New Clinical Quality Measures and PQRS EHR Reporting

New Clinical Quality Measures
and PQRS EHR Reporting
Presented By:
Sophie Scheidlinger
Quality Programs Advisor

PQRS
+ PQRS is a CMS quality improvement program that uses
incentives and penalties to promote reporting of quality data
+ Eligibility
 Providers who see Medicare Part B patients and are reimbursed
under the Medicare Physician Fee Schedule (PFS)
 Physicians, chiropractors, dentists, PAs, NPs, and others
+ 2014 Incentives and Penalties
 +0.5% incentive or -2% penalty in 2016
2

Reporting Options
+ Note that qualifying
for the incentive
means automatically
avoiding the penalty
+ EHR reporting
method cannot be
used to simply avoid
penalty
3

PQRS EHR Reporting
+Criteria for satisfactory EHR reporting
Report on at least 9 measures covering 3 National Quality
Strategy (NQS) domains for all eligible patients during
reporting period
 If EHR doesn’t contain patient data for at least 9
measures, then report measures that have Medicare
patient data
Providers must report on at least 1 CQM that has
Medicare patient data
4

PQRS EHR Reporting and Practice Fusion
+Practice Fusion will act as a Direct EHR Vendor
(EHR Direct).
This will allow our providers to use Practice Fusion to
directly submit their PQRS measures data to CMS in the
CMS specified format on their own behalf.
Late in 2014, the 2014 CQM Dashboard will allow for
selection of CQMs for reporting and generation of a file
for attestation
Submit a years worth of CQM data to CMS in 2015
5

PQRS Measure Selection Considerations
+ When choosing (clinical quality) measures for reporting:
 Those of interest and applicable to the practice
 Those available under the selected PQRS reporting option
 Those that apply to your Medicare patients
+ If CQMs that Practice Fusion supports do not meet these
criteria, providers will need to select another option besides
EHR reporting
6

Practice Fusion now supports 27 CQMs
Allowing more Practice Fusion providers to choose
the EHR Reporting Mechanism for PQRS reporting
7

Review of 14 newly released Clinical
Quality Measures
8

CQM Terminology
• The population of patients or encounters for which
the measure applies. Denominator
• The population of patients from the denominator who meet
the measure specified clinical requirements or the population
of encounters from the denominator where the measure
specific requirement has been performed.
Numerator
• Specifications that would remove a patient from the denominator of a
specific quality measure.
• Includes certain diagnoses that make it clinically unnecessary for the
patient to receive the numerator clinical action and/or provider or
patient determined reasons for refusing certain clinical actions.
Exclusion/Exceptio
n
• This is also known as the EHR reporting period and
refers to the time frame for which the CQMs will be
calculated.
Measurement
period

CQM Terminology
• The six NQS domains, one of which is assigned to each CMS
eCQM, are: Patient and Family Engagement, Patient Safety,
Care Coordination, Population and Public Health, Efficient Use
of Healthcare Resources, and Clinical Processes/Effectiveness
National Quality
Strategy (NQS)
Domains
• NQF reviews, endorses, and recommends use of standardized
quality measures. Not all quality measures are “NQF-endorsed,”
but those that are have an assigned NQF number.
National Quality
Forum (NQF)
• Lists of specific values (terms and their codes) derived from
single or multiple standard vocabularies used to define clinical
concepts (e.g. patients with diabetes, clinical visit, reportable
diseases) used in clinical quality measures and to support
effective health information exchange.
Value sets
• An HL7-based standard document format for
reporting clinical quality measure data to CMS for
quality improvement programs.
Quality Reporting
Document Architecture
(QRDA)

CMS22v2: Screening for High Blood Pressure and Follow-Up Documented
NQS Domain Population/Public Health
Denominator Numerator
Patients aged 18 and older before
the start of the measurement period.
Patients who were screened for high blood pressure AND have a recommended follow-up
plan documented, as indicated, if the blood pressure is pre-hypertensive or
hypertensive.
Practice Fusion
Suggested
Workflow
After recording the patient’s BP in the chart, determine if the patient is pre-hypertensive or
hypertensive, and then record the following in the Screenings/Interventions/Assessments section of the
new chart:
• Follow-up time frame (4 weeks, 1 year, etc.)
• The selected intervention as “Ordered, Reason (Finding of hypertension)”
Recommended Blood Pressure Follow-Up Interventions
Normal BP: No follow-up required for Systolic BP < 120 mmHg AND Diastolic BP <80 mmHg
Pre-Hypertensive BP: Follow-up with re-screen every year with systolic BP of 120-139 mmHg OR
diastolic BP of 80-89 mmHg AND recommend lifestyle modifications OR referral to Alternative/Primary
Care Provider
First Hypertensive BP Reading: Patients with 1 reading of systolic BP >= 140 mmHg OR diastolic BP
>= 90 mmHg: Follow-up with re-screen > 1 day and < 4 weeks AND recommend lifestyle modifications
OR referral to Alternative/Primary Care Provider
Second Hypertensive BP Reading: Patients with 2nd elevated reading of systolic BP >=140 mmHg OR
diastolic BP >= 90 mmHg: Follow-up with Recommended lifestyle recommendations AND one or more
of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider

CMS22v2: Screening for High Blood Pressure and Follow-Up Documented
12
Hypertension Screening Ranges
Normal BP Pre-hypertensive BP Hypertensive BP
120/80 mmHg 120/80 mmHg - 139/89 mmHg 140/90 mmHg
• Interventions that meet the numerator criteria of this measure include:
• Hypertension education
• Exercise education or exercise counseling
• Target weight discussed
• Dietary management education, guidance and counseling
• Nutrition education
• Referral to a primary care provider can be used as an intervention for this measure, but
this must be recorded in the Screenings/Intervention/Assessments section of the chart
note since “Finding of Hypertension” cannot be selected in the PF referral workflow.
• Patients who have BP values that are hypertensive (>= 140/90) at two or more visits also
must have one of following recorded:
• Rx for anti-hypertensive pharmacologic therapy,
• A lab order or result for hypertension (CBC with ordered manual differential panel,
urinalysis complete panel, etc.), or
• EKG study or EKG 12 channel panel (recorded under the S/I/A section of the chart)

CMS164v2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
NQS Domain Clinical Processes/Effectiveness
Patients 18 years of age and older with a visit
during the measurement period, and an
active diagnosis of ischemic vascular disease
(IVD) during the measurement period.
Patients who have documentation of use of
aspirin or another antithrombotic during the
measurement period.
Practice
Fusion
Suggested
Workflow
Medications that meet the numerator criteria for this measure include the
following:
• Prasurgrel (5mg and 10mg oral tablet)
• Aspirin (varying dosages and tablet types, for example: 81 mg chewable
tablet, 80 mg oral tablet, 228 mg chewing gum, 300 mg oral capsule, 162
mg enteric coated tablet, etc.)
• Clopidogrel (300mg and 75 mg oral tablet)

CMS164v2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
14
+ Diagnoses must include a start date and have no end date or have an
end date that has not passed to qualify the patient for the denominator.
 The Dx start date does not need to be during the measurement year.
+ Prescriptions and medications added to the patient’s medication list that
are “active” will qualify the patient for the numerator.
 A start date must be recorded for these medications to be included in
CQM calculations (but the start date does not need to be during the
measurement year).
 Active medications and prescriptions are those without a stop date or
those with a stop date that has not already passed.

CMS182v3: Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
Patients 18 years of age and older with a visit
during the measurement period, and an active
diagnosis of ischemic vascular disease (IVD)
during the measurement period.
Numerator 1: Patients with a complete lipid profile
performed during the measurement period
Numerator 2: Patients whose most recent LDL-C level
performed during the measurement period is <100 mg/dL
Practice
Fusion
Suggested
Workflow
This measure requires recorded lab results in the EHR. The following lab results meet
the criteria for Numerator 1 of this CQM:
• Lipid panel with direct LDL - Serum or Plasma (LOINC 57698-3), OR
• Lipid 1996 panel - Serum or Plasma (LOINC 24331-1), OR
• ALL of the following together during the measurement period:
• Total cholesterol Laboratory test (LOINC 2093-3)
• HDL-C Laboratory test (LOINC 2085-9)
• LDL-C Laboratory Test (LOINC 13457-7, 18262-6, or 2089-1)
• Triglycerides Laboratory test (LOINC 12951-0 or 2571-8)

CMS182v3: Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
16

CMS127v2: Pneumonia Vaccination Status for Older Adults
Patients 65 years of age and
older with a visit during the
measurement period.
Patients who have ever received a pneumococcal
vaccination.
Practice Fusion
Suggested
Workflow
Vaccines (both administered and historical) are entered in the Practice
Fusion in the immunizations screen.
• The pneumococcal vaccine can be recorded in the patient chart
under the Immunizations section of the EHR as “administered” or
“historical.”
• Data of vaccine must be before or during the measurement
period to count in the numerator.
• The only pneumococcal vaccine that meets this measure is
Pneumococcal polysaccharide vaccine, 23 valent (CVX 33)

CMS127v2: Pneumonia Vaccination Status for Older Adults
18
+ Access the patient’s immunizations section
+ Select whether the immunization was “Administered” or
“Historical”
+ Search for Pneumococcal, select “Pneumococcal, 23-valent,
adult”, include an administered date, and save

CMS125v2: Breast Cancer Screening
Women 41–69 years of age with a
visit during the measurement period.
Women with one or more mammograms during the measurement
period or the year prior to the measurement period.
Practice Fusion
Suggested
Workflow
• Breast cancer screenings must be recorded as “Performed” in the
Screenings/Intervention/Assessments section of the new chart note.
• Screenings that are dated during the measurement year or in the year prior
to the measurement year will count towards this measure.
• Screening assessments that meet the numerator of this measure include:
• Screening mammography
• Diagnostic mammography
• Breast mammogram screening
• Right mammogram screening
• Bilateral mammogram screening
• Breast mammogram spot
• Breast mammogram grid

CMS125v2: Breast Cancer Screening
20
Search for “Breast mammography screening” and select “Performed.” A result is not
required for this measure and the date of the screening is defaulted to the date of the chart
note unless otherwise changed by the provider.
Additional Tips
+ Women who had a bilateral
mastectomy or for whom there is
evidence of two unilateral
mastectomies recorded in the
EHR are excluded from this
measure.
+ Providers can record breast
cancer screenings that were
performed by another provider for
the purposes of this measure
using the same method of
recording under the
Screenings/Intervention/Assessm
ents section of the chart note.

CMS144v2
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
All patients aged 18 years and older with at least two encounters during the
measurement period, AND:
1) A Dx of heart failure, AND
2) One of the following:
• LVEF result that is <40%, OR
• A Dx of moderate or severe LVSD,
That occurs before or during the second encounter for the patient during the
measurement year.
Patients who were prescribed beta-blocker
therapy within a 12 month
period when seen in the outpatient
setting.
Practice
Fusion
Suggested
Workflow
• Patient is added to the measure denominator after their 2nd encounter of the measurement period.
• Beta-blockers that meet the numerator criteria for this measure include (but are not limited to):
• 24 HR Hydrochlorothiazide 12.5 MG / Metoprolol Tartrate 50 MG Extended Release Tablet
• 24 HR Metoprolol Tartrate 50 MG Extended Release Tablet (other dosages qualify as well)
• 24 HR carvedilol phosphate 80 MG Extended Release Capsule (other dosages qualify as well)
• Bisoprolol Fumarate 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet (other dosages qualify as
well)
• Carvedilol 25 MG Oral Tablet (other dosages qualify as well)

CMS144v2
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
22
+ Providers should ensure patients are prescribed or have an active medication for beta-blockers at any
encounter in which the patient meets the denominator criteria for this measure:
 A Dx of heart failure, AND
 One of the following:
1) LVEF result that is <40%, OR
2) A Dx of moderate or severe LVSD
+ LVEF results must be received as structured lab results in Practice Fusion
+ This CQM does not have any denominator exclusions, but the following represent denominator
exceptions:
 Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, low blood pressure, fluid overload,
asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical
reasons)
 Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient
reasons)
 Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the
healthcare system)

CMS147v2: Preventative Care and Screening: Influenza Immunization
All patients aged 6 months and older with at least two encounters
during the measurement period and one encounter that occurred
between October 1st of the previous measurement period and
March 31st of the current measurement period.
Patients who received an influenza
immunization OR who reported
previous receipt of an influenza
immunization
Practice
Fusion
Suggested
Workflow
• This measure is looking to see whether patients received the influenza vaccine during a
single flu season that occurs between October 1st of the previous year and March 31st of
the current year.
• Influenza vaccines that meet this measure include:
• Influenza, seasonal injectable (CVX 141)
• Influenza seasonal, injectable, preservative free (CVX 140)
• Influenza, high dose seasonal, preservative-free (CVX 135)
• Influenza, live, intranasal, quadrivalent (CVX 149)
• Seasonal influenza, intradermal, preservative free (CVX 144)
• Influenza, injectable, quadrivalent, preservative free (CVX 150)
• Influenza virus vaccine, live, attenuated, for intranasal use (CVX 111)

CMS147v2: Preventative Care and Screening: Influenza Immunization
24
+ Previous receipt of influenza (such as a patient who received the vaccine at work) can
be recorded:
 In the Screenings/Intervention/Assessments section of the chart note by search for
“Has influenza vaccination at…” or
 By recording a “historical” vaccine in the immunization section of the EHR and
including a date between October 1st - March 31st
+ To enable reporting of this measure at the close of the reporting period, this measure
will only assess the influenza season that ends in March of the reporting period. The
subsequent influenza season (ending March of the following year) will be measured and
reported in the following year.

CMS139v2: Falls: Screening for Future Fall Risk
NQS Domain Patient Safety
Patients aged 65 years and older with
a visit during the measurement period.
Patients who were screened for future fall risk at
least once within the measurement period.
Practice
Fusion
Suggested
Workflow
• Future fall risk: Patients are considered at risk for future falls if they have
had 2 or more falls in the past year or any fall with injury in the past year.
• Search for “Falls Risk Assessment” in the
Screenings/Interventions/Assessments section of the chart note and
indicate that it has been “performed.”
• The start date defaults to the date of the chart note but can be
backdated if needed.
• A result is not needed for the Falls Risk Assessment.

CMS139v2: Falls: Screening for Future Fall Risk
26
+ Search and record “Falls Risk Assessment” as “Performed” in the
Screenings/Interventions/Assessments section of the new chart note.
+ A result is not needed and the start date is defaulted to the date of the encounter. An
end date is not needed for this CQM.

CMS155v2:
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Patients 3-17 years of age with at
least one outpatient visit with a
primary care physician (PCP) or an
obstetrician/gynecologist (OB/GYN)
Numerator 1: Patients who had a height, weight and body mass
index (BMI) percentile recorded during the measurement period
Numerator 2: Patients who had counseling for nutrition during the
measurement period
Numerator 3: Patients who had counseling for physical activity
during the measurement period
Practice
Fusion
Suggested
Workflow
• BMI percentile is automatically calculated for patients in this age range who have height
and weight recorded
• Counseling for nutrition and physical activity are recorded under the
Screenings/Intervention/Assessments section
• Examples of interventions for counseling for nutrition (numerator 2) include: “nutrition education,”
“lifestyle education regarding diet,” and “weight control education.”
• Examples of interventions for counseling for physical activity (numerator 3) include: “exercise
education,” “patient advised about exercise,” and “recommendation to exercise.”

CMS155v2:
Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
28
+ To meet Numerator 1, providers
must record the height and weight
+ Numerator 2 includes all of the
requirements of Numerator 1 +
recording an intervention of
counseling for nutrition.
+ Numerator 3 includes all of the
requirements of Numerator 1 +
Numerator 2 + recording an
intervention for counseling for
physical activity.

CMS126v2: Use of Appropriate Medications for Asthma
Patients 5-64 years of age with
persistent asthma and a visit during
the measurement period.
Patients who were dispensed at least one prescription
for a preferred asthma therapy during the
measurement period.
Practice Fusion
Suggested
Workflow
“Persistent Asthma” for the purposes of this CQM must be recorded
using SNOMED by searching for and adding one of the following
diagnoses with a start date on or before the encounter:
• Moderate persistent asthma
• Mild persistent asthma
• Severe persistent asthma
Patients whose charts only include the ICD-9 code 493.90 (Asthma)
will not be included in this measure denominator.

CMS126v2: Use of Appropriate Medications for Asthma
30
+ For the moment, providers will not be able to record that a
medication has been dispensed for the purposes of this
CQM.
+ This is a required CQM for Comprehensive Primary Care
Initiative – other providers should not select this CQM for
reporting unless absolutely necessary.

CMS163v2: Diabetes: Low Density Lipoprotein (LDL) Management
Patients 18-75 years of age with diabetes
with a visit during the measurement
period.
Patients whose most recent LDL-C level
performed during the measurement period is
<100 mg/dL.
Practice
Fusion
Suggested
Workflow
The LDL-C test results that meet the numerator criteria for this measure
include:
• Cholesterol in LDL [Mass/volume] in Serum or Plasma (LOINC 2089-1)
• Cholesterol in LDL [Mass/volume] in Serum or Plasma by Direct assay
(LOINC 18262-6)
• Cholesterol in LDL [Mass/volume] in Serum or Plasma by calculation
(LOINC 13457-7)

CMS163v2: Diabetes: Low Density Lipoprotein (LDL) Management
32
+ This measure will look for the most recent (e.g. the last recorded) LDL-C result
in the EHR that occurred during the measurement period for the purposes of
the numerator criteria.
+ Patients with a diagnosis of gestational diabetes are excluded from this
measure.

CMS124v2: Cervical Cancer Screening
Women 23-64 years of age with a visit
Women with one or more Pap tests during the measurement
period or the two years prior to the measurement period.
Practice
Fusion
Suggested
Workflow
Pap test results can be sent to the Practice Fusion EHR by a lab partner.
The lab test results that meet the numerator criteria for this measure include (but are not
limited to):
• Cytology report of Cervical or vaginal smear or scraping Cyto stain (LOINC 47528-5)
• Cytology report of Cervical or vaginal smear or scraping Cyto stain thin prep (47527-7)
• Cytology Cervical or vaginal smear or scraping study (33717-0)
• Cytology study comment Cervical or vaginal smear or scraping Cyto stain (19774-9)
• Microscopic observation [Identifier] in Cervix by Cyto stain thin prep (18500-9)
• Microscopic observation [Identifier] in Cervix by Cyto stain (10524-7)

CMS124v2: Cervical Cancer Screening
34
+ Cervical cancer screenings cannot be entered into the EHR under
Screenings/Intervention/Assessments
+ They must be sent to the EHR by a lab partner

CMS153v2: Chlamydia Screening for Women
Women 16 to 24 years of age who are sexually active and
who had a visit in the measurement period.
Women with at least one chlamydia test
Practice
Fusion
Suggested
Workflow
Codes to identify sexually active women include codes for:
• pregnancy
• sexually transmitted infections
• contraceptives
• contraceptive devices
• infertility treatments

CMS153v2: Chlamydia Screening for Women
36
+ The U.S. Preventive Service Task Force recommends that sexually active non-pregnant
young women age 24 years or younger and older women (pregnant or
not) who are at increased risk should be screened for a chlamydial infection.
+ Chlamydia test results must come through structured lab results into the EHR.
+ Women who receive a pregnancy
test solely as a safety precaution
before ordering an x-ray or
specified medications are
excluded from this measure.
 Ensure that the pregnancy test and the
associated X-ray are recorded in the EHR
if a patient should be excluded.
 X-ray data elements can be found in the
Screenings/Intervention/Assessment
section of the chart note.

CMS149v2: Dementia: Cognitive Assessment
All patients, regardless of age, with a
diagnosis of dementia and at least two
encounters during the measurement period.
Patients for whom an assessment of cognition is
performed and the results reviewed at least once within a
12 month period.
Practice
Fusion
Suggested
Workflow
Cognitive assessments are conducted outside of the EHR but can be recorded in the
patient chart under Screenings/Intervention/Assessments. Standardized assessments that
meet this CQM criteria include:
• Total score BOMC
• Total score MoCA
• Total score MMSE
• Total score AD8
• Total score IQCODE
• Total score SLUMS
• Prior assessment brief interview for mental status (BIMS) summary score MDSv3

CMS149v2: Dementia: Cognitive Assessment
38
+ Patients will be added to the denominator of this measure in the CQM report after their
2nd encounter.
+ The cognitive assessment should be conducted and recorded during the 1st encounter
during the measurement period and reviewed during the 2nd encounter of the
measurement period
 However, this CQM will give credit if the assessment is recorded during any
encounter during the measurement year (since review of the assessment is not
measured as part of this CQM).
+ Use of a standardized tool or instrument to assess cognition other than those listed in
the previous table will still meet numerator performance.
 Search and record the data element “Assessment and interpretation of higher
cerebral function, cognitive testing” if you use an assessment tool not otherwise
listed.

Resources
+ Practice Fusion Quality Programs Page
 http://www.practicefusion.com/physician-quality-programs/
+ CMS Eligibility Site
 http://cms.gov/eHealth/downloads/EligibilityChart_090513_FINAL.p
df
+ PQRS Resources on Practice Fusion
 http://www.practicefusion.com/blog/resources-and-faqs-on-cqms-and-
pqrs-2014/
+ CQMs on the Forum
 https://forum.practicefusion.com/practicefusion/topics/how_does_th
e_2014_cqm_report_work?
39

Assistance
+ QualityNet Help Desk
+ CMS’s resource on the PQRS program
+ Available Monday – Friday; 7:00 AM-7:00 PM CST
+ Phone: 1-866-288-8912
+ Email: Qnetsupport@hcqis.org

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