Acronyms of Change, Part 6 (CQM)

Clinical Quality Measures (CQM) are based on specific evidence-based practices that have been shown to give the best results to the most people. To demonstrate meaningful use successfully, Eligible Professionals are required to report clinical quality measures specific to their health care environment. As an Eligible Professional (EP), you must report on 6 total measures: 3 required core measures (substituting alternate core measures where necessary) and 3 additional measures. CQM results (numerators, denominators, and exclusions) must be reported to CMS as part of the attestation process. 

You'll recall, I'm sure, the advent of the Physician Quality Reporting Initiative (PQRI) which has now been renamed PQRS. The "initiative" has become the "system". PQRI was what we called spring training or a pay-for-reporting practice run in anticipation of true pay-for-performance. In the sense that reporting of CQMs is now an attestation requirement, you are being paid for it. However, as is common to most elements of Stage 1 certification, the concepts are really just being introduced. Moving to stages 2 and 3, the bar is rising and more  is being required at each step. We are certainly not yet at full-blown pay-for-performance.

Beginning in 2012, eligible professionals may satisfy the meaningful use objective to report CQMs to CMS by reporting them through either the Registration and Attestation System or via participation in the new Physician Quality Reporting System-Medicare EHR Incentive Pilot. 


However, note that you are only able to participate if you are able to report CQMs based on a full calendar year. This likely means you had completed your Year 1 MU Attestation as of December 31, 2011 and were eligible to begin your year 2 as of January 1, 2012. If you started your Year 1 MU period on January 1, 2012 and are prepared to continue with PQRS through December 31, 2012 the participation in the Pilot may also be possible.


For more details on this new program, see its Quick Reference Guide. More details about CQMs are available here on the CMS.gov website. Or, you may read about Core Measure #10 here.


Alistair Jackson, M.Ed.