Quality Measures (eCQM)

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 using one of two different methods.

  • Method 1 – From the patients' chart.
    • On the patients' chart click the Actions drop down and select Quality measures.
  • Method 2 – From the patients' encounter.
    • When creating a patient encounter add the Quality Measures link to the encounter.

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 criterion. 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

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

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS50v5 Not Applicable Closing the Referral Loop: Receipt of Specialist Report. 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)
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For a patient to qualify for the denominator in the TRAKnet application the patient must have the following items:

  • A patient encounter with an office visit code. (Encounter must be completed/signed)
  • A Quality entry indicating the appropriate referral loop information.
  1. list item

This can be completed within an encounter using the Quality Measure link.

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  • An outgoing referral for the patient.
  1. Method 1 - click Actions on the patients' chart and select referrals, then click Add.
  2. Method 2 – click referrals on the patients' chart and select the referral management tab, then click Add.
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Once the patient has qualified for the Denominator the patient can be reported for the Numerator. To Report the patient for the numerator, create an incoming referral entry.

  • Click Actions on the patient’s chart and select referrals, click Add.
  1. Note that the incoming referral must be for the same provider as the outgoing referral.
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Controlling High Blood Pressure (CMS165/NQF0018)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS165v5 0018 Controlling High Blood Pressure. 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
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For patients to qualify for the Denominator they must be 18 years of age to 85 years of age, have a diagnosis of Hypertension and an office visit during the reporting period.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. To report the patient for the Numerator input the patient’s vitals in the patient’s chart and link them to the encounter.

Exclusions can be reported on the quality measures screen.

  1. Report quality measures from the patient’s chart by clicking the actions button and selecting Quality Measures.
  2. Report quality measures from an encounter by using the quality measures link within the encounter.
  3. On the quality measures screen scroll down to the Controlling high blood pressure and set the appropriate settings.
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Diabetes: Foot Exam (CMS123/NQF0056)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS122v5 0056 Diabetes: Foot Exam. 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
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For patients to qualify for the denominator they must be between the ages of 18 and 75, have a diagnosis of diabetes and have an office visit during the reporting period.

Once a patient has qualified for the denominator the patient can be reported for the numerator. To report the patient for the numerator the user must report they have performed a diabetic foot exam from the quality measures screen.

  1. Report quality measures from the patient’s chart by clicking the actions button and selecting Quality Measures.
  2. Report quality measures from an encounter by using the quality measures link within the encounter.
  3. On the quality measures screen scroll down to the Diabetes: Foot Exam and select true or false to indicate if a foot exam was performed or not.
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Diabetes: Hemoglobin A1c Poor Control (CMS122/NQF0059)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS122v5 0059 Diabetes: Hemoglobin A1c Poor Control. 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
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For patients to Qualify for the denominator in the TRAKnet application, the patient must be between 18 and 75 years of age, have a diabetic diagnosis and an encounter with an office visit code within the reporting period.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. To Report the patient for the numerator;

  • Create a lab order for an Hb A1c test.
  1. Click orders on the patient’s chart and select Lab Orders.
  2. Click add and enter the Vendor, Code, date ordered, date sent and any other available information.
  3. Link the lab order to the encounter
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  • Once the lab results are received, enter the results in the lab order.
  1. Note for this measure a lower number indicates better quality so patients will be removed from the numerator if they have a result lower than 9.0%.

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
CMS68v4 0419 Documentation of Current Medications in the Medical Record. 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
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For patients to Qualify for the denominator in the TRAKnet application the patient must have an encounter with an office visit code within the reporting period. Note that each encounter with an office visit code counts towards the denominator.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. To Report the patient for the numerator, create a quality measure indicating current medications were documented.

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

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS139v3 0101 Falls: Screening for Future Fall Risk. Percentage of patients 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
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For patients to Qualify for the denominator in the TRAKnet application, the patient must be 65 or older and have an encounter with an office visit code.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. To Report the patient for the numerator, create a quality measure indicating the patients' current fall risk screening.

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Preventive Care and Screening: BMI Screening and Follow-Up (CMS069/NQF0421)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
CMS69v5 0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. 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 18 years and older 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. All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period. Centers for Medicare & Medicaid Services (CMS)
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For patients to Qualify for the denominator in the TRAKnet application, the patient must be 18 or older at the time of the encounter and have at least one encounter with an office visit.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. For the patient to qualify for the numerator they must have a BMI recorded and a follow up plan documented if that BMI is out of normal range.

  • Record the patients Vitals including height and weight (BMI will be calculated according to these).
  • Record the appropriate Quality measure to indicate the screening was completed and a follow up was documented.
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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
CMS22v5 Not Applicable Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. 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
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For patients to qualify for the Denominator in the TRAKnet application, the patient must be 18 or older at the time of the encounter and have at least one encounter with an office visit.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. For the patient to qualify for the numerator, they must have vitals recorded for the patient and Quality Measures indicating screening for high blood pressure with a follow up documented.

  • Record the patients Vitals including their blood pressure.
  • Record the appropriate Quality measure to indicate a screening was completed and a follow up was documented.
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Preventive Care and Screening: Tobacco Use (CMS138/NQF0028)

Description from here:

CMS Measure NQF # Measure Title Measure Description Numerator Statement Denominator Statement Measure Steward
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)
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For patients to Qualify for the denominator in the TRAKnet application, the patient must be 18 or older at the time of the encounter and have at least two encounters with an office visit or one encounter with a preventive visit code.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator. For the patient to qualify for the numerator they must have a Quality Measures indicating they were screened for tobacco use and received cessation counseling.

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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
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
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For patients to Qualify for the denominator in the TRAKnet application, the patient must be between 3 and 17 years of age with an office visit.

Once the patient has qualified for the Denominator the patient can be reported for the Numerator in 3 categories.

  • To report for category one, record the patient’s vitals including height and weight and link the vitals to an encounter.
  • Record the appropriate Quality measure items through the quality measures link in an encounter.
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