CMS Measures Management System Blueprint.pdf

8/20/2019 CMS Measures Management System Blueprint.pdf

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A Blueprint

for the

CMS Measures Management System

Version 11.1 August 2015


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Blueprint 11.1 August 2015

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Section 1—Measure Development Concepts

Table of Contents

Table of Contents ................................................................................................................................................................ 1

List of Figures....................................................................................................................................................................... 8

List of Tables

........................................................................................................................................................................ 9

Preface: How to Use the Interactive Blueprint ................................................................................................................... 10

Structure of the Blueprint ................................................................................................................................................ 10

How Sections 1, 2, and 3 Work Together for eMeasure Processes ................................................................................. 10

How to Use the Glossary, Appendices, and Tools ............................................................................................................ 12

How External Resources Are Referenced ......................................................................................................................... 13

How To Formally Submit Changes For Upcoming Versions ............................................................................................ 14

Section 1—Measure Development Concepts ..................................................................................................................... 15

National Quality Strategy ................................................................................................................................................. 15

CMS Quality Strategy ....................................................................................................................................................... 16

Crosswalk Between the National Quality Strategy and the CMS Quality Strategy .......................................................... 17

Chapter 1—The CMS Measures Management System Blueprint .......................................................................................... 19

1.1—Role of the Measure Developer ............................................................................................................................... 21

1.2—Role of the Measure Developer͛s OR .................................................................................................................... 22

1.3—Role of the Measures Manager ............................................................................................................................... 22

1.4—Value Sets Governance ............................................................................................................................................ 23

Chapter 2—Priorities Planning .............................................................................................................................................. 25

2.1—Alignment, Harmonization, and Prioritization ......................................................................................................... 25

2.2—CMS Measure Planning Activities ............................................................................................................................ 27

2.3—Role of the Measure Developer in Priorities Planning............................................................................................. 30

2.4—Role of the Measures Manager in Priorities Planning ............................................................................................. 31

Chapter 3—Stakeholder Input

............................................................................................................................................... 33

3.1—Role of Person and Family (Caregiver) Engagement and Participation ................................................................... 34

3.2—Role of the Technical Expert Panel in Stakeholder Input ........................................................................................ 39

3.3—Role of Public Comment in Stakeholder Input......................................................................................................... 42

Chapter 4—Harmonization ................................................................................................................................................... 45

4.1—Adapted Measures .................................................................................................................................................. 47

4.2—Adopted Measures .................................................................................................................................................. 48

4.3—New Measures ......................................................................................................................................................... 49

Chapter 5—Concepts of Measure Evaluation ....................................................................................................................... 51

5.1—Measure Evaluation Criteria and Subcriteria ........................................................................................................... 52

5.2—Applying Measure Evaluation Criteria ..................................................................................................................... 53

5.3—Report of the Measure Developer͛s Evaluation of the Measures ........................................................................... 54

5.4—Developing and Evaluating the Business Case ......................................................................................................... 55

5.5—Evaluation Considerations for Special Types of Measures ...................................................................................... 61

5.6—Overview of Measure Evaluation Tools ................................................................................................................... 64

Chapter 6—Concepts of Selected Specific Measure Types .................................................................................................... 65

6.1—Cost and Resource Use Measures ........................................................................................................................... 66

6.2—Composite Performance Measures ......................................................................................................................... 67

6.3—Patient-Reported Outcome Measures..................................................................................................................... 69

6.4—Multiple Chronic Conditions Measures ................................................................................................................... 72

Section 2—Measure Lifecycle ............................................................................................................................................ 77

Chapter 1—Measure Conceptualization ............................................................................................................................... 79


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Chapter 1.A.—Information Gathering................................................................................................................................... 81

Chapter 1.B.—Technical Expert Panel ................................................................................................................................... 99

Chapter 1.C.—Public Comment ...........................................................................................................................................

109

Chapter 2—Measure Specification ...................................................................................................................................... 115

2.1—Deliverables ........................................................................................................................................................... 115

2.2—Technical Specification ..........................................................................................................................................

116

2.3—Harmonizing Measure Specifications .................................................................................................................... 139

2.4—Risk-Adjusted Outcome Measures ........................................................................................................................ 140

2.5—Cost Resource Use Measure Technical Specifications ........................................................................................... 155

2.6—Composite Measure Technical Specifications ....................................................................................................... 157

Chapter 3—Measure Testing .............................................................................................................................................. 163

3.1—Deliverables ........................................................................................................................................................... 164

3.2—Alpha and Beta Testing ..........................................................................................................................................

164

3.3—Procedure .............................................................................................................................................................. 167

3.4—Testing and Measure Evaluation Criteria............................................................................................................... 173

3.5—Testing Considerations for Selected Measure Types ............................................................................................. 181

Chapter 4—Measure Implementation ................................................................................................................................

185 4.1—National Quality Forum Endorsement ................................................................................................................... 185

4.2—Measure Selection ................................................................................................................................................. 194

4.3—Measure Rollout .................................................................................................................................................... 198

Chapter 5—Measure Use, Continuing Evaluation, and Maintenance ................................................................................

205

5.1—Measure Production and Monitoring .................................................................................................................... 206

5.2—Measure Update .................................................................................................................................................... 215

5.3—Comprehensive Reevaluation ................................................................................................................................

220

5.4—Ad Hoc Review ....................................................................................................................................................... 227

5.5—Possible Outcomes of Maintenance Reviews ........................................................................................................ 232

Section 3—eMeasure Lifecycle ........................................................................................................................................ 237

eMeasure Components .................................................................................................................................................. 238

Overview of the eMeasure Lifecycle ..............................................................................................................................

240

Chapter 1—eMeasure Conceptualization ...........................................................................................................................

243

1.1—Deliverables ...........................................................................................................................................................

244

1.2—eMeasure Feasibility Assessment .......................................................................................................................... 244

1.3—Information Gathering for eMeasures................................................................................................................... 245

1.4—Additional or Adapted Evaluation Subcriteria for Scientific Acceptability of the eMeasure Properties ...............

246

1.5—Technical Expert Panel/Subject Matter Expert ...................................................................................................... 247

Chapter 2—eMeasure Specification .................................................................................................................................... 249

2.1—Deliverables ...........................................................................................................................................................

249

2.2—JIRA Basics for eCQM Developers .......................................................................................................................... 250

2.3—Develop eMeasure Specifications.......................................................................................................................... 251

2.4—Procedure ..............................................................................................................................................................

253 2.5—eCQM Specifications Review Process ....................................................................................................................

276

2.6—Innovations in eSpecifications ............................................................................................................................... 282

Chapter 3—eMeasure Testing ............................................................................................................................................ 285

3.1—Deliverables ...........................................................................................................................................................

286

3.2—Types of eMeasure Testing .................................................................................................................................... 286

3.3—Phases of eMeasure Testing .................................................................................................................................. 294

3.4—Tools for Testing eMeasures.................................................................................................................................. 295

3.5—Procedure .............................................................................................................................................................. 295

3.6—Testing Challenges ................................................................................................................................................. 297


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Chapter 4—eMeasure Implementation ..............................................................................................................................

299

4.1—Deliverables ........................................................................................................................................................... 300

4.2—Preparing eMeasure Specifications for Public Release and Public Comment ....................................................... 301

4.3—NQF eMeasure Endorsement ................................................................................................................................ 302

4.4—eMeasure Rollout, Implementation, and Publication ...........................................................................................

303

Chapter 5—eMeasure Reporting ........................................................................................................................................ 309

5.1—Deliverables ...........................................................................................................................................................

309

5.2—Quality Reporting Document Architecture (QRDA) Category I ..............................................................................

309

5.3—Quality Reporting Document Architecture (QRDA) Category III ............................................................................ 310

5.4—Procedure .............................................................................................................................................................. 311

5.5—Continued Improvement and Maintenance .......................................................................................................... 312

Chapter 6—eMeasure Use, Continuing Evaluation, and Maintenance ............................................................................... 315

6.1—Deliverables ........................................................................................................................................................... 316

6.2—eMeasure Evaluation and Testing After Implementation ..................................................................................... 317

6.3—Annual Update Process for eMeasures .................................................................................................................

319

6.4—Comprehensive Reevaluation for eMeasures ....................................................................................................... 321

6.5—Ad Hoc Review for eMeasures ............................................................................................................................... 322

Section 4—Tools, Appendices, and Forms ....................................................................................................................... 323

Acronyms and Abbreviations ......................................................................................................................................... 323

Glossary ............................................................................................................................................................................... 325

Appendix A: XML View of a Sample eMeasure....................................................................................................................

347

Population criteria .......................................................................................................................................................... 348

Data criteria .................................................................................................................................................................... 349

Reporting stratification .................................................................................................................................................. 350

Supplemental data elements ......................................................................................................................................... 350

Appendix B: Electronic Specification (eMeasure) ................................................................................................................ 352

Appendix C: eMeasure QA Checklists ..................................................................................................................................

354

Appendix D: eMeasure Review Process Quick Reference ....................................................................................................

356

Appendix E: Time Unit and Time Interval Definitions ..........................................................................................................

357

Appendix F: Time Interval Calculation Conventions ............................................................................................................ 359

Timing relationships with no calculation unit defined ................................................................................................... 362

Other date/time-related calculations using QDM functions

..........................................................................................

363

Appendix G: Proportion Measure Calculations (exclusions, exceptions, and aggregation) ................................................ 364

Appendix H: Continuous Variable and Ratio Measure Calculations ....................................................................................

370

Measure Populations .....................................................................................................................................................

370

Individual Observations .................................................................................................................................................. 372

Measure Aggregate Calculations .................................................................................................................................... 372

Ratio Measure Example ................................................................................................................................................. 373

Measure aggregate calculations ....................................................................................................................................

374

Continuous Variable Measure Example ......................................................................................................................... 375

Appendix I: Harmonization of Inpatient Encounter Value Sets ........................................................................................... 376

Appendix J: Blueprint 11.1 Change Document .................................................................................................................... 379

Business Case Form Instructions ...................................................................................................................................... 384

Project Title: ...................................................................................................................................................................

384

Project Overview: ........................................................................................................................................................... 384

Date: ............................................................................................................................................................................... 384

Measure Name: .............................................................................................................................................................. 384 Blueprint 11.1 August 2015

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Summary: .......................................................................................................................................................................

384

Incidence and prevalence: ............................................................................................................................................. 384

Current performance, including any disparities: ............................................................................................................ 385

Major clinical, functional status and other benefits: ..................................................................................................... 385

Successful intervention is feasible: ................................................................................................................................

385

Costs of clinical care: ...................................................................................................................................................... 385

Complications or untoward effects: ...............................................................................................................................

385 Estimated size and trajectory of anticipated improvement: .......................................................................................... 385

Model and formulas used: .............................................................................................................................................

386

Limitations: ..................................................................................................................................................................... 386

Net benefit: .................................................................................................................................................................... 386

Blank Business Case Form Template ................................................................................................................................ 387

Project Title: ................................................................................................................................................................... 387


Date: ............................................................................................................................................................................... 387

Measure Name: ..............................................................................................................................................................

387

Summary: ....................................................................................................................................................................... 387

Incidence and prevalence: ............................................................................................................................................. 387

Current performance, including any disparities:

............................................................................................................

387 Major clinical, functional status and other benefits: .....................................................................................................

387

Successful intervention is feasible: ................................................................................................................................ 387

Costs of clinical care: ...................................................................................................................................................... 387

Complications or untoward effects: ............................................................................................................................... 388

Estimated size and trajectory of anticipated improvement:

..........................................................................................

388

Model and formulas used: ............................................................................................................................................. 388

Limitations: ..................................................................................................................................................................... 388

Net benefit: .................................................................................................................................................................... 388

Call for Measures Web Posting ........................................................................................................................................ 389

Project Title: ................................................................................................................................................................... 389

Dates: ............................................................................................................................................................................. 389

Project Overview: ...........................................................................................................................................................

389 Project Objectives: ......................................................................................................................................................... 389

Instructions: ................................................................................................................................................................... 389

Measure Information Form Instructions .......................................................................................................................... 390

Measure Name ...............................................................................................................................................................

390

Introduction Tab ............................................................................................................................................................. 390

NQF Conditions Tab........................................................................................................................................................ 390

Specifications Tab ........................................................................................................................................................... 391

Blank Measure Information Form Template .................................................................................................................... 401

Project Title: ................................................................................................................................................................... 401


Date: ............................................................................................................................................................................... 401

Measure Name ...............................................................................................................................................................

402

Descriptive Information ................................................................................................................................................. 402

Measure Specifications .................................................................................................................................................. 402

Measure Justification Form Instructions .......................................................................................................................... 403

Measure Name ............................................................................................................................................................... 403

Type of Measure ............................................................................................................................................................ 403

Importance Tab ..............................................................................................................................................................

403

Scientific Acceptability Tab ............................................................................................................................................ 411

Feasibility Tab ................................................................................................................................................................. 419


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Usability and Use Tab .....................................................................................................................................................

420

Related and Competing Measures Tab .......................................................................................................................... 421

Additional [Information] Tab .......................................................................................................................................... 422

Blank Measure Justification Form Template .................................................................................................................... 424

Project Title: ................................................................................................................................................................... 424


Date: ...............................................................................................................................................................................

424

Measure Name ...............................................................................................................................................................

424

Type of Measure ............................................................................................................................................................ 424

Importance ..................................................................................................................................................................... 424

Scientific Acceptability ................................................................................................................................................... 426

Feasibility ....................................................................................................................................................................... 428

Usability and Use ............................................................................................................................................................ 428

Related and Competing Measures ................................................................................................................................. 428

Additional Information ................................................................................................................................................... 428

Measure Evaluation Criteria and Instructions .................................................................................................................. 430

1. Evidence, Performance Gap, and Priority (Impact)—Importance to Measure and Report: ...................................... 430

2. Reliability and Validity—Scientific Acceptability of Measure Properties: .................................................................. 434

3. Feasibility: ..................................................................................................................................................................

441

4. Usability and Use: ....................................................................................................................................................... 444

5. Comparison to Related or Competing Measures: ...................................................................................................... 446

Blank Measure Evaluation Report Template .................................................................................................................... 448

Project Title: ................................................................................................................................................................... 448


Date: ............................................................................................................................................................................... 448

Measure Name: ..............................................................................................................................................................

448

Measure Set (or Setting): ............................................................................................................................................... 448

Measure Developer: ....................................................................................................................................................... 448

1. Evidence, Performance Gap, and Priority (Impact)—Importance to Measure and Report ....................................... 448

2. Reliability and Validity—Scientific Acceptability of Measure Properties ................................................................... 449

3. Feasibility

....................................................................................................................................................................

450

4. Usability and Use ........................................................................................................................................................ 450

5. Comparison to Related or Competing Measures ....................................................................................................... 451

Preliminary Recommendation for Endorsement ........................................................................................................... 451

Public Comment Call Web Posting ................................................................................................................................... 453

Project Title: ................................................................................................................................................................... 453

Dates: .............................................................................................................................................................................

453


Project Objectives: ......................................................................................................................................................... 453

Documents and Measures for Comment: ...................................................................................................................... 453

Expiration Notice: ........................................................................................................................................................... 453

Project Specific Instructions: ..........................................................................................................................................

453

Public Comment Summary Web Posting .......................................................................................................................... 454

Project Title: ................................................................................................................................................................... 454

Dates: .............................................................................................................................................................................

454



Comment Summary: ...................................................................................................................................................... 454

Expiration Notice:

...........................................................................................................................................................

454

Public Comment Summary Report Template ................................................................................................................... 455

Project Title: ................................................................................................................................................................... 455


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Dates: .............................................................................................................................................................................

455



Information About the Comments Received: ................................................................................................................ 455

Stakeholder Comments—General and Measure-Specific ..............................................................................................

455

Preliminary Recommendations ...................................................................................................................................... 455

Overall Analysis of the Comments and Recommendations ...........................................................................................

455

Technical Expert Panel Call for TEP Web Page Posting ..................................................................................................... 457

Project Title: ................................................................................................................................................................... 457

Dates: ............................................................................................................................................................................. 457



TEP Requirements: ......................................................................................................................................................... 457

TEP Expected Time Commitment: .................................................................................................................................. 458

Required Information: .................................................................................................................................................... 458

Technical Expert Panel (TEP) Nomination Form Template ............................................................................................... 459

Project Title: ................................................................................................................................................................... 459


Project Objectives: .........................................................................................................................................................

459



Instructions: ................................................................................................................................................................... 459

Applicant/Nominee Information (Self-Nominations Are Acceptable): .......................................................................... 461

Person Recommending the Nominee: ........................................................................................................................... 461

!pplicantNominee͛s Disclosure. ................................................................................................................................... 462

!pplicantNominee͛s !greement. ................................................................................................................................. 462

Technical Expert Panel Composition (Membership) List Template ................................................................................... 463

Project Title: ................................................................................................................................................................... 463

Dates: ............................................................................................................................................................................. 463


Project Overview: ...........................................................................................................................................................

463

Technical Expert Panel Composition (Membership) List Web Page Posting ..................................................................... 464

Project Title: ................................................................................................................................................................... 464

Dates: .............................................................................................................................................................................

464

Documents: .................................................................................................................................................................... 464



464




Technical Expert Panel Charter Template ........................................................................................................................ 466

Project Title: ...................................................................................................................................................................

466 Dates: ............................................................................................................................................................................. 466



466

TEP Objectives: ............................................................................................................................................................... 466

Scope of Responsibilities: ............................................................................................................................................... 466

Guiding Principles: .......................................................................................................................................................... 466

Estimated Number and Frequency of Meetings: ...........................................................................................................

466

Date Approved by TEP: ................................................................................................................................................... 466

TEP Membership: ........................................................................................................................................................... 467


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Expiration Notice:

...........................................................................................................................................................

467

Technical Expert Panel Summary Web Page Posting ........................................................................................................ 468

Project Title: ................................................................................................................................................................... 468

Dates: .............................................................................................................................................................................

468

Documents: .................................................................................................................................................................... 468



468

Expiration Notice:

...........................................................................................................................................................

468


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List of Figures

Figure 1: Glossary Definition Pop-up for Terms

......................................................................................................................... 12

Figure 2: Navigating PDF Bookmarks ......................................................................................................................................... 13

Figure 3: Navigation Pane Activation ......................................................................................................................................... 13

Figure 4: External Hyperlinks ..................................................................................................................................................... 14 Figure 5: CMS Measures Management System Model .............................................................................................................. 20

Figure 6: CMS Priorities Planning and Measure Selection ......................................................................................................... 27

Figure 7: Applying Measure Evaluation Criteria ........................................................................................................................ 53

Figure 8: Inputs and Uses for the Business Case ....................................................................................................................... 57

Figure 9: MMS Business Case Best Practices ............................................................................................................................. 59

Figure 10: Relationship Between Resource Use, Value, and Efficiency ..................................................................................... 67

Figure 11: Flow of the Measure Lifecycle .................................................................................................................................. 78

Figure 12: Flow of the Measure Lifecycle - Measure Conceptualization ................................................................................... 79

Figure 13: Information Gathering .............................................................................................................................................. 81

Figure 14: The Posting Process .................................................................................................................................................. 82

Figure 15: Flow of the Measure Lifecycle - Measure Specification ......................................................................................... 115

Figure 16: Structure Process Outcome Relationship ............................................................................................................... 140

Figure 17: Example of ROC Curves

...........................................................................................................................................

153

Figure 18: Flow of the Measure Lifecycle - Measure Testing .................................................................................................. 164

Figure 19: Overview of Measure Testing ................................................................................................................................. 168

Figure 20: Flow of the Measure Lifecycle - Measure Implementation .................................................................................... 185

Figure 21: Measure Submission ............................................................................................................................................... 187

Figure 22: Overview of the Measure Rollout Process .............................................................................................................. 199

Figure 23: Flow of the Measure Lifecycle - Measure Use, Continuing Evaluation, and Maintenance .................................... 206

Figure 24: Overview of the Measure Monitoring Process ....................................................................................................... 207

Figure 25: Measure Review Cycle Timeline ............................................................................................................................. 215

Figure 26: eMeasure Icon ........................................................................................................................................................ 238

Figure 27: eMeasure Lifecycle ................................................................................................................................................. 241

Figure 28: eMeasure Conceptualization Tools and Stakeholders ............................................................................................ 243

Figure 29: eMeasure Specification Tools and Stakeholders ....................................................................................................

249 Figure 30: eMeasure Specification Development Process....................................................................................................... 254

Figure 31: Vision for Robust Value Set Management .............................................................................................................. 271

Figure 32: eMeasure Testing Tools and Stakeholders ............................................................................................................. 286

Figure 33: eMeasure Implementation Tools and Stakeholders ............................................................................................... 300

Figure 34: QRDA Category I Sample Report ............................................................................................................................. 310

Figure 35: QRDA Category III Sample Report ........................................................................................................................... 311

Figure 36: eMeasure Use, Continuing Evaluation, and Maintenance Key Stakeholders ......................................................... 316

Figure 37: Annual Update Process for eMeasures...................................................................................................................

321

Figure 38: Proportion Measure Populations............................................................................................................................ 364

Figure 39: Ratio Measure Populations ..................................................................................................................................... 370

Figure 40: Continuous Variable Measure Populations ............................................................................................................ 371


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List of Tables

Table 1: Crosswalk between Sections 2 and 3 ........................................................................................................................... 11

Table 2: National Quality Strategy and CMS Quality Strategy ................................................................................................... 17

Table 3: Harmonization Decisions During Measure Development ............................................................................................ 47

Table 4: Environmental Scan Best Practices .............................................................................................................................. 84 Table 5: Attributes of Risk Adjustment Models .......................................................................................................................

143

Table 6: Types of Composite Measure Scoring ........................................................................................................................ 158

Table 7: Features of Alpha and Beta Testing ........................................................................................................................... 165

Table 8: Harmonization Decisions during Measure Maintenance ........................................................................................... 213

Table 9: Extent of Measure Evaluation as a Function of Prior Comprehensive Evaluation and Measure Use ........................

224

Table 10: CMS Criteria for Measure Disposition ...................................................................................................................... 233

Table 11: eCQM Metadata....................................................................................................................................................... 256

Table 12: Diagnoses Available for Use in eCQMs .................................................................................................................... 262

Table 13: Conventions for Constructing Age Logic .................................................................................................................. 263

Table 14: ONC HIT Standards Committee Recommended Vocabulary Summary ................................................................... 265

Table 15: ONC HIT Standards Committee Transition Vocabulary Standards Summary and Plan ............................................ 266

Table 16: Allergy and Intolerance Value Set Naming Convention ........................................................................................... 267

Table 17: Quality Data Model Categories With ONC HIT Standards Committee Recommended Vocabularies ......................

267

Table 18: Measure Populations Based on Type of Measure Scoring ....................................................................................... 271

Table 19: Value Set Review Areas and Remedial Actions ........................................................................................................ 278

Table 20: Sample eMeasure Identifier ..................................................................................................................................... 303

Table 21: Sample File Naming .................................................................................................................................................. 305

Table 22: Application of Evaluation Methods .......................................................................................................................... 317

Table 23: Example of XML View ............................................................................................................................................... 347

Table 24: Sample Electronic Specification ............................................................................................................................... 352

Table 25: Logic Review Checklist ............................................................................................................................................. 354

Table 26: Clinical Review Checklist .......................................................................................................................................... 355

Table 27: Naming File Attachments ......................................................................................................................................... 356

Table 28: Comment Boxes ....................................................................................................................................................... 356

Table 29: Time Unit and Time Interval Definitions ..................................................................................................................

357 Table 30: Time Interval Calculation Conventions .................................................................................................................... 359

Table 31: Harmonization of Inpatient Encounter Value Sets ................................................................................................... 376


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Preface: How to Use the Interactive Blueprint

Structure of the Blueprint

The Blueprint is divided into four sections. The first section contains measure development

concepts, the second describes procedural steps for measure development and maintenance, the

third covers procedural information specific to eMeasures, and the fourth is a collection of tools

and forms to be used during the measure lifecycle. Below is a more detailed explanation of each

section of the Blueprint:

Section 1—Measure Development Concepts—covers concepts that apply throughout the

measure lifecycle and provides background and a more in-depth description of those

concepts. This material is not repeated in the procedure sections but is referenced

wherever applicable.

Section 2—Measure Lifecycle—describes the procedural steps necessary to develop and

maintain a measure. Section 3—eMeasure Lifecycle—is constructed parallel to Section 2 because it also

describes measure development and maintenance procedures, but material in this section

is specific to eMeasures. The section references conceptual material from Section 1 and

procedural material from Section 2 where they apply to eMeasures.

Section 4—Tools, Appendices, and Forms—contains all of the tools, appendices, and forms

referenced in the Blueprint. It also contains a glossary and a list of acronyms used in the

Blueprint.

The Blueprint is now designed primarily as an electronic document with navigation bookmarks and

internal and external hyperlinks. Resources and forms are referenced throughout the Blueprint

where they are required, and key terms are linked to their appropriate glossary entries. Any text

formatted in blue represents an internal or external hyperlink.

How Sections 1, 2, and 3 Work Together for eMeasure Processes

Due to the increased use of eMeasures in CMS quality programs, the eMeasure Specification

section from previous editions of the Blueprint has been expanded to cover the complete

eMeasure lifecycle from development through maintenance. The concepts of measure

development and maintenance covered in Section 1 are linked to the procedures for general

measure development and maintenance in Section 2, and are referenced with the specifics of

eMeasure development and maintenance covered in Section 3.

Section 1 describes concepts that apply throughout the measure lifecycle. Where the concepts are

used procedurally, they are referenced to the appropriate information in sections 2 and 3. Section

2—Measure Lifecycle and Section 3—eMeasure Lifecycle are structured in a parallel manner

because many aspects of the process are used regardless of whether the measure is based on

paper medical records or an electronic health record. These common processes are not repeated

for both types of measures, but the topics are referenced wherever needed and linked to the

procedure description. The material in Section 3 covers procedures for all types of eMeasures


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including new (de novo), retooled (respecified), and reengineered (adapted) eMeasures, through

all phases of the eMeasure Lifecycle. General procedures for Measure Conceptualization, Measure

Specification, Measure Testing, Measure Implementation, and Measure Use and Continuing

Evaluation are not repeated in Section 3, but links are provided back to the more in-depth

discussion of the general processes in Section 2. Table 1 below provides a crosswalk between

Sections 2 and 3.

Table 1: Crosswalk between Sections 2 and 3

Section 2—Measure Lifecycle Section 3—eMeasure Lifecycle

Chapter 1—Measure Conceptualization Chapter 1—eMeasure Conceptualization

Chapter 1.A.—Information Gathering 1.1—Deliverables

Chapter 1.B.—Technical Expert Panel 1.2—eMeasure Feasibility Assessment

Chapter 1.C.—Public Comment 1.3—Information Gathering for eMeasures

1.4— Additional or Adapted Evaluation Subcriteria for

Scientific Acceptability of the eMeasure Properties

1.5—Technical Expert Panel/Subject Matter Expert

Chapter 2—Measure Specification Chapter 2—eMeasure Specification

2.1—Deliverables 2.1—Deliverables

2.2—Technical Specification 2.2—JIRA Basics for eCQM Developers

2.3—Harmonizing Measure Specifications 2.3—Develop eMeasure Specifications

2.4—Risk-Adjusted Outcome Measures 2.4—Procedure

2.5—Cost Resource Use Measure Technical 2.5—eCQM Specifications Review Process

Specifications 2.6—Innovations in eSpecifications

2.6—Composite Measure Technical Specifications

Chapter 3—Measure Testing Chapter 3—eMeasure Testing

3.1—Deliverables 3.1—Deliverables

3.2—Alpha and Beta Testing 3.2—Types of eMeasure Testing (data element, logic,

3.3—Procedure etc.)

3.4—Testing and Measure Evaluation Criteria

3.3—Phases of eMeasure Testing 3.5—Testing Considerations for Selected Measure 3.4—Tools for Testing eMeasures (Bonnie, Cypress)

Types 3.5—Procedure

3.6—Testing Challenges

Chapter 4—Measure Implementation

4.1—National Quality Forum Endorsement

4.2—Measure Selection

4.3—Measure Rollout

Chapter 4—eMeasure Implementation

4.1—Deliverables

4.2—Preparing eMeasure Specifications for Public

Release and Public Comment

4.3—NQF eMeasure Endorsement

4.4—eMeasure Rollout, Implementation, and

Publication

Chapter 5—eMeasure Reporting 5.1—Deliverables

5.2—Quality Reporting Document Architecture (QRDA)

Category I

5.3—Quality Reporting Document Architecture (QRDA)

Category III

5.4—Procedure

5.5—Continued Improvement and Maintenance


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Section 2—Measure Lifecycle Section 3—eMeasure Lifecycle

Chapter 5—Measure Use, Continuing Evaluation, and

Maintenance

5.1—Measure Production and Monitoring

5.2—Measure Update

5.3—Comprehensive Reevaluation

5.4—Ad Hoc Review

5.5—Possible outcomes of maintenance reviews

Chapter 6—eMeasure Use, Continuing Evaluation, and

Maintenance

6.1—Deliverables

6.2—eMeasure Evaluation and Testing After

Implementation

6.3—Annual Update Process for eMeasures

6.4—Comprehensive Reevaluation for eMeasures

6.5—Ad Hoc Review for eMeasures

Navigating between Sections 1, 2, and 3 by clicking on the hyperlinks will take the user to key

relevant information in the other appropriate section. This information may include further details

about the topic that were discussed in another section and are not repeated.

How to Use the Glossary, Appendices, and Tools

Definitions are provided for terms used throughout the Blueprint. The terms are included in the

Glossary, but they are also linked so that when the cursor hovers over the word, a short definition

pops up as illustrated in Figure 1: Glossary Definition Pop-up for Terms.

Figure 1: Glossary Definition Pop-up for Terms

References to appendices or forms located in Section 4 also include an internal hyperlink. When a

form is required or when an appendix is referenced, the hyperlinked text is formatted in blue.

Pressing the keyboard ͞trl͟ button and left clicking on the text will bring the reader to the

appropriate section, appendix, form, or other resource within the Blueprint. To return to the

original place in the document, press the Alt key and the left arrow together either in Word or in

the PDF version.

When viewed as a PDF, the bookmarks at the left of the screen correspond to the sections,

chapters, and subheadings listed in the Table of Contents. Clicking on the icon with the ribbon

reveals the bookmarks as depicted in Figure 2: Navigating PDF Bookmarks.


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Figure 2: Navigating PDF Bookmarks

These bookmarks can also be viewed in the Word document if the Navigation Pane is activated

from the View menu tab as illustrated in Figure 3: Navigation Pane Activation.

Figure 3: Navigation Pane Activation

Using either the Navigation Pane or the PDF bookmarks, the reader can move easily between

sections of interest within the Blueprint.

How External Resources Are Referenced

References to documents or Web pages available online are linked in the text. Pressing the

keyboard ͞trl͟ button and left -clicking on the hyperlinked blue text will connect the user to the

selected location. To reveal the destination URL, hover the cursor over the hyperlinked blue text.

The full URL is also spelled out in a corresponding footnote. Figure 4 depicts an external hyperlink.


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Figure 4: External Hyperlinks

How To Formally Submit Changes For Upcoming Versions

Recommendations for changes to the content, structure or organization of the Blueprint are

welcomed. Please submit all suggestions to the MMS support mailbox

([email protected]). Please include specifics about the recommended change, including

the:

Version of the Blueprint being referenced

Relevant section, chapter number, and title

Page number

Relevant text to modify, if applicable

New text to add, if applicable

Rationale for change

Point of contact information

Recommended changes will be accepted year-round, and incorporated into the next proximate cyclical

review of the document.


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mailto:[email protected]:[email protected]:[email protected]:[email protected]


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In response to an ever-increasing demand for quality measures, the Centers for Medicare &

Medicaid Services (CMS) has developed a standardized system for developing and maintaining the

quality measures used in its various quality initiatives and programs. Known as the Measures

Management System(MMS),1 CMS-funded measure developers (or contractors) should follow this

core set of business processes and decision criteria when developing, implementing, and

maintaining quality measures. The primary goal of the Measures Management System is to

provide information to measure developers to help them produce high-caliber quality measures

that are appropriate for accountability. This manual, the CMS Measures Management System

Blueprint, Version 11.1 (the Blueprint), documents the full Measures Management System core set

of business processes.2

National Quality Strategy

CMS selects measures to develop and implement based on several key inputs, most important ofwhich is the National Quality Strategy. The Patient Protection and Affordable Care Act of 2010,

commonly called the Affordable Care Act (ACA), 3 seeks to increase access to high-quality,

affordable healthcare for all Americans. Section 3011 of the ACA requires the Secretary of the

Department of Health and Human Services (DHHS) to establish a National Strategy for Quality

Improvement in Health Care (the National Quality Strategy) that sets priorities to guide this effort

and includes a strategic plan for how to achieve it. The initial National Quality Strategy established

three aims and six priorities for quality improvement.

The three aims are:

Better care.

Healthy people/healthy communities.

Smarter spending.

The six priorities are:

Making care safer by reducing harm caused in the delivery of care.

Ensuring that each person and his or her family (caregivers) are engaged as partners in their

care.

Promoting effective communication and coordination of care.

Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

Working with communities to promote wide use of best practices to enable healthy living.

1 Centers for Medicare & Medicaid Services. Measures Management System. Available at: http://www.cms.gov/Medicare/Quality-Initiatives

Patient-Assessment-Instruments/MMS/. Accessed on: May 6, 2015.2 Centers for Medicare & Medicaid Services. Measures Management System: Blueprint. Available at: https://www.cms.gov/Medicare/Quality

Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.html. Accessed on: May 6, 2015.3 111th Congress of the United States. Patient Protection and Affordable Care Act , 42 U.S.C & 18001 (2010). United States Government Printing

Office. Available at: http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf . Accessed on: May 6, 2015.


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http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiativeshttps://www.cms.gov/Medicare/Qualityhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiativeshttps://www.cms.gov/Medicare/Qualityhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdfhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.htmlhttp://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/


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Making quality care more affordable for individuals, families, employers, and governments

by developing and spreading new healthcare delivery models.4

The National Quality Strategy's first annual progress report to Congress,5 published in April 2012,

elaborated on these six priorities and established long-term goals and national tracking measures

to monitor quality improvement progress. The second annual progress report to Congress,published in July 2013, updated results of public and private payers͛ collaborative efforts to align

their quality measures͛ progress against the national tracking measures/ 6

At the DHHS level, the Secretary has articulated Delivery System Reform goals. These goals focus

on how Medicare and other payers pay providers, deliver care and distribute information, to

achieve a future state that is patient-centered, provides incentives for patient outcomes, is

sustainable, emphasizes coordinated care and shared decision-making with patients and relies on

transparency of quality and cost information. This future state promotes value-based payment

systems including value-based purchasing, Accountable Care Organizations, episode-based

payments and Patient-Centered Medical Homes. During January 2015, DHHS set internal goals for

value-based payments within the Medicare FFS system and invited private sector payers to matchor exceed DHHS goals:

Goal 1: 30% of Medicare payments are tied to quality or value through alternative payment

models by the end of 2016, and 50% by the end of 2018.

Goal 2: 85% of all Medicare fee-for-service payments are tied to quality or value by the end

of 2016, and 90% by the end of 2018.

CMS Quality Strategy

The CMS Quality Strategy pursues and aligns with the three broad aims of the National Quality

Strategy as well as Delivery System Reform payment goals. Like the National Quality Strategy, the

CMS Quality Strategy7 was developed through a participatory, transparent, and collaborative

process that included the input of a wide array of stakeholders. CMS͛s vision is to optimize health

outcomes by improving clinical quality and transforming the health system. The CMS Quality

Strategy pursues and aligns with the three broad aims of the National Quality Strategy and its six

priorities. Each of these priorities has become a goal in the CMS Quality Strategy. In addition, CMS

has developed four foundational principles: eliminate racial and ethnic disparities, strengthen

infrastructure and data systems, enable local innovations, and foster learning organizations.

4 Department of Health and Human Services, Agency for Health Research and Quality, National Quality Strategy. Working For Quality . Available at:

http://www.ahrq.gov/workingforquality/. Accessed on: May 6, 2015.5 Department of Health and Human Services. Agency for Health Research and Quality, National Quality Strategy. 2011 Report to Congress: National

Strategy for Quality Improvement in Health Care. Mar 2011. Available at: http://www.ahrq.gov/workingforquality/nqs/nqs2011annlrpt.htm.

Accessed on: May 6, 2015.6 Department of Health and Human Services, Agency for Health Research and Quality, National Quality Strategy. 2012 Annual Progress Report to

Congress National Strategy for Quality Improvement in Health Care . Available at:

http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.htm. Accessed on: May 6, 2015.7 Department of Health and Human Services, Centers for Medicare & Medicaid Services. CMS Quality Strategy 2013 —Beyond . Available at:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Quality

Strategy.pdf. Accessed on: May 15, 2015.


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