Brief Introduction to Quality Reporting

In order to encourage eligible clinicians and entities to adopt, implement, and upgrade certified EHR technology (CEHRT), the Centers for Medicare and Medicaid Services (CMS) established the Medicare and Medicaid EHR Incentive Programs. These programs were intended to help develop and standardize meaningful use of the certified technologies available on the market, hence the more informal name of the programs, Meaningful Use (MU). Along with MU, there have been other common ones, such as the Physician Quality Reporting System (PQRS) and the Value-Based Modifier (VM).

In 2015 the signing of the Medicare Access and CHIP Reauthorization Act (MACRA) took place. MACRA combines the intent and value from previous, now-legacy incentive programs (i.e., PQRS, VM, MU) into two possible tracks. These are known collectively as the Quality Payment Program (QPP). The focus, here, is on one track–the Merit-based Incentive Payment System (MIPS) track. MIPS uses updated quality, promoting interoperability, and improvement activities measures, to stay aligned with the focus of patient health outcomes.

In addition to all of this, there are resources available from the Agency for Healthcare Research and Quality. Below, you will find our quality measure documentation, as it relates to CMS-specific programs. Peruse leisurely, and anticipate updates and changes as we grow with each of our client’s reporting and quality needs.

  • Stage 1 & 2: Legacy.
  • Modified Stage 2: For 2018, Medicare eligible hospitals, critical access hospitals, and dual-eligible hospitals are directed to these program requirements. Medicare-eligible professionals are directed to the requirements of the QPP.
  • Stage 3: Exclusive to eligible hospitals, critical access hospitals, and dual-eligible hospitals. Eligible professionals are directed to the Promoting Interoperability measures, found under MIPS.
  • MIPS: Consists of measure sets for Cost, Quality, Promoting Interoperability (previously, Advancing Care Information), and Improvement Activities, not to mention those for varying specialties.

SYSTEM prides itself on being a certified EHR technology, and as such, we offer an extensive array of certified measures for participation in the various incentive programs available. Check them out!