What is the correct way for a qualified registry to report eCQM #309 Cervical Cancer Screening?
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Paulo
Aug 31, 2017, 11:08:19 AM8/31/17
to Developer Group for QPP APIs
Hi,
Measure #309 is EHR a measure.
If a qualified registry wanted to submit registry measures #1, #130 and EHR measure #309 would it use:
"submissionMethod": "registry" for measures 1 and 130
"submissionMethod": "electronicHealthRecord" for measure #309 ?
{
"programName": "mips",
"entityType": "individual",
"taxpayerIdentificationNumber": "000101115",
"nationalProviderIdentifier": "0007623650",
"performanceYear": 2017,
"measurementSets": [
{
"category": "aci",
"submissionMethod": "registry",
"performanceStart": "2017-03-08",
"performanceEnd": "2017-08-15",
"measurements": [
{
"measureId": "ACI_INFBLO_1",
"value": true
},
{
"measureId": "ACI_ONCDIR_1",
"value": true
},
{
"measureId": "ACI_TRANS_PPHI_1",
"value": true
},
{
"measureId": "ACI_TRANS_PHCDRR_3",
"value": true
},
{
"measureId": "ACI_TRANS_HIE_1",
"value": {
"numerator": 50,
"denominator": 50
}
},
{
"measureId": "ACI_TRANS_PEA_1",
"value": {
"numerator": 100,
"denominator": 100
}
},
{
"measureId": "ACI_TRANS_EP_1",
"value": {
"numerator": 50,
"denominator": 50
}
}
]
},
{
"category": "ia",
"submissionMethod": "registry",
"performanceStart": "2017-04-01",
"performanceEnd": "2017-06-30",
"measurements": [
{
"measureId": "IA_EPA_4",
"value": true
},
{
"measureId": "IA_EPA_3",
"value": true
},
{
"measureId": "IA_BMH_8",
"value": true
},
{
"measureId": "IA_PSPA_6",
"value": true
},
{
"measureId": "IA_PSPA_10",
"value": true
}
]
},
{
"category": "quality",
"submissionMethod": "registry",
"performanceStart": "2017-04-12",
"performanceEnd": "2017-08-23",
"measurements": [
{
"measureId": "130",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
},
{
"measureId": "001",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
}
]
},
{
"category": "quality",
"submissionMethod": "electronicHealthRecord",
"performanceStart": "2017-04-12",
"performanceEnd": "2017-08-23",
"measurements": [
{
"measureId": "309",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
}
]
}
]
}
The API reply is:
{
"data": {
"score": {
"name": "total",
"title": "Total Score",
"detail": "0.0.18",
"value": 47.1,
"parts": [
{
"name": "ia",
"title": "IA component of final score",
"detail": "Scoring based on weight of 15%.",
"value": 15,
"original": {
"name": "ia",
"title": "Improvement Activities Score",
"value": 40,
"metadata": {
"maxContribution": 40
},
"parts": [
{
"name": "IA_EPA_4",
"title": "Additional improvements in access as a result of QIN/QIO TA",
"value": 10,
"metadata": {
"maxContribution": 20
}
},
{
"name": "IA_EPA_3",
"title": "Collection and use of patient experience and satisfaction data on access",
"value": 10,
"metadata": {
"maxContribution": 20
}
},
{
"name": "IA_PSPA_10",
"title": "Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments",
"value": 10,
"metadata": {
"maxContribution": 20
}
},
{
"name": "IA_PSPA_6",
"title": "Consultation of the Prescription Drug Monitoring program",
"value": 20,
"metadata": {
"maxContribution": 20
}
},
{
"name": "IA_BMH_8",
"title": "Electronic Health Record Enhancements for BH data capture",
"value": 10,
"metadata": {
"maxContribution": 20
}
}
],
"warnings": []
},
"metadata": {
"maxContribution": 15
}
},
{
"name": "aci",
"title": "ACI component of final score",
"detail": "Scoring based on weight of 25%.",
"value": 23.75,
"original": {
"name": "aci",
"title": "Advancing Care Information Score",
"value": 95,
"metadata": {
"maxContribution": 100
},
"parts": [
{
"name": "aci_base",
"value": 90,
"detail": "",
"metadata": {
"maxContribution": 100
},
"parts": [
{
"name": "ACI_TRANS_PEA_1",
"value": 20,
"metadata": {
"maxContribution": 20
}
},
{
"name": "ACI_TRANS_HIE_1",
"value": 20,
"metadata": {
"maxContribution": 20
}
}
],
"warnings": []
},
{
"name": "aci_performance",
"value": 0,
"detail": "",
"metadata": {
"maxContribution": 100
},
"parts": [],
"warnings": []
},
{
"name": "aci_bonus",
"value": 5,
"detail": "",
"metadata": {
"maxContribution": 100
},
"parts": [
{
"name": "ACI_TRANS_PHCDRR_3",
"value": 5,
"metadata": {
"maxContribution": 5
}
}
],
"warnings": []
},
{
"name": "cehrt_bonus",
"value": 0,
"detail": "",
"metadata": {
"maxContribution": 100
},
"parts": [],
"warnings": []
}
],
"warnings": []
},
"metadata": {
"maxContribution": 25
}
},
{
"name": "quality",
"title": "QUALITY component of final score",
"detail": "Scoring based on weight of 60%.",
"value": 8.4,
"original": {
"name": "quality",
"value": 14,
"detail": "Picked the highest scoring measurement set registry",
"parts": [
{
"name": "quality",
"value": 14,
"detail": "registry",
"parts": [
{
"name": "001",
"value": 3,
"detail": "Contributing 3",
"metadata": {
"measureClass": "Class 1",
"measureTitle": "Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)",
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"highPriorityBonusIgnored": true,
"decileScore": 3,
"performanceDenominator": 0,
"performanceNumerator": 0,
"eligiblePopulation": 0,
"partialDecileScore": null,
"decile": -1,
"deciles": [
100,
83.1,
68.18,
53.13,
40.65,
30.19,
22.73,
16.81,
10.32
],
"processingStatus": "PICKED",
"messages": {
"decileScore": "Applied minimum decile score",
"highPriorityBonus": "Measure having highest decile score (preference given to outcome, intermediate outcome, and patient engagement experience) is not eligible for high priority bonus",
"measurementPicker": "Picked at 1"
}
}
},
{
"name": "130",
"value": 11,
"detail": "Contributing 11",
"metadata": {
"measureClass": "Class 1",
"measureTitle": "Documentation of Current Medications in the Medical Record",
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 1,
"decileScore": 10,
"performanceDenominator": 0,
"performanceNumerator": 0,
"eligiblePopulation": 0,
"partialDecileScore": 1,
"decile": 10,
"deciles": [
0,
61.27,
82.12,
91.72,
96.87,
99.31,
100,
100,
100
],
"processingStatus": "PICKED",
"messages": {
"decileScore": "Applied maximum decile score",
"measurementPicker": "Picked at 2"
}
}
}
],
"metadata": {
"messages": {
"denominator": "At least 1 high or outcome or patient experience measure available. So denominator is 60"
},
"measuresPicked": [
"001",
"130"
]
}
},
{
"name": "quality",
"value": 11,
"detail": "electronicHealthRecord",
"parts": [
{
"name": "309",
"value": 11,
"detail": "Contributing 11",
"metadata": {
"measureClass": "Class 1",
"measureTitle": "Cervical Cancer Screening",
"endToEndBonus": 1,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"decileScore": 10,
"performanceDenominator": 0,
"performanceNumerator": 0,
"eligiblePopulation": 0,
"partialDecileScore": 1,
"decile": 10,
"deciles": [
0,
8.89,
15.09,
21.8,
28.84,
36.67,
45,
54.78,
69
],
"processingStatus": "PICKED",
"messages": {
"decileScore": "Applied maximum decile score",
"measurementPicker": "Picked at 1"
}
}
}
],
"metadata": {
"messages": {
"denominator": "No high or outcome exists. Denominator is 60, but only top 5 scoring measures are considered"
},
"measuresPicked": [
"309"
]
}
}
]
},
"metadata": {
"maxContribution": 60
}
}
],
"warnings": [
"Disclaimer: Scoring is subject to change, based on periodic policy updates, eligibility reviews, and technical integration developments."
],
"errors": []
}
}
}
steven....@semanticbits.com
Sep 5, 2017, 9:11:50 AM9/5/17
to Developer Group for QPP APIs
Hey Paulo,
Are you trying use the eHR benchmark for 309? The way you have listed will create two measurement sets for Quality.
Paulo
Sep 5, 2017, 1:37:44 PM9/5/17
to Developer Group for QPP APIs
Hi Steven,
Yes, our qualified registry is trying to get the EHR benchmark for 309.
If we submit #309 with "submissionMethod": "registry", then we get the registry benchmarks (see below). The registry benchmark is really a QCDR benchmark and not a qualified registry benchmark because #309 is a EHR measure and it was not previously a qualified registry measure. It was in the past a QCDR measure.
API Input:
{
"programName": "mips",
"entityType": "individual",
"taxpayerIdentificationNumber": "000101115",
"nationalProviderIdentifier": "0007623650",
"performanceYear": 2017,
"measurementSets": [
{
"category": "quality",
"submissionMethod": "registry",
"performanceStart": "2017-04-12",
"performanceEnd": "2017-08-23",
"measurements": [
{
"measureId": "130",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
},
{
"measureId": "001",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
},
{
"measureId": "309",
"value": {
"isEndToEndReported": false,
"performanceMet": 100,
"performanceNotMet": 0,
"populationTotal": 100,
"eligiblePopulation": 100
}
}
]
}
]
}
API Scoring Output:
{
"data": {
"score": {
"name": "total",
"title": "Total Score",
"detail": "0.0.19",
"value": 24,
"parts": [
{
"name": "quality",
"title": "QUALITY component of final score",
"detail": "Scoring based on weight of 60%.",
"value": 24,
"original": {
"name": "quality",
"value": 40,
"detail": "Picked the highest scoring measurement set registry",
"parts": [
{
"name": "quality",
"value": 40,
"benchmarkType": "registry",
"eMeasureId": "CMS122v5",
"cpcPlusGroup": "A"
"benchmarkType": "registry",
"eMeasureId": "CMS68v6",
"cpcPlusGroup": null
}
},
{
"name": "309",
"value": 10,
"detail": "Contributing 10",
"metadata": {
"measureClass": "Class 1",
"measureTitle": "Cervical Cancer Screening",
"endToEndBonus": 0,
"outcomeOrPatientExperienceBonus": 0,
"highPriorityBonus": 0,
"decileScore": 10,
"performanceDenominator": 0,
"performanceNumerator": 0,
"eligiblePopulation": 0,
"partialDecileScore": 0,
"decile": 10,
"deciles": [
0,
28.95,
35.92,
43.03,
45.57,
49.26,
51.41,
53.79,
59.24
],
"processingStatus": "PICKED",
"messages": {
"decileScore": "Applied maximum decile score",
"measurementPicker": "Picked at 3"
},
"benchmarkType": "registry",
"eMeasureId": "CMS124v5",
"cpcPlusGroup": "C"
}
}
],
"metadata": {
"messages": {
"denominator": "At least 1 high or outcome or patient experience measure available. So denominator is 60"
},
"measuresPicked": [
"001",
"130",
"309"
],
"reweightedScore": 24
}
}
]
},
"metadata": {
"maxContribution": 60
}
}
],
"warnings": [
"Disclaimer: Scoring is subject to change, based on periodic policy updates, eligibility reviews, and technical integration developments."
],
"errors": []
}
}
}
---------------------------------------------------
steven....@semanticbits.com
Sep 5, 2017, 2:45:19 PM9/5/17
to Developer Group for QPP APIs
The suggested methodology for selecting the eHR benchmark with a submission method of Registry is to make the isEndToEndReported: True. We are currently in the process of developing this functionality. Please let me know if you need any additional information.
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