cms measures management system blueprint.pdf
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A Blueprint
for the
CMS Measures Management System
Version 11.1 August 2015
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Section 1—Measure Development Concepts
Table of Contents
Table of Contents ................................................................................................................................................................ 1
List of Figures....................................................................................................................................................................... 8
List of Tables
........................................................................................................................................................................ 9
Preface: How to Use the Interactive Blueprint ................................................................................................................... 10
Structure of the Blueprint ................................................................................................................................................ 10
How Sections 1, 2, and 3 Work Together for eMeasure Processes ................................................................................. 10
How to Use the Glossary, Appendices, and Tools ............................................................................................................ 12
How External Resources Are Referenced ......................................................................................................................... 13
How To Formally Submit Changes For Upcoming Versions ............................................................................................ 14
Section 1—Measure Development Concepts ..................................................................................................................... 15
National Quality Strategy ................................................................................................................................................. 15
CMS Quality Strategy ....................................................................................................................................................... 16
Crosswalk Between the National Quality Strategy and the CMS Quality Strategy .......................................................... 17
Chapter 1—The CMS Measures Management System Blueprint .......................................................................................... 19
1.1—Role of the Measure Developer ............................................................................................................................... 21
1.2—Role of the Measure Developer͛s OR .................................................................................................................... 22
1.3—Role of the Measures Manager ............................................................................................................................... 22
1.4—Value Sets Governance ............................................................................................................................................ 23
Chapter 2—Priorities Planning .............................................................................................................................................. 25
2.1—Alignment, Harmonization, and Prioritization ......................................................................................................... 25
2.2—CMS Measure Planning Activities ............................................................................................................................ 27
2.3—Role of the Measure Developer in Priorities Planning............................................................................................. 30
2.4—Role of the Measures Manager in Priorities Planning ............................................................................................. 31
Chapter 3—Stakeholder Input
............................................................................................................................................... 33
3.1—Role of Person and Family (Caregiver) Engagement and Participation ................................................................... 34
3.2—Role of the Technical Expert Panel in Stakeholder Input ........................................................................................ 39
3.3—Role of Public Comment in Stakeholder Input......................................................................................................... 42
Chapter 4—Harmonization ................................................................................................................................................... 45
4.1—Adapted Measures .................................................................................................................................................. 47
4.2—Adopted Measures .................................................................................................................................................. 48
4.3—New Measures ......................................................................................................................................................... 49
Chapter 5—Concepts of Measure Evaluation ....................................................................................................................... 51
5.1—Measure Evaluation Criteria and Subcriteria ........................................................................................................... 52
5.2—Applying Measure Evaluation Criteria ..................................................................................................................... 53
5.3—Report of the Measure Developer͛s Evaluation of the Measures ........................................................................... 54
5.4—Developing and Evaluating the Business Case ......................................................................................................... 55
5.5—Evaluation Considerations for Special Types of Measures ...................................................................................... 61
5.6—Overview of Measure Evaluation Tools ................................................................................................................... 64
Chapter 6—Concepts of Selected Specific Measure Types .................................................................................................... 65
6.1—Cost and Resource Use Measures ........................................................................................................................... 66
6.2—Composite Performance Measures ......................................................................................................................... 67
6.3—Patient-Reported Outcome Measures..................................................................................................................... 69
6.4—Multiple Chronic Conditions Measures ................................................................................................................... 72
Section 2—Measure Lifecycle ............................................................................................................................................ 77
Chapter 1—Measure Conceptualization ............................................................................................................................... 79
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Section 1—Measure Development Concepts
Chapter 1.A.—Information Gathering................................................................................................................................... 81
Chapter 1.B.—Technical Expert Panel ................................................................................................................................... 99
Chapter 1.C.—Public Comment ...........................................................................................................................................
109
Chapter 2—Measure Specification ...................................................................................................................................... 115
2.1—Deliverables ........................................................................................................................................................... 115
2.2—Technical Specification ..........................................................................................................................................
116
2.3—Harmonizing Measure Specifications .................................................................................................................... 139
2.4—Risk-Adjusted Outcome Measures ........................................................................................................................ 140
2.5—Cost Resource Use Measure Technical Specifications ........................................................................................... 155
2.6—Composite Measure Technical Specifications ....................................................................................................... 157
Chapter 3—Measure Testing .............................................................................................................................................. 163
3.1—Deliverables ........................................................................................................................................................... 164
3.2—Alpha and Beta Testing ..........................................................................................................................................
164
3.3—Procedure .............................................................................................................................................................. 167
3.4—Testing and Measure Evaluation Criteria............................................................................................................... 173
3.5—Testing Considerations for Selected Measure Types ............................................................................................. 181
Chapter 4—Measure Implementation ................................................................................................................................
185 4.1—National Quality Forum Endorsement ................................................................................................................... 185
4.2—Measure Selection ................................................................................................................................................. 194
4.3—Measure Rollout .................................................................................................................................................... 198
Chapter 5—Measure Use, Continuing Evaluation, and Maintenance ................................................................................
205
5.1—Measure Production and Monitoring .................................................................................................................... 206
5.2—Measure Update .................................................................................................................................................... 215
5.3—Comprehensive Reevaluation ................................................................................................................................
220
5.4—Ad Hoc Review ....................................................................................................................................................... 227
5.5—Possible Outcomes of Maintenance Reviews ........................................................................................................ 232
Section 3—eMeasure Lifecycle ........................................................................................................................................ 237
eMeasure Components .................................................................................................................................................. 238
Overview of the eMeasure Lifecycle ..............................................................................................................................
240
Chapter 1—eMeasure Conceptualization ...........................................................................................................................
243
1.1—Deliverables ...........................................................................................................................................................
244
1.2—eMeasure Feasibility Assessment .......................................................................................................................... 244
1.3—Information Gathering for eMeasures................................................................................................................... 245
1.4—Additional or Adapted Evaluation Subcriteria for Scientific Acceptability of the eMeasure Properties ...............
246
1.5—Technical Expert Panel/Subject Matter Expert ...................................................................................................... 247
Chapter 2—eMeasure Specification .................................................................................................................................... 249
2.1—Deliverables ...........................................................................................................................................................
249
2.2—JIRA Basics for eCQM Developers .......................................................................................................................... 250
2.3—Develop eMeasure Specifications.......................................................................................................................... 251
2.4—Procedure ..............................................................................................................................................................
253 2.5—eCQM Specifications Review Process ....................................................................................................................
276
2.6—Innovations in eSpecifications ............................................................................................................................... 282
Chapter 3—eMeasure Testing ............................................................................................................................................ 285
3.1—Deliverables ...........................................................................................................................................................
286
3.2—Types of eMeasure Testing .................................................................................................................................... 286
3.3—Phases of eMeasure Testing .................................................................................................................................. 294
3.4—Tools for Testing eMeasures.................................................................................................................................. 295
3.5—Procedure .............................................................................................................................................................. 295
3.6—Testing Challenges ................................................................................................................................................. 297
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Section 1—Measure Development Concepts
Chapter 4—eMeasure Implementation ..............................................................................................................................
299
4.1—Deliverables ........................................................................................................................................................... 300
4.2—Preparing eMeasure Specifications for Public Release and Public Comment ....................................................... 301
4.3—NQF eMeasure Endorsement ................................................................................................................................ 302
4.4—eMeasure Rollout, Implementation, and Publication ...........................................................................................
303
Chapter 5—eMeasure Reporting ........................................................................................................................................ 309
5.1—Deliverables ...........................................................................................................................................................
309
5.2—Quality Reporting Document Architecture (QRDA) Category I ..............................................................................
309
5.3—Quality Reporting Document Architecture (QRDA) Category III ............................................................................ 310
5.4—Procedure .............................................................................................................................................................. 311
5.5—Continued Improvement and Maintenance .......................................................................................................... 312
Chapter 6—eMeasure Use, Continuing Evaluation, and Maintenance ............................................................................... 315
6.1—Deliverables ........................................................................................................................................................... 316
6.2—eMeasure Evaluation and Testing After Implementation ..................................................................................... 317
6.3—Annual Update Process for eMeasures .................................................................................................................
319
6.4—Comprehensive Reevaluation for eMeasures ....................................................................................................... 321
6.5—Ad Hoc Review for eMeasures ............................................................................................................................... 322
Section 4—Tools, Appendices, and Forms ....................................................................................................................... 323
Acronyms and Abbreviations ......................................................................................................................................... 323
Glossary ............................................................................................................................................................................... 325
Appendix A: XML View of a Sample eMeasure....................................................................................................................
347
Population criteria .......................................................................................................................................................... 348
Data criteria .................................................................................................................................................................... 349
Reporting stratification .................................................................................................................................................. 350
Supplemental data elements ......................................................................................................................................... 350
Appendix B: Electronic Specification (eMeasure) ................................................................................................................ 352
Appendix C: eMeasure QA Checklists ..................................................................................................................................
354
Appendix D: eMeasure Review Process Quick Reference ....................................................................................................
356
Appendix E: Time Unit and Time Interval Definitions ..........................................................................................................
357
Appendix F: Time Interval Calculation Conventions ............................................................................................................ 359
Timing relationships with no calculation unit defined ................................................................................................... 362
Other date/time-related calculations using QDM functions
..........................................................................................
363
Appendix G: Proportion Measure Calculations (exclusions, exceptions, and aggregation) ................................................ 364
Appendix H: Continuous Variable and Ratio Measure Calculations ....................................................................................
370
Measure Populations .....................................................................................................................................................
370
Individual Observations .................................................................................................................................................. 372
Measure Aggregate Calculations .................................................................................................................................... 372
Ratio Measure Example ................................................................................................................................................. 373
Measure aggregate calculations ....................................................................................................................................
374
Continuous Variable Measure Example ......................................................................................................................... 375
Appendix I: Harmonization of Inpatient Encounter Value Sets ........................................................................................... 376
Appendix J: Blueprint 11.1 Change Document .................................................................................................................... 379
Business Case Form Instructions ...................................................................................................................................... 384
Project Title: ...................................................................................................................................................................
384
Project Overview: ........................................................................................................................................................... 384
Date: ............................................................................................................................................................................... 384
Measure Name: .............................................................................................................................................................. 384 Blueprint 11.1 August 2015
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Section 1—Measure Development Concepts
Summary: .......................................................................................................................................................................
384
Incidence and prevalence: ............................................................................................................................................. 384
Current performance, including any disparities: ............................................................................................................ 385
Major clinical, functional status and other benefits: ..................................................................................................... 385
Successful intervention is feasible: ................................................................................................................................
385
Costs of clinical care: ...................................................................................................................................................... 385
Complications or untoward effects: ...............................................................................................................................
385 Estimated size and trajectory of anticipated improvement: .......................................................................................... 385
Model and formulas used: .............................................................................................................................................
386
Limitations: ..................................................................................................................................................................... 386
Net benefit: .................................................................................................................................................................... 386
Blank Business Case Form Template ................................................................................................................................ 387
Project Title: ................................................................................................................................................................... 387
Project Overview: ........................................................................................................................................................... 387
Date: ............................................................................................................................................................................... 387
Measure Name: ..............................................................................................................................................................
387
Summary: ....................................................................................................................................................................... 387
Incidence and prevalence: ............................................................................................................................................. 387
Current performance, including any disparities:
............................................................................................................
387 Major clinical, functional status and other benefits: .....................................................................................................
387
Successful intervention is feasible: ................................................................................................................................ 387
Costs of clinical care: ...................................................................................................................................................... 387
Complications or untoward effects: ............................................................................................................................... 388
Estimated size and trajectory of anticipated improvement:
..........................................................................................
388
Model and formulas used: ............................................................................................................................................. 388
Limitations: ..................................................................................................................................................................... 388
Net benefit: .................................................................................................................................................................... 388
Call for Measures Web Posting ........................................................................................................................................ 389
Project Title: ................................................................................................................................................................... 389
Dates: ............................................................................................................................................................................. 389
Project Overview: ...........................................................................................................................................................
389 Project Objectives: ......................................................................................................................................................... 389
Instructions: ................................................................................................................................................................... 389
Measure Information Form Instructions .......................................................................................................................... 390
Measure Name ...............................................................................................................................................................
390
Introduction Tab ............................................................................................................................................................. 390
NQF Conditions Tab........................................................................................................................................................ 390
Specifications Tab ........................................................................................................................................................... 391
Blank Measure Information Form Template .................................................................................................................... 401
Project Title: ................................................................................................................................................................... 401
Project Overview: ........................................................................................................................................................... 401
Date: ............................................................................................................................................................................... 401
Measure Name ...............................................................................................................................................................
402
Descriptive Information ................................................................................................................................................. 402
Measure Specifications .................................................................................................................................................. 402
Measure Justification Form Instructions .......................................................................................................................... 403
Measure Name ............................................................................................................................................................... 403
Type of Measure ............................................................................................................................................................ 403
Importance Tab ..............................................................................................................................................................
403
Scientific Acceptability Tab ............................................................................................................................................ 411
Feasibility Tab ................................................................................................................................................................. 419
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Usability and Use Tab .....................................................................................................................................................
420
Related and Competing Measures Tab .......................................................................................................................... 421
Additional [Information] Tab .......................................................................................................................................... 422
Blank Measure Justification Form Template .................................................................................................................... 424
Project Title: ................................................................................................................................................................... 424
Project Overview: ........................................................................................................................................................... 424
Date: ...............................................................................................................................................................................
424
Measure Name ...............................................................................................................................................................
424
Type of Measure ............................................................................................................................................................ 424
Importance ..................................................................................................................................................................... 424
Scientific Acceptability ................................................................................................................................................... 426
Feasibility ....................................................................................................................................................................... 428
Usability and Use ............................................................................................................................................................ 428
Related and Competing Measures ................................................................................................................................. 428
Additional Information ................................................................................................................................................... 428
Measure Evaluation Criteria and Instructions .................................................................................................................. 430
1. Evidence, Performance Gap, and Priority (Impact)—Importance to Measure and Report: ...................................... 430
2. Reliability and Validity—Scientific Acceptability of Measure Properties: .................................................................. 434
3. Feasibility: ..................................................................................................................................................................
441
4. Usability and Use: ....................................................................................................................................................... 444
5. Comparison to Related or Competing Measures: ...................................................................................................... 446
Blank Measure Evaluation Report Template .................................................................................................................... 448
Project Title: ................................................................................................................................................................... 448
Project Overview: ........................................................................................................................................................... 448
Date: ............................................................................................................................................................................... 448
Measure Name: ..............................................................................................................................................................
448
Measure Set (or Setting): ............................................................................................................................................... 448
Measure Developer: ....................................................................................................................................................... 448
1. Evidence, Performance Gap, and Priority (Impact)—Importance to Measure and Report ....................................... 448
2. Reliability and Validity—Scientific Acceptability of Measure Properties ................................................................... 449
3. Feasibility
....................................................................................................................................................................
450
4. Usability and Use ........................................................................................................................................................ 450
5. Comparison to Related or Competing Measures ....................................................................................................... 451
Preliminary Recommendation for Endorsement ........................................................................................................... 451
Public Comment Call Web Posting ................................................................................................................................... 453
Project Title: ................................................................................................................................................................... 453
Dates: .............................................................................................................................................................................
453
Project Overview: ........................................................................................................................................................... 453
Project Objectives: ......................................................................................................................................................... 453
Documents and Measures for Comment: ...................................................................................................................... 453
Expiration Notice: ........................................................................................................................................................... 453
Project Specific Instructions: ..........................................................................................................................................
453
Public Comment Summary Web Posting .......................................................................................................................... 454
Project Title: ................................................................................................................................................................... 454
Dates: .............................................................................................................................................................................
454
Project Overview: ........................................................................................................................................................... 454
Project Objectives: ......................................................................................................................................................... 454
Comment Summary: ...................................................................................................................................................... 454
Expiration Notice:
...........................................................................................................................................................
454
Public Comment Summary Report Template ................................................................................................................... 455
Project Title: ................................................................................................................................................................... 455
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Dates: .............................................................................................................................................................................
455
Project Overview: ........................................................................................................................................................... 455
Project Objectives: ......................................................................................................................................................... 455
Information About the Comments Received: ................................................................................................................ 455
Stakeholder Comments—General and Measure-Specific ..............................................................................................
455
Preliminary Recommendations ...................................................................................................................................... 455
Overall Analysis of the Comments and Recommendations ...........................................................................................
455
Technical Expert Panel Call for TEP Web Page Posting ..................................................................................................... 457
Project Title: ................................................................................................................................................................... 457
Dates: ............................................................................................................................................................................. 457
Project Overview: ........................................................................................................................................................... 457
Project Objectives: ......................................................................................................................................................... 457
TEP Requirements: ......................................................................................................................................................... 457
TEP Expected Time Commitment: .................................................................................................................................. 458
Required Information: .................................................................................................................................................... 458
Technical Expert Panel (TEP) Nomination Form Template ............................................................................................... 459
Project Title: ................................................................................................................................................................... 459
Project Overview: ........................................................................................................................................................... 459
Project Objectives: .........................................................................................................................................................
459
TEP Expected Time Commitment: .................................................................................................................................. 459
TEP Requirements: ......................................................................................................................................................... 459
Instructions: ................................................................................................................................................................... 459
Applicant/Nominee Information (Self-Nominations Are Acceptable): .......................................................................... 461
Person Recommending the Nominee: ........................................................................................................................... 461
!pplicantNominee͛s Disclosure. ................................................................................................................................... 462
!pplicantNominee͛s !greement. ................................................................................................................................. 462
Technical Expert Panel Composition (Membership) List Template ................................................................................... 463
Project Title: ................................................................................................................................................................... 463
Dates: ............................................................................................................................................................................. 463
Expiration Notice: ........................................................................................................................................................... 463
Project Overview: ...........................................................................................................................................................
463
Technical Expert Panel Composition (Membership) List Web Page Posting ..................................................................... 464
Project Title: ................................................................................................................................................................... 464
Dates: .............................................................................................................................................................................
464
Documents: .................................................................................................................................................................... 464
Project Overview: ........................................................................................................................................................... 464
Project Objectives: .........................................................................................................................................................
464
TEP Requirements: ......................................................................................................................................................... 464
TEP Expected Time Commitment: .................................................................................................................................. 464
Expiration Notice: ........................................................................................................................................................... 465
Technical Expert Panel Charter Template ........................................................................................................................ 466
Project Title: ...................................................................................................................................................................
466 Dates: ............................................................................................................................................................................. 466
Project Overview: ........................................................................................................................................................... 466
Project Objectives: .........................................................................................................................................................
466
TEP Objectives: ............................................................................................................................................................... 466
Scope of Responsibilities: ............................................................................................................................................... 466
Guiding Principles: .......................................................................................................................................................... 466
Estimated Number and Frequency of Meetings: ...........................................................................................................
466
Date Approved by TEP: ................................................................................................................................................... 466
TEP Membership: ........................................................................................................................................................... 467
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Expiration Notice:
...........................................................................................................................................................
467
Technical Expert Panel Summary Web Page Posting ........................................................................................................ 468
Project Title: ................................................................................................................................................................... 468
Dates: .............................................................................................................................................................................
468
Documents: .................................................................................................................................................................... 468
Project Overview: ........................................................................................................................................................... 468
Project Objectives: .........................................................................................................................................................
468
Expiration Notice:
...........................................................................................................................................................
468
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Section 1—Measure Development Concepts
List of Figures
Figure 1: Glossary Definition Pop-up for Terms
......................................................................................................................... 12
Figure 2: Navigating PDF Bookmarks ......................................................................................................................................... 13
Figure 3: Navigation Pane Activation ......................................................................................................................................... 13
Figure 4: External Hyperlinks ..................................................................................................................................................... 14 Figure 5: CMS Measures Management System Model .............................................................................................................. 20
Figure 6: CMS Priorities Planning and Measure Selection ......................................................................................................... 27
Figure 7: Applying Measure Evaluation Criteria ........................................................................................................................ 53
Figure 8: Inputs and Uses for the Business Case ....................................................................................................................... 57
Figure 9: MMS Business Case Best Practices ............................................................................................................................. 59
Figure 10: Relationship Between Resource Use, Value, and Efficiency ..................................................................................... 67
Figure 11: Flow of the Measure Lifecycle .................................................................................................................................. 78
Figure 12: Flow of the Measure Lifecycle - Measure Conceptualization ................................................................................... 79
Figure 13: Information Gathering .............................................................................................................................................. 81
Figure 14: The Posting Process .................................................................................................................................................. 82
Figure 15: Flow of the Measure Lifecycle - Measure Specification ......................................................................................... 115
Figure 16: Structure Process Outcome Relationship ............................................................................................................... 140
Figure 17: Example of ROC Curves
...........................................................................................................................................
153
Figure 18: Flow of the Measure Lifecycle - Measure Testing .................................................................................................. 164
Figure 19: Overview of Measure Testing ................................................................................................................................. 168
Figure 20: Flow of the Measure Lifecycle - Measure Implementation .................................................................................... 185
Figure 21: Measure Submission ............................................................................................................................................... 187
Figure 22: Overview of the Measure Rollout Process .............................................................................................................. 199
Figure 23: Flow of the Measure Lifecycle - Measure Use, Continuing Evaluation, and Maintenance .................................... 206
Figure 24: Overview of the Measure Monitoring Process ....................................................................................................... 207
Figure 25: Measure Review Cycle Timeline ............................................................................................................................. 215
Figure 26: eMeasure Icon ........................................................................................................................................................ 238
Figure 27: eMeasure Lifecycle ................................................................................................................................................. 241
Figure 28: eMeasure Conceptualization Tools and Stakeholders ............................................................................................ 243
Figure 29: eMeasure Specification Tools and Stakeholders ....................................................................................................
249 Figure 30: eMeasure Specification Development Process....................................................................................................... 254
Figure 31: Vision for Robust Value Set Management .............................................................................................................. 271
Figure 32: eMeasure Testing Tools and Stakeholders ............................................................................................................. 286
Figure 33: eMeasure Implementation Tools and Stakeholders ............................................................................................... 300
Figure 34: QRDA Category I Sample Report ............................................................................................................................. 310
Figure 35: QRDA Category III Sample Report ........................................................................................................................... 311
Figure 36: eMeasure Use, Continuing Evaluation, and Maintenance Key Stakeholders ......................................................... 316
Figure 37: Annual Update Process for eMeasures...................................................................................................................
321
Figure 38: Proportion Measure Populations............................................................................................................................ 364
Figure 39: Ratio Measure Populations ..................................................................................................................................... 370
Figure 40: Continuous Variable Measure Populations ............................................................................................................ 371
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Section 1—Measure Development Concepts
List of Tables
Table 1: Crosswalk between Sections 2 and 3 ........................................................................................................................... 11
Table 2: National Quality Strategy and CMS Quality Strategy ................................................................................................... 17
Table 3: Harmonization Decisions During Measure Development ............................................................................................ 47
Table 4: Environmental Scan Best Practices .............................................................................................................................. 84 Table 5: Attributes of Risk Adjustment Models .......................................................................................................................
143
Table 6: Types of Composite Measure Scoring ........................................................................................................................ 158
Table 7: Features of Alpha and Beta Testing ........................................................................................................................... 165
Table 8: Harmonization Decisions during Measure Maintenance ........................................................................................... 213
Table 9: Extent of Measure Evaluation as a Function of Prior Comprehensive Evaluation and Measure Use ........................
224
Table 10: CMS Criteria for Measure Disposition ...................................................................................................................... 233
Table 11: eCQM Metadata....................................................................................................................................................... 256
Table 12: Diagnoses Available for Use in eCQMs .................................................................................................................... 262
Table 13: Conventions for Constructing Age Logic .................................................................................................................. 263
Table 14: ONC HIT Standards Committee Recommended Vocabulary Summary ................................................................... 265
Table 15: ONC HIT Standards Committee Transition Vocabulary Standards Summary and Plan ............................................ 266
Table 16: Allergy and Intolerance Value Set Naming Convention ........................................................................................... 267
Table 17: Quality Data Model Categories With ONC HIT Standards Committee Recommended Vocabularies ......................
267
Table 18: Measure Populations Based on Type of Measure Scoring ....................................................................................... 271
Table 19: Value Set Review Areas and Remedial Actions ........................................................................................................ 278
Table 20: Sample eMeasure Identifier ..................................................................................................................................... 303
Table 21: Sample File Naming .................................................................................................................................................. 305
Table 22: Application of Evaluation Methods .......................................................................................................................... 317
Table 23: Example of XML View ............................................................................................................................................... 347
Table 24: Sample Electronic Specification ............................................................................................................................... 352
Table 25: Logic Review Checklist ............................................................................................................................................. 354
Table 26: Clinical Review Checklist .......................................................................................................................................... 355
Table 27: Naming File Attachments ......................................................................................................................................... 356
Table 28: Comment Boxes ....................................................................................................................................................... 356
Table 29: Time Unit and Time Interval Definitions ..................................................................................................................
357 Table 30: Time Interval Calculation Conventions .................................................................................................................... 359
Table 31: Harmonization of Inpatient Encounter Value Sets ................................................................................................... 376
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Section 1—Measure Development Concepts
Preface: How to Use the Interactive Blueprint
Structure of the Blueprint
The Blueprint is divided into four sections. The first section contains measure development
concepts, the second describes procedural steps for measure development and maintenance, the
third covers procedural information specific to eMeasures, and the fourth is a collection of tools
and forms to be used during the measure lifecycle. Below is a more detailed explanation of each
section of the Blueprint:
Section 1—Measure Development Concepts—covers concepts that apply throughout the
measure lifecycle and provides background and a more in-depth description of those
concepts. This material is not repeated in the procedure sections but is referenced
wherever applicable.
Section 2—Measure Lifecycle—describes the procedural steps necessary to develop and
maintain a measure. Section 3—eMeasure Lifecycle—is constructed parallel to Section 2 because it also
describes measure development and maintenance procedures, but material in this section
is specific to eMeasures. The section references conceptual material from Section 1 and
procedural material from Section 2 where they apply to eMeasures.
Section 4—Tools, Appendices, and Forms—contains all of the tools, appendices, and forms
referenced in the Blueprint. It also contains a glossary and a list of acronyms used in the
Blueprint.
The Blueprint is now designed primarily as an electronic document with navigation bookmarks and
internal and external hyperlinks. Resources and forms are referenced throughout the Blueprint
where they are required, and key terms are linked to their appropriate glossary entries. Any text
formatted in blue represents an internal or external hyperlink.
How Sections 1, 2, and 3 Work Together for eMeasure Processes
Due to the increased use of eMeasures in CMS quality programs, the eMeasure Specification
section from previous editions of the Blueprint has been expanded to cover the complete
eMeasure lifecycle from development through maintenance. The concepts of measure
development and maintenance covered in Section 1 are linked to the procedures for general
measure development and maintenance in Section 2, and are referenced with the specifics of
eMeasure development and maintenance covered in Section 3.
Section 1 describes concepts that apply throughout the measure lifecycle. Where the concepts are
used procedurally, they are referenced to the appropriate information in sections 2 and 3. Section
2—Measure Lifecycle and Section 3—eMeasure Lifecycle are structured in a parallel manner
because many aspects of the process are used regardless of whether the measure is based on
paper medical records or an electronic health record. These common processes are not repeated
for both types of measures, but the topics are referenced wherever needed and linked to the
procedure description. The material in Section 3 covers procedures for all types of eMeasures
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Section 1—Measure Development Concepts
including new (de novo), retooled (respecified), and reengineered (adapted) eMeasures, through
all phases of the eMeasure Lifecycle. General procedures for Measure Conceptualization, Measure
Specification, Measure Testing, Measure Implementation, and Measure Use and Continuing
Evaluation are not repeated in Section 3, but links are provided back to the more in-depth
discussion of the general processes in Section 2. Table 1 below provides a crosswalk between
Sections 2 and 3.
Table 1: Crosswalk between Sections 2 and 3
Section 2—Measure Lifecycle Section 3—eMeasure Lifecycle
Chapter 1—Measure Conceptualization Chapter 1—eMeasure Conceptualization
Chapter 1.A.—Information Gathering 1.1—Deliverables
Chapter 1.B.—Technical Expert Panel 1.2—eMeasure Feasibility Assessment
Chapter 1.C.—Public Comment 1.3—Information Gathering for eMeasures
1.4— Additional or Adapted Evaluation Subcriteria for
Scientific Acceptability of the eMeasure Properties
1.5—Technical Expert Panel/Subject Matter Expert
Chapter 2—Measure Specification Chapter 2—eMeasure Specification
2.1—Deliverables 2.1—Deliverables
2.2—Technical Specification 2.2—JIRA Basics for eCQM Developers
2.3—Harmonizing Measure Specifications 2.3—Develop eMeasure Specifications
2.4—Risk-Adjusted Outcome Measures 2.4—Procedure
2.5—Cost Resource Use Measure Technical 2.5—eCQM Specifications Review Process
Specifications 2.6—Innovations in eSpecifications
2.6—Composite Measure Technical Specifications
Chapter 3—Measure Testing Chapter 3—eMeasure Testing
3.1—Deliverables 3.1—Deliverables
3.2—Alpha and Beta Testing 3.2—Types of eMeasure Testing (data element, logic,
3.3—Procedure etc.)
3.4—Testing and Measure Evaluation Criteria
3.3—Phases of eMeasure Testing 3.5—Testing Considerations for Selected Measure 3.4—Tools for Testing eMeasures (Bonnie, Cypress)
Types 3.5—Procedure
3.6—Testing Challenges
Chapter 4—Measure Implementation
4.1—National Quality Forum Endorsement
4.2—Measure Selection
4.3—Measure Rollout
Chapter 4—eMeasure Implementation
4.1—Deliverables
4.2—Preparing eMeasure Specifications for Public
Release and Public Comment
4.3—NQF eMeasure Endorsement
4.4—eMeasure Rollout, Implementation, and
Publication
Chapter 5—eMeasure Reporting 5.1—Deliverables
5.2—Quality Reporting Document Architecture (QRDA)
Category I
5.3—Quality Reporting Document Architecture (QRDA)
Category III
5.4—Procedure
5.5—Continued Improvement and Maintenance
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Section 1—Measure Development Concepts
Section 2—Measure Lifecycle Section 3—eMeasure Lifecycle
Chapter 5—Measure Use, Continuing Evaluation, and
Maintenance
5.1—Measure Production and Monitoring
5.2—Measure Update
5.3—Comprehensive Reevaluation
5.4—Ad Hoc Review
5.5—Possible outcomes of maintenance reviews
Chapter 6—eMeasure Use, Continuing Evaluation, and
Maintenance
6.1—Deliverables
6.2—eMeasure Evaluation and Testing After
Implementation
6.3—Annual Update Process for eMeasures
6.4—Comprehensive Reevaluation for eMeasures
6.5—Ad Hoc Review for eMeasures
Navigating between Sections 1, 2, and 3 by clicking on the hyperlinks will take the user to key
relevant information in the other appropriate section. This information may include further details
about the topic that were discussed in another section and are not repeated.
How to Use the Glossary, Appendices, and Tools
Definitions are provided for terms used throughout the Blueprint. The terms are included in the
Glossary, but they are also linked so that when the cursor hovers over the word, a short definition
pops up as illustrated in Figure 1: Glossary Definition Pop-up for Terms.
Figure 1: Glossary Definition Pop-up for Terms
References to appendices or forms located in Section 4 also include an internal hyperlink. When a
form is required or when an appendix is referenced, the hyperlinked text is formatted in blue.
Pressing the keyboard ͞trl͟ button and left clicking on the text will bring the reader to the
appropriate section, appendix, form, or other resource within the Blueprint. To return to the
original place in the document, press the Alt key and the left arrow together either in Word or in
the PDF version.
When viewed as a PDF, the bookmarks at the left of the screen correspond to the sections,
chapters, and subheadings listed in the Table of Contents. Clicking on the icon with the ribbon
reveals the bookmarks as depicted in Figure 2: Navigating PDF Bookmarks.
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Section 1—Measure Development Concepts
Figure 2: Navigating PDF Bookmarks
These bookmarks can also be viewed in the Word document if the Navigation Pane is activated
from the View menu tab as illustrated in Figure 3: Navigation Pane Activation.
Figure 3: Navigation Pane Activation
Using either the Navigation Pane or the PDF bookmarks, the reader can move easily between
sections of interest within the Blueprint.
How External Resources Are Referenced
References to documents or Web pages available online are linked in the text. Pressing the
keyboard ͞trl͟ button and left -clicking on the hyperlinked blue text will connect the user to the
selected location. To reveal the destination URL, hover the cursor over the hyperlinked blue text.
The full URL is also spelled out in a corresponding footnote. Figure 4 depicts an external hyperlink.
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Section 1—Measure Development Concepts
Figure 4: External Hyperlinks
How To Formally Submit Changes For Upcoming Versions
Recommendations for changes to the content, structure or organization of the Blueprint are
welcomed. Please submit all suggestions to the MMS support mailbox
([email protected]). Please include specifics about the recommended change, including
the:
Version of the Blueprint being referenced
Relevant section, chapter number, and title
Page number
Relevant text to modify, if applicable
New text to add, if applicable
Rationale for change
Point of contact information
Recommended changes will be accepted year-round, and incorporated into the next proximate cyclical
review of the document.
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Section 1—Measure Development Concepts
Section 1—Measure Development Concepts
In response to an ever-increasing demand for quality measures, the Centers for Medicare &
Medicaid Services (CMS) has developed a standardized system for developing and maintaining the
quality measures used in its various quality initiatives and programs. Known as the Measures
Management System(MMS),1 CMS-funded measure developers (or contractors) should follow this
core set of business processes and decision criteria when developing, implementing, and
maintaining quality measures. The primary goal of the Measures Management System is to
provide information to measure developers to help them produce high-caliber quality measures
that are appropriate for accountability. This manual, the CMS Measures Management System
Blueprint, Version 11.1 (the Blueprint), documents the full Measures Management System core set
of business processes.2
National Quality Strategy
CMS selects measures to develop and implement based on several key inputs, most important ofwhich is the National Quality Strategy. The Patient Protection and Affordable Care Act of 2010,
commonly called the Affordable Care Act (ACA), 3 seeks to increase access to high-quality,
affordable healthcare for all Americans. Section 3011 of the ACA requires the Secretary of the
Department of Health and Human Services (DHHS) to establish a National Strategy for Quality
Improvement in Health Care (the National Quality Strategy) that sets priorities to guide this effort
and includes a strategic plan for how to achieve it. The initial National Quality Strategy established
three aims and six priorities for quality improvement.
The three aims are:
Better care.
Healthy people/healthy communities.
Smarter spending.
The six priorities are:
Making care safer by reducing harm caused in the delivery of care.
Ensuring that each person and his or her family (caregivers) are engaged as partners in their
care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Working with communities to promote wide use of best practices to enable healthy living.
1 Centers for Medicare & Medicaid Services. Measures Management System. Available at: http://www.cms.gov/Medicare/Quality-Initiatives
Patient-Assessment-Instruments/MMS/. Accessed on: May 6, 2015.2 Centers for Medicare & Medicaid Services. Measures Management System: Blueprint. Available at: https://www.cms.gov/Medicare/Quality
Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.html. Accessed on: May 6, 2015.3 111th Congress of the United States. Patient Protection and Affordable Care Act , 42 U.S.C & 18001 (2010). United States Government Printing
Office. Available at: http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf . Accessed on: May 6, 2015.
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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiativeshttps://www.cms.gov/Medicare/Qualityhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiativeshttps://www.cms.gov/Medicare/Qualityhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/
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Section 1—Measure Development Concepts
Making quality care more affordable for individuals, families, employers, and governments
by developing and spreading new healthcare delivery models.4
The National Quality Strategy's first annual progress report to Congress,5 published in April 2012,
elaborated on these six priorities and established long-term goals and national tracking measures
to monitor quality improvement progress. The second annual progress report to Congress,published in July 2013, updated results of public and private payers͛ collaborative efforts to align
their quality measures͛ progress against the national tracking measures/ 6
At the DHHS level, the Secretary has articulated Delivery System Reform goals. These goals focus
on how Medicare and other payers pay providers, deliver care and distribute information, to
achieve a future state that is patient-centered, provides incentives for patient outcomes, is
sustainable, emphasizes coordinated care and shared decision-making with patients and relies on
transparency of quality and cost information. This future state promotes value-based payment
systems including value-based purchasing, Accountable Care Organizations, episode-based
payments and Patient-Centered Medical Homes. During January 2015, DHHS set internal goals for
value-based payments within the Medicare FFS system and invited private sector payers to matchor exceed DHHS goals:
Goal 1: 30% of Medicare payments are tied to quality or value through alternative payment
models by the end of 2016, and 50% by the end of 2018.
Goal 2: 85% of all Medicare fee-for-service payments are tied to quality or value by the end
of 2016, and 90% by the end of 2018.
CMS Quality Strategy
The CMS Quality Strategy pursues and aligns with the three broad aims of the National Quality
Strategy as well as Delivery System Reform payment goals. Like the National Quality Strategy, the
CMS Quality Strategy7 was developed through a participatory, transparent, and collaborative
process that included the input of a wide array of stakeholders. CMS͛s vision is to optimize health
outcomes by improving clinical quality and transforming the health system. The CMS Quality
Strategy pursues and aligns with the three broad aims of the National Quality Strategy and its six
priorities. Each of these priorities has become a goal in the CMS Quality Strategy. In addition, CMS
has developed four foundational principles: eliminate racial and ethnic disparities, strengthen
infrastructure and data systems, enable local innovations, and foster learning organizations.
4 Department of Health and Human Services, Agency for Health Research and Quality, National Quality Strategy. Working For Quality . Available at:
http://www.ahrq.gov/workingforquality/. Accessed on: May 6, 2015.5 Department of Health and Human Services. Agency for Health Research and Quality, National Quality Strategy. 2011 Report to Congress: National
Strategy for Quality Improvement in Health Care. Mar 2011. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.
Accessed on: May 6, 2015.6 Department of Health and Human Services, Agency for Health Research and Quality, National Quality Strategy. 2012 Annual Progress Report to
Congress National Strategy for Quality Improvement in Health Care . Available at:
http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.htm. Accessed on: May 6, 2015.7 Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMS Quality Strategy 2013 —Beyond . Available at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality
Strategy.pdf. Accessed on: May 15, 2015.
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