Outrunning The MIPS Bear: Quality Portion (Article 2 of 5)

Outrunning the MIPS Bear – Article (2 of 5)

MIPS: Quality

Ok, gotta outrun Da Bear – let him eat somebody else. Can you say “Darwinism?” It’s a serious ‘survival of the fittest’ approach but hey, right now the bar is low: they’re calling this a ‘transition’ year. Fine, I’ll take it; good year to get started; requirements are going to go up from here so let me get on board, get the good habits established.

As stated in the previous article, there are 4 categories to consider while running away from Da Bear:

  1. Quality
  2. Promoting Interoperability (PI)
  3. Improvement Activities (IA)
  4. Cost

Of the 4, Quality represents 50% of my final score, by far the biggest chunk represented by any single category, so, by gum, let’s get this one going. What is the Quality portion of this deal?

Well, straight from the CMS Horse’s mouth/website (qpp.cms.gov), Quality is defined from on high: “Participants must submit data for at least 6 measures for the 12 month performance period.” And further, that: “One of the measures should be an outcome measure; if you have no applicable outcome measure, you can submit a high priority measure instead.”

Ok, thank goodness for CMS stone tablets/websites – what measures should I pick?

I click on a friendly blue button labeled “Explore the measures” and am confronted by, Holy Toledo, 275 Quality Measures. After getting control of my rapid breathing and forcing my eyes to roll back down out of my forehead, I see that I can filter by Specialty Measure Set. After picking Urology as my Specialty the list is magically reduced to 22 measures: whew! And if I further filter by Submission Method, EHR, the list is reduced to 8: All right then! I guess I’ll stop bounding about the room shouting obscenities about CMS and see if I can get my arms around this Quality business of theirs. Government – sheesh.

Eight measures: just 8.

One of those has to be an outcome measure, whatever that is (I’ll deal with that later), OR a high priority measure (whatever that is – worry about that later) instead. A quick scan of the 8 returns no outcome measure, but there is one high priority measure: Documentation of Current Medications. Check: gotta take that one. The 6 I’ll pick:


Measure CMS ID NQF Type EHR Documentation process
Documentation of Meds in Current Record CMS68v7 419 High Priority Measure, Process Medical record>Medications>Request Med HX or Add Meds
Tobacco Screening CMS138v6 28 Process Medical record>History>Tobacco Assessment
Bone density eval CMS645vq1 NA Process Medical record>History>Bone Density
High BP Screening CMS22v6 NA Process Medical record>Vital signs>Record
Diabetes: Medical Attention for Nethropathy CMS134v6 62 Process Medical record>History>Nethropathy
BMI screening CMS69v6 421 Process Medical record>Vital signs>Record


Now all I’ve got to make sure that my staff is documenting these measures where it makes sense, within clinical workflow, so that my clinical quality measures populate!

Done! Check! Quality, step one, is handled. I’m still ahead of Da Bear, and I betcha, I’m willing to bet real money, that already I’m ahead of a lot of folks who haven’t bothered to get this far. Got $5 you want to put down on that bet? Here’s mine…

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Brad Sclar has founded several successful Healthcare IT companies within the last 20 years in the Denver area — PRS Network, Phasis Group, and MD-IT. In addition to multiple IT certifications he supports voice recognition software into multiple EMR environments nationwide, serves as the CIO of the PRS IT Division, overseeing template development, maintenance of client LAN installations, custom software development, HL7 interfaces between EMRs, and the installation of the Health Record portion of the EMR software packages that PRS represents. Currently, he is involved in launching a Urology focused MSO.