1. Clinical Quality Measures (CQMs) and Physician Privileging
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Introduction
Clinical Quality Measures (CQMs) and Physician Privileging
February 5, 2015

2. Overview
CQM selection requirements for 2014 for Eligible Professionals and Hospitals
EHR Reporting Options
Physician Quality Reporting System (PQRS)
Incorporating CQM outcomes with Physician Renewals or Privileges

3. 2014 Clinical Quality Measures (CQMs)
Eligible Professionals (EPs) are required to report 9 out of 64 measures
Eligible Hospitals (EHs) are required to report 16 out of 29 measures
For both EPs and EHs, the quality measures selected must cover at least 3 of the 6 available National Quality Strategy (NQS) domains:
Patient and Family Engagement
Patient Safety
Care Coordination
Population/Public Health
Efficient Use of Healthcare Resources
Clinical Process/Effectiveness

4. EHR Reporting Options for EPs and EHs
EHR Reporting Options for EPs in 2014:
Options that only apply for the EHR Incentive Program
Option 1: Attest to CQMs through the EHR Registration & Attestation System (
Option 2: eReport CQMs through Physician Quality Reporting System (PQRS) Portal
Options that Align with Other Quality Programs
Option 3: Report individual eligible professionals’ CQMs through PQRS Portal
Option 4: Report group’s CQMs through PQRS Portal
Option 5: Report group’s CQMs through Pioneer ACO participation or Comprehensive Primary Care Initiative participation
EHR Reporting Options for EHs in 2014:
Option 1: Attest to CQMs through the Registration & Attestation System
Option 2: eReport through Hospital Inpatient Quality Reporting (IQR)

5. Physician Quality Reporting System (PQRS)
PQRS provides an incentive payment to practices with EPs (identified on claims by NPI and TIN), or group practices participating in the Group Practice Reporting Option (GPRO) who report data on quality measures for covered Medicare Physician Fee Schedule (PFS) services.
Eligible Professionals:
Medicare Physicians (Doctor of Medicine, Osteopathy, Dental, Oral Surgery, etc.)
Practitioners (PA, NP, CRNA, CNS, CSW, etc.)
Therapists (PT, OT, etc.)
PQRS Reporting Methods:
Medicare Part B claims
Qualified PQRS registry
Direct EHR
CEHRT from Data Submission Vendor
Qualified clinical data registry (QCDR)

6. Incorporating CQM outcomes with Physician Privileges
1. Using NQF search criteria options and categories to structure renewals or privileges for a given EP:
National Quality Strategy Priorities
Affordable Care
Effective Communication
Patient Safety
Person/Family Centered Care
Care Setting
Ambulatory Care
Behavioral Health
Hospital/Acute Care Facility
Emergency Services
Clinical Condition/Topic Area
Cardiovascular
Infectious Disease
Neurology
Prevention
Data Source
Administrative Claims
Paper Medical Records
Electronic Clinical Data
EHR
Labs
Pharmacy
Level of Analysis
Clinician based
Individual
Team based
Health Plan
Facility
Measure Type
Composite
Outcome
Process
2. Using QRDA I and III reports for eCQMs chosen
only 18% (or 42 measures) of NQF-endorsed measures are in eMeasure format
QRDA I – patient specific
QRDA III – population specific

7. Incorporating CQM outcomes with Physician Privileges
3. Using PQRS components to structure renewals or privileges for a given EP or group:
Factors considered when selecting specific measures
Clinical conditions usually treated
Types of care typically provided (e.g., preventive, chronic)
Settings where care is usually delivered (e.g., emergency department, surgical suite)
Quality improvement goals for 2014
Other quality reporting programs in use or being considered
PQRS Outcomes
Incentive Payments and Adjustments
PQRS Feedback Reports
Maintenance of Certification Program
Value-based Payment Modifier Program
Specialty Measure Sets for 2015 (suggested but not required)
Cardiology (
General/Family Practice(
Radiology (