Harmonization during Measure Maintenance

Harmonization and alignment work are parts of both measure development and measure maintenance. This discussion is about procedures for harmonization and alignment after the measure is in use and is in maintenance mode. There are four steps to apply during measure maintenance to help ensure the measure’s continued harmonization after implementation.

Decide Whether Harmonization is Indicated

The measure developer should conduct an environmental scan for similar, existing measures and similar or related measures in development. Although the measure developer likely completed this step during initial measure development, the related measures may no longer be in harmony because of changes to specifications and new measures created.

The table describes harmonization issues and actions based on the numerator and denominator specifications.

Harmonization Decisions during Measure Maintenance

MeasureHarmonization IssueAction

Numerator: Same measure focus

Denominator: Same target population

Competing measures
  • Use existing measure (i.e., adopted) or justify development of a de novo measure
  • A different data source will require new harmonized specifications (e.g., respecified)

Numerator: Same measure focus

Denominator: Different target population

Related measures
  • Harmonize on measure focus (i.e., respecified)
  • Justify differences
  • Respecify existing measure by expanding the target population

Numerator: Different measure focus

Denominator: Same target population

Related measures
  • Harmonize on target population
  • Justify differences

Numerator: Different measure focus

Denominator: Different target population

No harmonization issue
  •  No action or develop de novo measure – harmonization not appropriate

Implement Harmonization Decisions

After evaluating for harmonization, the possible outcomes are

  • retain the measure with minor updates and provide justification if there are related measures
  • revise the measure specifications to harmonize
  • retire the measure and replace it with a different measure

Test Scientific Acceptability of Measure Properties

If harmonization results in changes to the measure specifications, the measure developer must test the scientific acceptability, including re-analysis of reliability, validity, and denominator and numerator exclusion appropriateness. 

The CMS CBE Evaluates for Harmonization during Measure Maintenance

The CMS CBE evaluates the measure for harmonization potential during the measure’s endorsement maintenance review. The measure developer may be unaware of newly developed similar or related measures until after submission to the CMS CBE for review. If the CMS CBE identifies similar or related measures and harmonization has not taken place, or measure developers have adequately justified the reasons for not doing so, the CMS CBE committee reviewing the measures can request measure developers to create a harmonization plan addressing the possibility and challenges of harmonizing certain aspects of their respective measures. The CMS CBE will consider the response and decide whether to recommend the measure for continued endorsement.

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