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Important Update on CQM Reporting for 2015

Please take note of the changes to Clinical Quality Measure (CQM) Reporting for 2015:

Providers participating in the EHR Incentive Program (Meaningful Use)  or electronically reporting for the Physician Quality Reporting System (PQRS) Program are required to use the 2014 eCQM Specifications for their 2015 calendar year reporting.

Run The Updater On Your Server

This important update is to notify users that McKesson has now released a software patch on 11/4/2015 for Medisoft Clinical, LytecMD, and Practice Partner that will update the CQM reporting tool from the 2013 eCQM specifications to the new 2014 eCQM Specifications. Practices must run the updater on the server to apply the patch.
If there are any questions on running this update, feel free to contact our Support department for further assistance.

Review Your Selected Reporting Measures

Depending on the specific quality measures the provider is reporting, installing the software patch alone may not be enough as a number of the measures require configuration and workflow training in order to ensure the data is being captured in a manner that the report can read the data.
We are advising all providers to both update the software and review the measures they have selected for any changes to the configuration and workflow. A new user guide was released in conjunction with this update which includes all of the details on configuration and reporting.
Access and Download the guide here: CQM Report User’s Guide 2015

Need Any Assistance? Our Trainers Can Help.

If you need assistance with configuration, implementation and training on CQMs we recommend working one-on-one with one of our Certified Trainers. Call us at (888) 799-4777 to get set up with your training.

CQM News Flash for Medisoft Clinical, LytecMD, & Practice Partner Users!

McKesson released the following letter on January 16, 2015:

This letter provides information regarding the current capability of Practice Partner® v11.0 as it relates to submission of the following reports:

  • Physician Quality Reporting System (PQRS) 
  • Electronic Clinical Quality Measures (eCQM) reports 
  • Comprehensive Primary Care Initiative (CPCI) reports

McKesson certified Practice Partner v11.0 with the Office of the National Coordinator for HealthCare IT (ONC) is using a tool called Cypress. Cypress is one of the rigorous and repeatable testing tools used by ONC to certify Electronic Health Records (EHRs) and EHR modules in calculating performance metric reports and Clinical Quality Measures (CQMs) for Meaningful Use (MU) Stage 2.

The Centers for Medicare & Medicaid Services (CMS) recently indicated the Quality Reporting Document Architecture (QRDA) file format certified previously with Cypress is not the layout they accept. The QRDA format that CMS accepts is the combined format for CQM, CPCI and PQRS. Therefore, McKesson needs to make modifications to Practice Partner v11.0 to allow for the required format that CMS will accept for PQRS reporting.

McKesson is working diligently with CMS to understand the changes needed in Practice Partner v11.0 in order to provide our customers the ability to report on PQRS measures via CEHRT. To date, we have successfully registered for QualityNet and we are conducting focused testing and certification on the QRDA file format to help ensure that the changes made meet CMS requirements.

IMPORTANT NOTE: Until this testing is complete, customers will not be able to submit CQM data electronically.

There are 64 possible Clinical Quality Measure (CQM) reports required for Stage 2 certification. These same measures are valid for PQRS submission. Practice Partner currently provides 38 of these reports, with another five that will be released in January 2015, bringing the total number to 43. These 43 measures should cover the majority of primary care and specialty requirements. Additional measures will be considered in the future road map based on request, but currently there are no additional CQM reports slated to be added.

For practices participating in the CPCI program, please watch for future notification on how to attest manually for this incentive program.

We will continue to provide updates with our progress as it relates to the above information.

Sincerely,

Tom Reinecke
Director – Product Management
Business Performance Services

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What does this mean for Medisoft Clinical / LytecMD / Practice Partner Users?

Users that are participating in the EHR Incentive Program can meet the requirements for Meaningful Use by selecting to report CQM data through attestation. This will satisfy the requirements for Meaningful Use, however it will not satisfy the requirements for the PQRS program.

With this announcement it is imperative that Practices that have not already submitted PQRS data for 2014 make proper arrangements to do so.

Facts about PQRS:

  • Providers can earn a Bonus payment of 0.5% of their total estimated Medicare Part B allowed charges by reporting PQRS data for 2014.
  • There is a 2% payment adjustment/penalty that will be deducted from all Medicare Part B payments for services provided in 2016 if providers do not satisfactorily report PQRS for 2014.
  • The deadline to submit PQRS data for 2014 is February 28, 2015.

There are several ways to report PQRS data for 2014 including:

  1. Claims Based Reporting:
    Requires appropriate G codes for 9 individual measures to have been billed on Medicare Part B Claims for 50% of applicable patients for the entire calendar year of 2014
  2. Qualified Registry Reporting: 
    Option A: Choose 1 Measure group to report 20 applicable patients
    – 12 Month OR 6 Month Reporting Period)
    – At least 11 patients must be Medicare patients
    Option B: Choose 9 Individual Measures aross 3 NQS Domains for at least 50% of Medicare patients to whom the individual measures apply.
    – 12 Month Reporting Period
    List of 2014 Qualified Registries
  3. Direct EHR Reporting:
    Report on 9 Individual Measures across 3 NQS Domains for applicable patients for a 12 Month Reporting Period.
    – In 2014 CMS is allowing providers to single report quality measures to PQRS for the entire year (12 Month reporting period) and have it qualify for the CQM requirement under Meaningful Use. However, because the 2014 CEHRT versions of Medisoft Clinical/LytecMD/Practice Partner (v11) were not released until after the start of the year, and due to the fact that many of the measures require configuration or changes to documentation in order to capture the data in a manner that will produce numbers on the CQM reports, it is unlikely that any providers will have a full year’s worth of data in their CQM reports. In addition, the announcement cited above from McKesson confirms that direct EHR Reporting is not available at this time.
  4. EHR Reporting via Data Submission Vendor:
    Report on 9 Individual Measures across 3 NQS Domains for applicable patients for a 12 Month Reporting Period.
    – McKesson is not currently partnered with any Data Submission Vendors, however, there may be Data Submission Vendors that are compatible with Medisoft Clinical/LytecMD/Practice Partner as a third party solution. Providers are responsible for working directly with third party vendors to report via this method.
    – Data Submission Vendors require the applicable data to be recorded in a structured manner for the entire 12 month reporting period in order for them to accurately export and report the data on the providers behalf.
  5. Qualified Clinical Data Registry (QCDR):
    Report on 9 Individual Measures across 3 NQS Domains for applicable patients for a 12 Month Reporting Period.
    – McKesson is not currently partnered with any QCDRs, however there may be QCDRs that are compatible with Medisoft Clinical/Lytec MD/Practice Partner as a third party solution. Providers are responsible for working directly with third party vendors to report via this method. 2014 Certified QCDRs List

For practices that did not report PQRS data through claims in 2014 we are recommending Qualified Registry Reporting. While AZCOMP has no direct experience with any of the Registries, and therefore cannot endorse any specific registry, we have found sites such as MDInteractive.com that have made the process for reporting PQRS simple. For example, if providers qualify to report under a measure group then MDInteractive.com has a worksheet (usually 1-2 pages with 9 or fewer questions) that only need to be filled out for a total of 20 applicable patients (11 must be Medicare). We have heard that the entire process generally takes an office 4-6 hours to identify the patients, fill out the worksheets and enter the information into the registry. For specific questions regarding registry reporting please contact the registry of your choice directly as AZCOMP does not directly support registry reporting.

For Questions Regarding the PQRS program contact the QualityNet Help Desk

  • Available Monday – Friday; 7:00 AM–7:00 PM CST
  • General CMS Physician Quality Reporting System Incentive Program information
  • Portal password issues
  • Feedback report availability and access
  • PQRI-IACS registration questions
  • PQRI-IACS login issues

Phone: 1-866-288-8912

TTY: 1-877-715-6222

Email: Qnetsupport@hcqis.org

 

Disclaimer: AZCOMP Technologies, Inc, (AZCOMP) is providing this material as an informational reference for eligible professionals. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the EHR Incentive program is constantly changing, and it is the responsibility of each provider to remain abreast of the EHR Incentive program requirements.

Meaningful Use Well Check

Time for your end of the year Meaningful Use Well Check 🙂

Meaningful Use Well CheckAs 2014 is drawing to a close the window of opportunity is also closing for meeting Meaningful Use requirements in 2014.  This year we have seen changes to the EHR Incentive Program as well as updates released for the software.  Missing any of these changes could put your practice in jeopardy of not qualifying for meaningful use.  Please take a few moments to review some of the basics to make sure your practice is still on track to successfully attesting for 2014!

Review the Flexibility Rule:

CMS is allowing practices that have not had sufficient time to fully implement the 2014 Certified Electronic Health Records Technology (CEHRT), due to delays in availability, the options to attest using 2011 CEHRT. If you qualify for the CEHRT Options under the flexibility rule, determine which Stage you will attest for this year:

  • Stage 1 2013 Definition
  • Stage 1 2014 Definition
  • Stage 2

For an overview of how to determine if you are eligible for the flexibility rule review: Meaningful Use 911 Webinar

Run your Performance Metric Reports

Run your performance metric reports regularly to ensure you are meeting the thresholds! Remember in v11 you can use the drill down capability in the reports to identify which patients are not included in your numerators. In many cases it will not be too late to make corrections in the patient’s chart to ensure that the data is captured properly so that it can be reflected in your performance metrics report.

Review Menu Objectives

Review Menu objectives to ensure you have the right number to report! CMS is no longer allowing users to claim an exemption and have that count towards their total required menu objectives. If you have claimed an exemption in the past make sure you have selected an additional menu objective to attest to this year. For providers in Stage 1 that may find they are short a measure, it is not too late to send out patient reminders and we have a free webinar you can watch to teach you how to do it!

Patient Reminders Webinar

Providers attesting for Stage 1 2014 Definition or Stage 2 must have a patient portal (Webview)

For more information on changes effective this year, view the following CMS document: 2014 Changes Tipsheet

Review CQM Reports

Providers attesting to Stage 1 2014 Definition or Stage 2 must report 9 CQMs this year. Many CQMs require configuration. Some issues have been identified with the CQM reports in v11, please make sure you are on the latest update of the report so you can ensure you are getting the most accurate numbers, contact support right away if you need updates.

For more information review our recent blog post: New Clinical Quality Measures (CQM) Manual Released!

Ensure that you have supporting documentation for the Yes/No Attestation measures

Ensure that you have supporting documentation for the Yes/No Attestation measures. Not all measures have a threshold and therefore there is no performance metric the system can produce on a report to indicate whether the provider met the measure. CMS recommends keeping supporting documentation for each of the Yes/No attestation measures that the provider attests to. Providers should keep copied of supporting documentation for 6 years post attestation in case of an audit. Yes/No Measures include:

ObjectiveAudit ValidationRecommended Supporting Documentation
Drug-Drug/Drug-Allergy Interaction ChecksFunctionality is available, enabled, and active in the system for the duration of the EHR reporting period.One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Clinical Decision SupportFunctionality is available, enabled, and active in the system for the duration of the EHR reporting period.One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Protect Electronic Health InformationSecurity risk analysis of the certified EHR technology was performed prior to the end of the reporting yearCopy of a completed security risk analysis that was conducted during the calendar year the provider is attesting for. It can be performed outside of the reporting period but must be completed no earlier than the first of the year, and no later than the last day of the year.
Drug Formulary ChecksFunctionality is available, enabled, and active in the system for the duration of the EHR reporting period.One or more screenshots from the certified EHR system that are dated during the EHR reporting period selected for attestation.
Generate Lists of Patients by Specific ConditionsOne report listing patients of the provider with a specific condition.Report from the certified EHR system that is dated during the EHR reporting period selected for attestation.
Immunization Registries·Data Submission, and Syndromic Surveillance Data SubmissionOne test of certified EHR technology’s capacity to submit electronic data and follow-up submission if the test is successful.
  • Dated screenshots from the EHR system that document a test submission to the registry or public health agency (successful or unsuccessful). Should include evidence to support that it was generated for that provider’s system (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.).
  • A dated record of successful or unsuccessful electronic transmission (e.g, screenshot from another system, etc.). Should include evidence to support that it was generated for that provider (e.g., identified by National Provider Identifier (NPI), CMS Certification Number (CCN), provider name, practice name, etc.).
  • Letter or email from registry or public health agency confirming the receipt (or failure of receipt) of the submitted data, including the date of the submission, name of parties involved, and whether the test was successful.
ExclusionsDocumentation to support each exclusion to a measure claimed bythe provider.Report from the certified EHR system that shows a zero denominator for the measure or otherwise documents that the provider qualifies for the exclusion.

Preparing for Attestation

A few tools that can help you prepare for your attestation are the CMS attestation worksheets and the attestation calculators that allow you to practice attesting to see if you are passing before submitting your actual attestation:

Stage WorksheetCalculator
Stage 1 2013 DefinitionAttestation Worksheet Stage 1 (2013)Stage 1 Calculator
Stage 1 2014 DefinitionAttestation Worksheet Stage 1 (2014)Stage 1 Calculator
Stage 2Attestation Worksheet Stage 2Stage 2 Calculator

Look Ahead!

Just a reminder, as it stands today the reporting period for 2015 is a full calendar year for all providers that have previously participated in the EHR Incentive program. All providers are required to be on the 2014 CERT for the entire reporting period. If you are scheduled for Stage 2 in 2015 please ensure that you have taken proper steps to configure your EHR for the new objectives and requirements.

We are here to help!

If you need assistance with any of the checklist items above please contact us immediately to schedule time with a trainer. The timeframe is limited and schedules are filling up so do not delay!

We know the amount of work each of you have put into making changes to your practice in order to meet meaningful use objectives, and congratulate each of you for taking the steps to ensure your patients are receiving the BEST care!

 

Disclaimer: AZCOMP Technologies, Inc, (AZCOMP) is providing this material as an informational reference for eligible professionals. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the EHR Incentive program is constantly changing, and it is the responsibility of each provider to remain abreast of the EHR Incentive program requirements.

New Clinical Quality Measures (CQM) Manual Released!

An updated Medisoft Clinical/LytecMD/Practice Partner Clinical Quality Measures (CQM) User’s Manual has been released!

The manual includes changes to configuration requirements for some of the measures as well as details on where the reports pull information from in order to calculate the denominators and numerators. CQM Report User’s Guide Nov 2014

Who should review the new CQM manual?

  • Providers that are participating in the EHR Incentive Program in 2014 who will be attesting under Stage 1 2014 Objectives
  • Providers who will be reporting Stage 2 Objectives in 2014
  • All providers that are participating in the EHR Incentive Program in 2015 (Remember unless 2015 is your first year to participate the 2015 reporting period is currently scheduled as a full calendar year. This means providers need to be ready to capture CQM data starting January 1, 2015)

As a reminder, providers attesting Stage 1 2014 Objectives, or Stage 2 for 2014 and in 2015 will be required to report a total of 9 measures covering at least 2 of the National Quality Strategy domains. Under 2014 rules providers are no longer required to report a core set of measures, however CMS has outlined a recommended set of 9 Adult Measures, and 9 Pediatric Measures. For detailed information please visit the EHR Incentive Website: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html

No Threshold Requirement for CQM Reporting

For providers that are unable to find 9 out of the available measures in their CEHRT that apply to their specialty, CMS has stated: “We understand cases may exist where an EP may not find a full set of CQMs where they have data for both the numerator and denominator. We remind providers that they may submit a zero as the denominator for a CQM if that is the resulting calculation displayed by their EHR” https://www.federalregister.gov/articles/2014/09/04/2014-21021/medicare-and-medicaid-programs-modifications-to-the-medicare-and-medicaid-electronic-health-record

CQM Reporting in 2014 using the Flexibility Rule

Under the new Flexibility Rule providers may be eligible for the following options for 2014 Reporting:

CEHRT Options 2014

According to the Final Rule, Providers must attest to the required set of objectives and measures applicable for the CEHRT option they choose, as well as the CQMs that relate to that option.

CQM Reporting Options Flexibility Rule

If a provider chooses the 2013 Stage 1 objectives and measures they must attest to the CQMs using the reporting requirements specified for 2013. (6 total measures comprising of 3 core/alternate core, and 3 additional measures) The reports for 2013 CQMs are only available if the provider is running Medisoft Clinical/LytecMD/Practice Partner v9.5.2.

CQM Comparison

According to the final rule, “If a provider elects to use a combination of 2011 Edition and 2014 Edition CEHRT and chooses to attest to the 2013 Stage 1 objectives and measures for its EHR reporting period in 2014, the provider would be required to report CQMs by attestation using the same measure sets and reporting criteria outlined earlier for providers who elect to use only 2011 Edition CEHRT for the EHR reporting period in 2014. Because of the differences in how CQMs are calculated and tested between the 2011 and the 2014 Editions of CEHRT, we further proposed that a provider may attest to data for the CQMs derived exclusively from the 2011 Edition CEHRT for the portion of the reporting period in which 2011 Edition CEHRT was in place.”

Since the 2013 CQM Reports are only available in Medisoft Clinical/LytecMD/Practice Partner v9.5.2 providers are reminded that they should run the CQM report PRIOR to upgrading with a date range equal to the first day of the reporting period up to the date of the upgrade. Providers are advised to maintain copies of the report as supporting documentation for their attestation. Once the upgrade to v11 has been completed the practice will not have access to run the 2013 CQM report again.

EHR Incentive Program CQM Reporting Options for Eligible Professionals in 2014 Include:

    • Option 1: Attest to CQMs through the EHR Registration & Attestation System (Reporting Period: 90 day period for first time participants, all others must select any 3 month quarter.)
    • Option 2: eReport CQMs through Physician Quality Reporting System (PQRS) Portal (Reporting Period: Entire calendar year)

Because the 2014 CEHRT versions of Medisoft Clinical/LytecMD/Practice Partner (v11) were not released until after the start of the year, and due to the fact that many of the measures require configuration or changes to documentation in order to capture the data in a manner that will produce numbers on the CQM reports, it is unlikely that any providers will have a full year’s worth of data in their CQM reports. In addition v11 is not currently compatible with PQRS direct EHR reporting requirements. Therefore, participants of the EHR Incentive program should report their numbers for their 3-Month quarter/reporting period in 2014 through attestation. We further recommend reporting PQRS data through a qualified registry. For more information on PQRS registry reporting visit: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2014_PQRS_Registry_Made_Simple_F01-08-2014.pdf

For assistance with configuration or training please contact us to schedule some one-on-one time with a Certified Trainer!

Disclaimer: AZCOMP Technologies, Inc, (AZCOMP) is providing this material as an informational reference for eligible professionals. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the CMS programs are constantly changing, and it is the responsibility of each provider to remain abreast of the CMS program requirements.