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CQR - Looking to Discuss CQR with Another Site

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MU, CQR, PQRS, etc.

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lbertran

(@lbertran)

Posts: 2

Active Member

Topic starter

We're concerned about the accuracy of data in CQR. We've spoken to a couple of sites that are writing their own reports to submit because they have the same concerns, but we don't have those report writing resources.

We'd like to have a conversation with a site who's using CQR and who feel good about the validity of their data in CQR.

Posted : May 29, 2015 2:46 am

[email protected]

(@pvassauradclinic-com)

Posts: 32

Eminent Member

I would really like to tag along on this one if you don't mind. We have discovered some real issues with CQR, and I worry we will never be able to rely on it. We have also been trying to identify other means of reporting but do not have the reporting writing expertise that others might. I look forward to seeing the dialogue and appreciate the question!

Posted : May 29, 2015 2:58 am

acantu

(@acantu)

Posts: 722

Prominent Member

Hi Lynn, we too have used our own reporting that I created to help assist in MU. But once completed, I am going to trace back to see where all the CQR data is being pulled from. I know the CPS has changed the processes and table locations on where a lot of the data is being pulled from when comparing the crystal reports to the CQR version. I recommend, if you need to complete any MU to use the Crystal Version if you are unable to do your own reports, or I actually have a solution already for Stage I, if you are interested. Let me know if you would like to talk further.

Posted : May 29, 2015 2:58 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

We have the same concerns and are looking to create crystal reports as a substitute for the MU Core measures. Thankfully CMS allows custom reports for the Core measures. Unfortunately they do not for the CQMs but the saving grace is there are no thresholds for the CQMs so we are ok with using the CQR for it - although still not very happy.

I'd be interested in discussing the concerns as well, we've pinpointed a lot of the oddities and would like to see if others have noticed them as well (or noticed others). At the beginning of the year we tried to recreate the CQR in crystal to get a better enterprise dashboard, that is how we uncovered most of our concerns.

Thanks

Mike

Posted : May 29, 2015 3:29 am

pdangelo

(@pdangelo)

Posts: 140

Estimable Member

We are on CPS12 SP8 and meeting all CORE measures for stage 2 in CQR. However, we are having difficulty with CQM's. We are a 5 provider pediatric practice and only a small number of the reports actually apply to our patient population. Unfortunately, many of the CQM reports that would apply to us do not seem to work properly in CQR:

CMS68 Documentation of Current Meds (seems to work randomly, but we don't know why)

CMS50 Closing the Referral Loop (We get denominator but no numerator)

CMS117 Immunization Status (Denominator but only a few in the numerator)

CMS155 Weight/Phys Activity/Nutritional Counseling (Denominators but no numerators)

CMS126 Appropriate Meds for Asthma (No numerator and only one in the denominator)

CMS136 Follow up Care ADHD/meds prescribed (No numerator OR denominator)

I would be happy to review workflows with a similar practice to help with core measures if someone can help us with CQM's!

Posted : May 29, 2015 3:39 am

[email protected]

(@pvassauradclinic-com)

Posts: 32

Eminent Member

Michael,
Is there another thread already going with the oddities you have noticed with the CQR data? If so, I can post what we have discovered there rather than derail this thread. thanks, Paula

Posted : May 29, 2015 3:48 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

Hi Paula,

I had started one back in February with what we had found at that point:

https://centricityusers.com/forum/general-cqr-quirksoddities/

I have a few more I can add and I will update with a new post in there shortly, there may be others I am forgetting as well.

Thanks

Mike

Posted : May 29, 2015 3:55 am

tcross

(@tcross)

Posts: 165

Estimable Member

I also would like to tag along on this one. We are meeting many CQR measures but are still stuck on VDT, patient messaging and TOC summaries being sent electronically. CQM's are hit and miss and it seems to be the same measures peopke have already mentioned with the addition of colonoscopies. I would love to have soem Crystal reports for Stage 2. Does anyone know of any out there that we could load and try out? I do not have Crystal writing capabilities either.
Terry

Posted : May 29, 2015 5:15 am

(@thaulk)

Posts: 131

Estimable Member

We keep getting the message that we have never calculated , I am looking to go to CECity for my reporting needs

Posted : May 29, 2015 9:34 am

chaddix

(@chaddix)

Posts: 177

Estimable Member

We are having issues with 2 specific CQR measures in Stage 2:

Stage2_Core15_Measures1And2: "514" entries in the MUActivityLog table are not counted in either Measure 1 or Measure 2. SPR 63247.
Stage2_Core10: The way CQR calculates denominators and numerators does not match GE's documentation, nor does it match CMS definitions. CPS Support disagrees with my assessment. There is also an issue of document double-counting...basically, a document gets counted once for each time it is signed.

We reported issues with several Stage 1 calculations, but we stopped tracking these once once our providers moved to Stage 2. These may still be issues.

Stage1_Core6: Patients were not counting in numerator, despite having an allergy in the allergy list.
Stage1_Core5B (Electronic Access): Patients were not counting in numerator, despite being signed up for Patient Portal. The specific scenario was when a patient had multiple appointments in the reporting period and was signed up for the Patient Portal during their most recent visit.

Posted : June 1, 2015 4:46 am

ealagow

(@ealagow)

Posts: 28

Eminent Member

Could someone point me to documentation that CMS will allow custom reports for Core Measures for MU2?

We are so frustrated with CQR and completely agree that "The way CQR calculates denominators and numerators does not match GE's documentation, nor does it match CMS definitions."

thanks!

Posted : June 1, 2015 6:26 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

Chaddix - I have a whole host of other things in this thread:

https://centricityusers.com/forum/general-cqr-quirksoddities/

I'd be curious if you are seeing them in CPS as well.

Ealagow - I cannot get the CMS FAQ to load right now but will post the link once I can get in again (I have a few links, can't remember which one is which in my bookmarks).

Posted : June 1, 2015 9:27 am

chaddix

(@chaddix)

Posts: 177

Estimable Member

bruins1986: I responded to some of things you are seeing on the other thread. It looks like these issues are global and not specific to C-EMR or CPS.

Posted : June 1, 2015 10:15 am

[email protected]

(@pvassauradclinic-com)

Posts: 32

Eminent Member

Michael,
It looks like the FAQ is down for all EHR Incentive Program topics. I have not been able to get on all day. I'll open a new thread here if I do not find the answers I am looking for elsewhere.

Posted : June 1, 2015 10:36 am

bruins1986

(@bruins1986)

Posts: 233

Reputable Member

ealagow - here are two links to CMS FAQs that say CMS does not require certified reports for the core or menu measures (but it does for the CQMs):

https://questions.cms.gov/faq.php?id=5005&faqId=3063

https://questions.cms.gov/faq.php?id=5005&faqId=3209

Thanks
Mike

Posted : June 2, 2015 3:50 am

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