMs in the RPMS EHR include:

  • Controlling high blood pressure
  • Use of high-risk medications in the elderly
  • Preventive care and screening: Tobacco use screening and cessation intervention
  • Use of imaging studies for low back pain
  • Preventive care and screening for clinical depression and follow-up plan
  • Documentation of current medications in the medical record
  • Preventive care and screening: Body Mass Index (BMI) screening and follow-up
  • Closing the referral loop: receipt of specialist report
  • Functional status assessment for complex chronic conditions