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Clinical Quality Measures and Meaningful Use

Hess, Cathy Thomas BSN, RN, CWOCN

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Advances in Skin & Wound Care: May 2014 - Volume 27 - Issue 5 - p 240
doi: 10.1097/01.ASW.0000446523.27067.30
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Four years ago in the May 2010 Practice Points column, we discussed the future need for implementing the “meaningful use” of an electronic health record (EHR), understanding the importance of documenting “meaningful” data to the Centers for Medicare and Medicaid (CMS), and measuring the actual impact on patient care. The background information to the Meaningful Use initiatives began with the Health Information Technology for Economic and Clinical Health Act provision of the American Recovery and Reinvestment Act of 2009. This initiative provided billions of dollars in incentives for the adoption and use of Health Information Technology by Medicare and Medicaid providers for the next decade. For these eligible providers (EPs) and hospitals to receive the financial incentives set forth (Table 1), they must achieve meaningful use using a certified EHR. The meaningful use requirements are grouped into 3 stages:

Table 1
Table 1:
  • Stage 1 focuses on capturing data
  • Stage 2 focuses on reporting health information and tracking of defined clinical data sets
  • Stage 3 focuses on improving performance and health outcomes

Supporting the meaningful use efforts is the implementation of clinical quality measures (CQMs). The CMS has led the charge to implement CQMs within its programs, including meaningful use and the Physician Quality Reporting System. Through the transmission of data, CQMs assist the CMS in understanding the care provided to the patient/beneficiary, and, ultimately, the data collected will improve quality care for the patient population.

As we continue to build our arsenal for “meaningful documentation,” we need to take a closer look at this important tool, CQMs, and its impact on our business. We can do this by understanding these requirements as stated by the CMS1:

“Clinical quality measures, or CQMs, are tools that help us measure and track the quality of healthcare services provided by eligible professionals (EPs), eligible hospitals (EHs) and critical access hospitals (CAHs) within our health care system. These measures use a wide variety of data that are associated with a provider’s ability to deliver high-quality care or relate to long term goals for health care quality. CQMs measure many aspects of patient care including: health outcomes, clinical processes, patient safety, efficient use of healthcare resources, care coordination, patient engagements, population and public health, and clinical guidelines.

Continuously measuring and reporting these CQMs helps to ensure that our health care system can deliver effective, safe, efficient, patient-centered, equitable, and timely care.

Currently, in Stage 1 of meaningful use for the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, CQMs are required as a core meaningful use objective. EPs, EHs, and CAHs who wish to participate in the EHR Incentive Program must submit data from certified EHR Technology CQMs in order to receive an incentive payment in the EHR Incentive Program. In Stage 2, CQMs are no longer a core meaningful use objective; however, EPs, EHs, and CAHs are still required to submit CQMs in order to successfully participate in the program.

Beginning in 2014, all providers, regardless of whether they are in Stage 1 or Stage 2 of meaningful use, will be required to report on the 2014 CQMs finalized in the Stage 2 rule. CMS has also provided information on what to report in 2013 as well as how to begin the transition for reporting in 2014. In addition, beginning in 2014, all EPs and EHs beyond their first year of meaningful use will be required to submit CQMs electronically.”

It is not too late to start documenting meaningful use and CQMs. As documented by the CMS, Table 1“illustrates the maximum incentive payments an EP can receive by year and the total incentive payments possible if an EP successfully demonstrates meaningful use and qualifies for an incentive payment each year. As shown, the total amount of the incentive payment an EP can receive is dependent in part on the year in which the EP successfully demonstrates meaningful use.”2

Meaningful use drives meaningful documentation coupled with the ability to measure and track the quality of healthcare services provided by eligible professionals and hospitals within our healthcare system. With this knowledge in hand, it is time to take action before the program transitions from incentive payments to penalties for noncompliance.


1. Centers for Medicare & Medicaid Services. Clinical quality measures. Last accessed March 27, 2014.
2. Centers for Medicare & Medicaid Services. Medicare electronic health record incentive payments for eligible professionals. Last accessed March 27, 2014.
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