Throughout the healthcare landscape, providers and hospitals must navigate various different incentive programs and quality improvement programs, with which come numerous requirements for clinical quality measures.

However, provided the vast number of clinical quality measures, these can be difficult for industry stakeholders to manage. Between the measure requirements for various programs — from meaningful use, to physician programs, to the impending implementation of MACRA — clinical quality reporting is easily jumbled.

Clinical quality measures (CQMs) are a part of the Centers for Medicare & Medicaid Services (CMS) various healthcare improvement efforts, such as the EHR Incentive Programs, otherwise known as meaningful use. In order for a healthcare provider or organization to be considered for incentive payments under meaningful use, they must submit information on their CQMs to CMS.

However, their use goes beyond rewarding hospitals and providers for quality work. CMS also uses CQMs to perform various quality improvement projects and public health projects.

By measuring CQMs in various categories of performance by eligible professionals, eligible hospitals, and critical access hospitals, CMS can ensure that quality healthcare is available to the individuals who visit them, and work to improve the categories in which the industry is falling behind.

As listed on the CMS website, CQMs assess the following:

  • health outcomes
  • clinical processes
  • patient safety
  • efficient use of health care resources
  • care coordination
  • patient engagements
  • population and public health
  • adherence to clinical guidelines

In order to ensure that CQMs are accurate and useable, ONC is in charge of assessing the EHR and other technologies used to obtain the CQM data.

“ONC certifies that electronic health record (EHR) technologies are capable of accurately calculating the electronic clinical quality measure (eCQM) results for several incentive programs,” the agency explains on its website.


CQMs are developed by various healthcare industry stakeholders, including those at the National Quality Forum.

“NQF-endorsed measures are considered the gold standard for healthcare measurement in the United States,” NQF explains on its website. “Expert committees that are comprised of various stakeholders, including patients, providers, and payers, evaluate measures for NQF endorsement. The federal government and many private sector entities use NQF-endorsed measures above all others because of the rigor and consensus process behind them.”

NQF helps develop quality measures that boost the kind of quality improvement projects CMS is at the helm of, as well as works to drive the initiative for measures quality measures through electronic formats such as the EHR.

CMS has also developed its own process by which it develops clinical quality measures called the Measures Management System. The MMS sets a standard of business processes and other criteria for other industry contractors, like the NQF, to develop CQMs.

CMS’s efforts in developing clinical quality measures is ever-evolving. Earlier this year, the agency published an update on how it will continue to develop clinical quality measures, especially in the industry’s transition to the Medicare Access and CHIP Reauthorization Act (MACRA).

While CMS added new CQMs in the wake of MACRA implementation, it notes that it will continue working with industry experts to develop these measures.

“The MACRA law provides the opportunity to further progress the Medicare program and our national health care system toward paying for value rather than volume,” said Kate Goodrich, MD, MHS, director of the Center for Clinical Standards and Quality at CMS, in a blog post.

“However, the successful implementation of the Quality Payment Program established by MACRA requires a partnership with patients, their families, frontline clinicians, and professional organizations to develop measures that are meaningful, applicable, and useful across payers and health care settings.”


While there are numerous different uses for clinical quality reporting, it is most closely associated with the EHR Incentive Programs, or meaningful use.

When eligible providers, eligible hospitals, and critical access hospitals submit reports on the required quality measures, CMS reimburses them accordingly.

However, several healthcare experts believed quality reporting measures for meaningful use too arduous and often repetitive. In a focus group study published in the American Journal ofManaged Care, “top performers” in meaningful use stated that the program should create more flexibility for providers.

“While participants in one focus group unanimously agreed that there should be a core group of CQMs for all providers, regardless of specialty, that focuses on important public health issues — such as measures related to tobacco abuse and obesity — participants at the other 2 focus groups maintained that while a few CQMs could be applicable to all providers, there should be flexibility with CQMs tailored for both primary care physicians and specialists,” the authors wrote.

Earlier this year, CMS went to lengths to reduce the reporting burden for quality measures under meaningful use by streamlining measures under seven categories. By streamlining these measures, CMS reportedly hoped providers and hospitals could put more quality into reporting each measure.

“In the U.S. health care system, where we are moving to measure and pay for quality, patients and care providers deserve a uniform approach to measure quality,” explained CMS Acting Administrator Andy Slavitt. “This agreement today will reduce unnecessary burden for physicians and accelerate the country’s movement to better quality.”

CMS has also adjusted some of the clinical quality reporting as the industry faces Stage 3 Meaningful Use, starting in 2017. Most of these efforts have been geared toward streamlining the process for physicians and hospitals reporting to the programs.

Beyond meaningful use, clinical quality reporting remains and important aspect of performance improvement for eligible providers and small physician groups, mainly through the Physician Quality Reporting System.

According to CMS, PQRS helps providers understand the quality in care they deliver to their patients. When providers submit high performance data to PQRS, they receive relatively substantial incentive payments.

However, PQRS also includes a negative reimbursement program of up to 2 percent for providers who do not satisfactorily meet the standards under the program. Although this program is technically optional, that 2 percent negative reimbursement provides as strong incentive for participation.


As a result of the Medicare Access and CHIP Reauthorization Act (MACRA), the healthcare industry has been introduced to the Merit-Based Payment System (MIPS), which will make changes to clinical quality measures.

MIPS replaces the sustainable growth rate (SGR) formula by reassessing hospital and provider quality. By using three pre-existing performance models, MIPS will score providers on a scale of zero to 100, and their incentive payment will reflect that score.

The point allocation goes as follows:

  • Meaningful use: 25 points
  • Physician Quality Reporting System/Value-based Modifier: 30 points
  • Value-based Modifier Cost: 30 points
  • Clinical Practice Improvement: 15 points

Meaningful use as a part of a larger incentive program will ideally help yield higher provider performance, say many industry experts.

“More Meaningful Use and Certification criteria are not the answer,” wrote CIO of Beth Israel Deaconess Medical Center John D. Halamka, MD, MS. “Paying for outcomes that encourage government, payers, providers, patients and health IT developers to work together, instead of being adversaries, is the path forward.”

Likewise, incorporating PQRS as a part of a larger overall incentive program will ideally reduce reporting burden.

As noted at the top of this article, CMS has also modified how it will develop clinical quality measures under MACRA.

In its final draft, CMS explained that it has reassessed to established clinical quality measures in six categories, including clinical care, patient safety, care coordination, patient and caregiver experience, prevention and population health, and affordable care.

CMS stated that these quality measures will continue to evolve, provided the input of healthcare experts, providers, and patients. Further, the agency noted that it will consult with other federal agencies to reduce duplicate reporting for the numerous quality improvement programs in the industry.

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