MIPS eCQMs vs Registry Measures: What’s the difference?

By Susan Moschella. Posted May 04, 2018 in Quality Reporting, MACRA/MIPS Program, Academy

Two of the available options for Eligible Clinicians to submit their Quality measures data to CMS include EHR direct data submission or Qualified Registry data submission. Today, we are going to learn what measures are available in each of those reporting options and how the measures differ.

Electronic Clinical Quality Measures, or eCQMs, are only available for submission through a certified EHR such as Medisolv. “Registry measures,” on the other hand, are only available for submission through a Qualified Registry also like Medisolv. 

Eligible Clinicians may choose to submit any of the 53 eCQMs or 243 Qualified Registry measures listed on the Quality Payment Program (QPP) website.

By choosing six Quality measures from either of these submission methods, you will be well on your way to successfully meeting your MIPS requirements for the Quality category.

Let’s take a look at what makes these two reporting options different and why a clinician may choose one option over the other. 

Capturing MIPS eCQMs vs Registry Measures

The main difference between eCQMs and Registry measures is that eCQMs require structured data to be captured electronically, often at the point of care, while in most cases, Registry measures have some level of additional manual data collection from the medical record often referred to as data abstraction.

For example, with Registry measures, an abstractor can review the patient’s records (electronic and paper documentation) to assess whether the patient has passed or failed the measure. Even if a physician documented in a hand-written note that they prescribed aspirin for the patient, an abstractor could use that documentation to confirm that the patient did pass the Registry measure #0067: Coronary Artery Disease (CAD): Antiplatelet Therapy.

With eCQMs, the clinician documents in a structured field within the Electronic Health Record (EHR), usually as part of a clinical workflow ( e.g., ordering a medication using an electronic order entry system or documents a valid reason for not doing an expected intervention). This data is consumed by the eCQM calculation engine without additional manual data entry.

Below we summarize differences in both types of measures.

MIPS eCQM Process

MIPS-eCQM-Process


MIPS Registry Measure Process

MIPS-Registry-Process

 
Calculating eCQMs vs Registry Measures

In addition to differences in data capture, the specifications and result calculations are also quite different.

Comparing Specifications

The specifications for each measure differ significantly as well. Let’s take a look at the differences between the specifications at a very high-level.

MIPS Registry Description Section

MIPS eCQM Description Section

#0067: Coronary Artery Disease (CAD): Antiplatelet Therapy

CMS122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control

registry description eCQM description

If you compare the descriptions, it all looks pretty similar. Each measure has a name, type, description and rationale. 

Now let’s review the logic.

Registry Specification Logic (Algorithm)

eCQM Specification Logic

#0067: Coronary Artery Disease (CAD): Antiplatelet Therapy

CMS122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control

registry logic eCQM logic

When you get to the logic, it starts to look different. With the Registry measure, a nice visual guides the abstractor through the measure. As you answer yes or no, it will lead you to the correct end result.

In the eCQM logic, you will see what’s called Boolean logic, which guides a computer through the measure logic and places patients into the appropriate result. Data elements in the EHR are mapped to codes. Each line you see in that logic will require a corresponding code to ensure that it’s captured correctly. If there isn’t a code present or if it’s the wrong code or if the documentation is not in the EHR, the patient may fall out of the measure.

Why would an Eligible Clinician choose eCQMs vs Registry measures?

One of the most common reasons Eligible Clinicians choose Registry measures is if there are not enough measures relevant to their specialty to meet the minimum reporting requirement. The down side is continued abstraction burden and lack of timely results to clinicians for performance improvement.

On the flip side, eCQMs (though they may be more difficult to implement) provide near real-time reporting and have less costly ongoing maintenance.

I hope this quick summary of the differences between MIPS eCQM vs Registry measures was helpful. In a future blog, we will explore some other quality reporting options available in the Quality Payment Program (QPP).

If you need help submitting your Quality data using eCQMs, Registry or Web Interface methods, reach out to us today. We can help you with all of your MIPS reporting needs.


WEBINAR:

Wednesday, October 24, 2018
1 p.m. ET | 12 p.m. CT | 10 a.m. PT

QUALITY REPORTING: 2018 AND BEYOND

Tying payments to performance across quality and cost dimensions requires robust measurement and reporting. Hospitals and providers, however, are demanding relief from regulatory burdens including quality reporting. What gives?

In response to both internal needs and external pressures, CMS continues to propose dramatic changes in its Quality Reporting programs. While this session will primarily focus on these hospital and ambulatory changes for quality reporting in 2018, future reporting trends and lessons applicable across the continuum of care will also be discussed. In addition, we’ll share some strategies that will help you to better manage multiple measure types for the major regulatory reporting programs.

Objectives

  • Review 2018 reporting requirements and discuss future trends in quality reporting. 
  • Gain insight into what quality reporting is likely to look like beyond 2018. 
  • Learn strategies to help you stay on top of the complex and changing reporting requirements year after year.


Speaker info:
Dr. Zahid Butt, MD, FACG
Medisolv, President & Chief Executive Officer

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Susan Moschella

Susan Moschella

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