Data Quality & Measures

To qualify as a meaningful user, eligible professionals and eligible hospitals must demonstrate that they meet all of the required stage 1 objectives and associated measures. Measures are grouped into two categories: meaningful use (HIT functionality) measures and clinical quality measures.

Stage 1 Meaningful Use (HIT Functionality) Measures

Functionality measures describe either the eligible provider or eligible hsopital requirement for each objective and the target compliance in order to meet the eligibility criteria. Many of these targets are percentages for which CMS provides a numerator, demoninator, and required percentage threshold.

Functionality objectives/measures are divided into "core" and "menu" sets.

Core Set

Participants must achieve each objective and corresponding measure in the core set.
There are 15 objectives for eligible professionals and 14 for eligible hospitals.

Menu Set

There are 12 menu set objectives total, 10 applying to eligible professionals and 10 applying to eligible hospitals.
Participants must choose five menu set objectives and corresponding measures.
At least one of the five menu set objectives must be a population/public health measure.
Menu set objectives/measures not chosen as part of stage 1 will be deferred to stage 2 of the program.

Visit the online Journal of AHIMA and read Meaningful Use: Review of Changes to Objectives and Measures in Final Rule for a complete list of stage 1 meaningful use objectives and measures.

Stage 1 Meaningful Use Clinical Quality Measures

When Congress developed the meaningful use EHR incentive program, one of its goals was to improve the quality and efficiency of care for the Medicare and Medicaid populations. Accordingly, eligible hospitals and providers that participate in the program will be required to capture and report clinical quality measures using certified EHR technology.

For purposes of the incentive program, CMS defines clinical quality measures as the "processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care."

Clinical Quality Measures for Eligible Providers

For the 2011/2012 reporting period, CMS finalized 44 clinical quality measures for eligible providers.
Three of the measures are designated as "core clinical quality measures" and must be reported by all eligible providers for stage 1 meaningful use.
CMS expanded the core clinical quality measure set to include three alternate core clinical quality measures. In instances where the denominator for one or more of the core clinical quality measures is zero, the eligible provider will be required to report results for up to three alternate core clinical quality measures.
Eligible providers must report on a total of six clinical quality measures: three core measures (or alternate core measures) and three additional quality measures other than core or alternate.
If all six core and alternate core clinical quality measures have zeros in the denominators, the eligible provider is still required to report on three additional clinical quality measures from the full measure set.
Four of the clinical quality measures also align with the measure set selected under the Children's Health Insurance Program Reauthorization Act (CHIPRA).
Eligible Professionals Clinical Quality Measures: CMS Instructions for Reporting Numerators, Denominators & Exclusions
Eligible Professionals: Clinical Quality Measure Specifications (6.35 MB zip file)

Clinical Quality Measures for Eligible Hospitals

For the 2011/2012 reporting period, CMS finalized 15 clinical quality measures for eligible hospitals.
None of the stage 1 clinical quality measures overlap with existing RHQDAPU program reporting requirements.
Eligible hospitals will report numerators, denominators and exclusions, even if one or more values are zero.
CMS removed the alternate Medicaid list of clinical quality measures that were discussed in the proposed rule for eligible hospitals.
Eligible Hospitals: Clinical Quality Measure Specifications (HITSP Technical Note 906, Version 1.1)
For the two Emergency Department (ED) Throughput clinical quality measures (ED-1/NQF 0495 and ED-2/NQF 0497), view the CMS Emergency Department Throughput Measures Stratification document for information on the numerators/denominators/exclusions.

National Quality Forum (NQF)

The National Quality Forum (NQF), a non-profit organization that aims to improve the quality of healthcare for all Americans, is playing an integral part in advancing the use of health information technology for performance measurement and meaningful use.

Under contract with DHHS, NQF is currently overseeing the development of eMeasure (electronic measure) specifications for 110 clinical quality measures defined for stage 1 (and considered for future stages) of meaningful use.
- NQF will convene a body of experts to participate in an eMeasure Format Review Panel to conduct a transparent and thorough review of the retooled measures.

NQF will conduct four 14-day public comment cycles from October 2010 through May 2011 to gather input on measures that have been retooled.
eMeasure specifications will leverage the NQF Quality Data Set Model, an "information model" intended to enable automation of concepts used in quality measures and clinical care through EHR technology.

NQF convened the Health IT Utilization Expert Panel to assess the current landscape of EHR utilization measurement around effective use and provide recommendations related to necessary additional systems capabilities. Measuring effective utilization will require identifying system capabilities needed to track and monitor when and how EHRs are used, such as which components have been used, by whom, and how often (e.g., frequency of orders directly entered by an authorizing provider through CPOE).
- Expert Panel work efforts are expected to take place in early 2010. A public comment period is tentatively planned to occur in September/October 2010.

Data Quality & Measures

National Quality Forum (NQF)

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