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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
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What clinical quality measures will I need to report on?

Menu Objective for Eligible Professionals:  

  • Report ambulatory clinical quality measures to CMS or the States.

Menu Objective for Eligible Hospitals:  

  • Report hospital clinical quality measures to CMS or the States.  

Measure:

  • For 2011, provide aggregate numerator, denominator, and exclusions through attestation.  For 2012, electronically submit the clinical quality measures.  

Eligible professionals must report on the 3 required core clinical quality measures and 3 additional clinical quality measures chosen by the professional from the menu set of 38 measures.  The quality measures that were selected for inclusion in the Final Rule all have electronic specifications and can be automatically calculated by certified EHR technology without necessitating any manual calculations.  For each objective with a percentage-based measure, the EHR can electronically record the numerator and denominator and generate a report with the numerator, denominator, and resulting percentage.  For 2011, eligible professionals will provide this information via attestation.  Descriptions and electronic measure specifications for all 44  clinical quality measures go to exit disclaimer are listed in Table 6 of the Final Rule on pages 44398-44408.

The required core set of clinical quality measures for eligible professionals are:

Hypertension: blood pressure measurement (percent of patient visits for patients 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure recorded) 

Preventive care and screening measure pair: tobacco use assessment and tobacco cessation intervention (percent of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year, and who received advice to quit smoking or tobacco use or whose provider recommended or discussed smoking or tobacco use cessation medications, methods or strategies)

Adult weight screening and follow-up (percent of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medial record and if the most recent BMI is outside parameters, a follow-up plan is documented.)

If one or more of these required core measures are not applicable to an eligible professional (e.g., adult weight screening and follow-up is not applicable to a pediatrician), the professional reports a zero for that measure and substitutes an alternate core measure.  “Alternate core” set measures are weight assessment and counseling for children and adolescents; influenza immunization for patients 50 years old or older; and childhood immunization status.   

Eligible hospitals must report on all 15 of the eligible hospital clinical quality measures.

Related Resources:

EHR Incentive Program Final Rule – See Federal Register Table 6, pages 44398-44408, for a complete description of the 44 clinical quality measures and electronic measure specifications for Meaningful Use.
Overview of Meaningful Use Stage 1 Quality Measures for the Safety Net Community go to exit disclaimer– HRSA OHITQ webinar that provides an overview of the inpatient and outpatient CQMs and the role of the National Quality Forum to endorse the measures.
CMS Overview of Clinical Quality Measures – A list of the three core, three alternate core, and 38 additional clinical quality measures.  
Understanding Quality Measurement – Agency for Healthcare Research and Quality’s (AHRQ) definition of healthcare quality.
Quality Improvement with an Electronic Health Record go to exit disclaimer– Information on the positive quality effects of EHRs.
Improving Safety with Health Information Technology go to exit disclaimer– Article discussing the patient safety benefits of using health information technology.
Health Information Technology for Improving Quality of Care in Primary Care Settings – More information from AHRQ on the positive quality effects of health information technology.

Developed by the Health Resources and Services Administration as a resource for health centers and other safety net and ambulatory care providers who are seeking to implement health IT.
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