eCQM Certification Subgroup Slides July 28 2015

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eCQM Certification Subgroup
After-Action Kaizen Meetings
July 28th, 2015

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Today’s Topics
■ Cypress enhancements for QRDA validation testing.
■ Discuss what additional improvements can be made in
support CMS submission and reduced error rates:
– How much lead time (prior to submission) is needed for
validation tools for optimal testing (e.g., timeline)?
– What changes to submission systems or procedures would you
recommend to streamline or improve the submission process?
– Write a “submission plan” that reflects the best practices you
believe would guarantee first pass success in submission.
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Performance Rate Validation
■ Performance Rates is an optional template in the HL7 Base
implementation Guide.
– However, it is mandatory in the CMS Combined IG
■ Cypress will not issue an error if a Performance Rate is not
provided
■ However, Cypress will issue an error if a Performance Rate
is provided, but is calculated incorrectly
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NUMER
DENOM – DENEX - DENEXCEP
If DENOM – DENEX – DENEXCEP = 0 a NullFlavor “NA” is expected
As an unrounded decimal to
the .000001

4. © 2013 The MITRE Corporation. All rights Reserved.
Measure Duplication
■ Measures and Measure Populations should only be reported
once in a QRDA Cat III file
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CMS 182
• Performance Rate 1
• Performance Rate 2
• IPP
• DENOM
• NUMER 1
• NUMER 2
CMS 182
• Performance Rate 1
• Performance Rate 2
• IPP
• DENOM
• NUMER 1
• NUMER 2
CMS 182
• Performance Rate 1
• Performance Rate 2
• IPP
• DENOM
• NUMER 1
• NUMER 2
CMS 182
• Performance Rate 1
• IPP
• DENOM
• NUMER 1
CMS 182
• Performance Rate 2
• IPP
• DENOM
• NUMER 2
Cat III file Cat III file Cat III file

5. © 2013 The MITRE Corporation. All rights Reserved.
Measure Period
■ Cypress will now be issuing errors if the time period in the
Reporting Parameters Act does not match the Measurement
Period
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Data Criteria
■ “The EHR is then commanded to export the patient test data
in accordance with 170.314(c)(1)(ii) to produce a set of
QRDA Category I files containing the proper elements from
the QDM that are required to calculate the CQMs that are
being tested.
■ These QRDA files are loaded back into Cypress where they
are tested for validity (valid QRDA Category I XML
documents) and correctness (contain only the elements
required to calculate the CQMs, and no more).”
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CMS 160
CMS 159
Cat III test CMS 160
Cat I test
CMS 159
Cat I test
CMS 160
CMS 159
Cat III test
CMS 160
CMS 159
Cat I test
CMS 159
CMS 160
Cat I test
CMS 160
CMS 160
CMS 159
Cat I file
CMS 160
CMS 160
CMS 159
CMS 160
CMS 160
CMS 159
CMS 160
CMS 160
CMS 159
Cat I file
https://jira.oncprojectracking.org/browse/CYPRESS-538
CMS 160
CMS 160
CMS 159
CMS 2

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OPEN DISCUSSION
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8. © 2013 The MITRE Corporation. All rights Reserved.
Next eCQM Certification Subgroup Meeting
■ Tuesday August 25th at 2pm EST
■ Completed Webinars will be posted on the Cypress Website
on the Timeline Tab.
– http://projectcypress.org/timeline.html
■ Send questions and feedback to the Cypress Talk List as
talk@projectcypress.org
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