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Measure Specification

Respecifying Registry Measures to Electronic Clinical Quality Measures (eCQMs)

Use of registries is becoming more common, including for reporting quality measures to CMS. Respecifying registry measures for use in quality programs can provide a convenient and useful source to expand the availability of measures, especially digital measures, primarily eCQMs

Qualified Registries and Qualified Clinical Data Registries (QCDRs) support MIPS-eligible clinician quality reporting. Both registry types can report Merit-based Incentive Payment System (MIPS) measures as an alternative to direct reporting for clinicians. Additionally, QCDRs may have their own measures accepted by CMS for MIPS reporting. Both types of registries may collect additional measures from their members not accepted by CMS. It is these actively collected measures unique to registries the measure developers may find useful as a source of measures for respecification to eCQMs or other digital measures. Also, there may be other registries with quality measures not participating in the MIPS registry options.

Respecification of registry measures can present varying levels of complexity depending on several scenarios:

  • Existing MIPS measures. Eligible clinicians can report to CMS via registries (Qualified Registries or QCDRs) as an alternative to direct submission by clinicians. Eligible clinicians can report these measures via registries, but the measures are not unique to registries. As MIPS program measures, they have gone through the rule-making process and a high level of review and approval. Respecification to eCQMs presents primarily technical issues of data abstraction and calculation rather than basic development or application to a different population or setting. If respecification of MIPS measures was for a different setting such as the hospital, other issues would arise, as discussed in Respecified Measures
  • MIPS QCDR measures. As MIPS measures, these measures have also gone through the rule-making process indicating a high level of review and approval. However, the measure’s limitation to registry submission may imply the data may present particular challenges in terms of collection feasibility from individual EHRs. Full testing of the measure is an important aspect of respecification. 
  • Registries may collect measures not approved as MIPS measures. These measures have generally gone through a limited review, i.e., required for approval for submission to the registry. Although the measures are in use, they may have a limited, documented development process. Thus, they may require substantial basic development work as part of the respecification process.
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