Quality Measures (CQM)

This page will explain how to document quality measures in TRAKnet and how to run the Quality Measures report.

Quality Measures

Per CMS, Quality Measures are defined as

Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.1

Documenting in TRAKnet

Quality Measures are documented in TRAKnet directly from the patient's electronic chart. To access the Quality Measures interface, from the patient's chart click on Actions > Quality Measures. This will open the Clinical Measures Factors window, seen to the right.

To add a new quality measures record for this patient, click the green Add button in the upper left-hand corner of the screen. This will open the Patient Clinical Measure Factors Editor window, seen below.

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The quality measure screen is broken down by each criteria and consists primarily of true or false fields. Once all information has been documented, click Save to save this form.

To ensure successful completion of these measures, you must link the quality measures record to the encounter where the measures were met. To do this, select the measure in the list, then click Link. Select the appropriate date of service from the list and click OK.

There are some measures that are not documented on this screen. To best understand each CQM measure, we have provided the list of measures in the TRAKnet report below, with a breakdown of their criteria, description, and information.

Measure Descriptions

Childhood Immunization Status (CMS117/NQF0038)

This category is meant to document any allergies to specific vaccines that this patient may have. These fields are all true or false fields.

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS117v3 0038 Childhood Immunization Status. Domain: Population/Public Health Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday Children who have evidence showing they received recommended vaccines, had documented history of the illness, had a seropositive test result, or had an allergic reaction to the vaccine by their second birthday. Children who turn 2 years of age during the measurement period and who have a visit during the measurement period. National Committee for Quality Assurance 240

As a podiatrist, it is likely that this measure will not relate to your scope of practice.

Closing the Referral Loop: Receipt of Specialist Report (CMS50)

This category is meant to document if a referral was sent to another provider and whether or not documentation was sent back to the referring provider.

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS50v3 Not Applicable Closing the Referral Loop: Receipt of Specialist Report. Domain: Care Coordination Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred. Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred. Number of patients, regardless of age, who were referred by one provider to another provider, and who had a visit during the measurement period. Centers for Medicare & Medicaid Services (CMS) 374

Controlling High Blood Pressure (CMS165/NQF0018)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS165v3 0018 Controlling High Blood Pressure. Domain: Clinical Process/Effectiveness Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period. Patients 18-85 years of age who had a diagnosis of essential hypertension within the first six months of the measurement period or any time prior to the measurement period. National Committee for Quality Assurance 236 GPRO HTN-2

Diabetes: Foot Exam (CMS123/NQF0056)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS122v3 0056 Diabetes: Foot Exam. Domain: Clinical Process/Effectiveness Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the measurement period. Patients who received visual, pulse and sensory foot examinations during the measurement period. Patients 18-75 years of age with diabetes with a visit during the measurement period. National Committee for Quality Assurance 163

Diabetes: Hemoglobin A1c Poor Control (CMS122/NQF0059)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS122v3 0059 Diabetes: Hemoglobin A1c Poor Control. Domain: Clinical Process/Effectiveness Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%. Patients 18-75 years of age with diabetes with a visit during the measurement period. National Committee for Quality Assurance 1 GPRO DM-2

Documentation of Current Medications in the Medical Record (CMS68/NQF0419)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS68v4 0419 Documentation of Current Medications in the Medical Record. Domain: Patient Safety Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. Eligible professional attests to documenting, updating or reviewing the patient’s current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration. All visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement period. Quality Insights of Pennsylvania/Centers for Medicare & Medicaid Services 130

Falls: Screening for Future Fall Risk (CMS139/NQF0101)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS139v3 0101 Falls: Screening for Future Fall Risk. Domain: Patient Safety Percentage of patietns 65 years of age and older who were screened for future fall risk during the measurement period. Patients who were screened for future fall risk at least once within the measurement period. Patients aged 65 years and older with a visit during the measurement period. National Committee for Quality Assurance 318 GPRO CARE-2

HIV/AIDS: Medical Visit (CMS62)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS62v2 Not Applicable HIV/AIDS: Medical Visit. Domain: Clinical Process/Effectiveness Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two medical visits during the measurement year with a minimum of 90 days between each visit. Patients with at least two medical visits during the measurement year with a minimum of 90 days between each visit. All patients, regardless of age, with a diagnosis of HIV/AIDS seen within a 12 month period. National Committee for Quality Assurance (NCQA) 368

Preventive Care and Screening: BMI Screening and Follow-Up (CMS139/NQF0421)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS69v3 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. Domain: Population/ Public Health Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 65 years and older BMI => 23 and < 30 kg/m2 Age 18 – 64 years BMI => 18.5 and < 25 kg/m2. Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. There are two (2) Initial Patient Populations for this measure: Initial Patient Population 1: All patients 65 years of age and older on the date of the encounter with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses measurement of height and/or weight, the patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status, or there is any other reason documented in the medical record by the provider explaining why BMI measurement was not appropriate. Initial Patient Population 2: All patients 18 through 64 years on the date of the encounter with at least one eligible encounter during the measurement period NOT INCLUDING encounters where the patient is receiving palliative care, refuses measurement of height and/or weight, the patient is in an urgent or emergent. Centers for Medicare & Medicaid Services (CMS) 128 GPRO PREV-9

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (CMS22)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS22v3 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. Domain: Population/ Public Health Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is prehypertensive or hypertensive. All patients aged 18 years and older before the start of the measurement period. Quality Insights of Pennsylvania/ Centers for Medicare & Medicaid Services 317 GPRO PREV-11

Preventive Care and Screening: Tobacco Use (CMS138/NQF0028)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS138v3 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. Domain: Population/ Public Health Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period. American Medical Association-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI) 226 GPRO PREV-10

Weight Assessment and Counseling for Children and Adolescents (CMS155/NQF0024)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward PQRS# (For reporting in 2015)
CMS155v3 0024 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents. Domain: Population/ Public Health Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/ Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. - Percentage of patients with height, weight, and body mass index (BMI) percentile documentation - Percentage of patients with counseling for nutrition - Percentage of patients with counseling for physical activity. Numerator 1: Patients who had a height, weight and body mass index (BMI) percentile recorded during the measurement period. Numerator 2: Patients who had counseling for nutrition during a visit that occurs during the measurement period. Numerator 3: Patients who had counseling for physical activity during a visit that occurs during the measurement period. Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the measurement period. National Committee for Quality Assurance 239

Additional Criteria Information

The below links will direct the user toward additional criteria information that will explain exactly what criteria must be met to accomplish each measure:

EP Measures Table
2014 eCQM Specifications for Eligible Professionals Update June 2015
eCQM Library

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