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

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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 National Quality Forum (NQF) and the Centers for Medicare and Medicaid Services (CMS). Although many quality measures exist, NQF and CMS have selected 64 ambulatory and 44 inpatient measures that can be used to demonstrate MU. While CQM reporting is no longer a core objective in 2014, all providers are still required to report on CQMs in order to demonstrate MU.

Note that since EPs and EHS are allowed to select from among several CQMs, the RPMS EHR will only include 16 inpatient and 18 ambulatory CQMs. Review the list below to see which measures will be available.

2014 CQM list [PDF - 88 KB]

Also going into effect for FY/CY 2014, all Medicare-eligible providers beyond their first year of demonstrating MU must report their CQM data electronically to CMS Exit Disclaimer: You Are Leaving www.ihs.gov. (EPs and EHs that are only participating in the Medicaid EHR Incentive Program should consult with their SMHPs regarding the specific format required.)

Keep in mind:

  • CQMs have no required thresholds.
  • Data should be reported directly from the certified EHR.
  • Reporting zeros is acceptable.
  • CQMs may not be applicable to everyone (e.g., specialists).

Requirements

EPs must report on 9 of 64 approved CQMs, and EHs must report on 16 of 29 approved CQMs. Unlike prior years, for FY/CY 2014, CMS is not requiring the submission of a core set of CQMs. Instead, CMS has created two recommended core sets of CQMs, one for adults and one for children. EPs and EHs are encouraged to report from the recommended core set to the extent that those CQMs are applicable to the scope of practice and patient population.

In addition, EPs and EHs must select CQMs from at least three of the six National Quality Strategy domains listed below.

  • Patient and Family Engagement
  • Patient Safety
  • Care Coordination
  • Population and Public Health
  • Efficient Use of Healthcare Resources
  • Clinical Processes/ Effectiveness

Reporting Options

Beginning in 2014, all Medicare-eligible providers beyond their first year of demonstrating MU must report their CQM data electronically to CMS. EPs can report CQMs electronically either individually or as a group using the following methods:

  • Physician Quality Reporting System (PQRS) - Electronic submission of samples of patient-level data in the Quality Reporting Data Architecture (QRDA) Category I format. EPs can also report as a group using the PQRS GPRO tool. EPs who electronically report using this PQRS option will meet both their EHR Incentive Program and PQRS reporting requirements.
  • CMS-designated transmission method - Electronic submission of aggregate-level data in QRDA Category III format. EHs will report their CQMs electronically in the QRDA Category I format through the infrastructure similar to the EHR Reporting Pilot for hospitals, which will be the basis for an EHR-based reporting option in the Hospital Inpatient Quality Reporting program. They may also submit aggregate-level data in QRDA III format.

Helpful Resources

Listed below are links to a variety of CQM tools.

Final 2014 CQMs for Eligible Professionals Exit Disclaimer: You Are Leaving www.ihs.gov
Final 2014 CQMs for Eligible Hospitals and CAHs Exit Disclaimer: You Are Leaving www.ihs.gov
CQM TipSheet Exit Disclaimer: You Are Leaving www.ihs.gov
eCQM Library for 2014 Exit Disclaimer: You Are Leaving www.ihs.gov
2014 CQM Pediatric Recommended Core Set Table Exit Disclaimer: You Are Leaving www.ihs.gov
2014 CQM Adult Recommended Core Set Table Exit Disclaimer: You Are Leaving www.ihs.gov
2014 CQMs for Eligible Professionals Exit Disclaimer: You Are Leaving www.ihs.gov
CQM Resource Table Exit Disclaimer: You Are Leaving www.ihs.gov
2014 CQMs finalized Exit Disclaimer: You Are Leaving www.ihs.gov