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QCDR/MIPS

Effortless MIPS Reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow. 

QCDR/MIPS

10 reasons why you should choose OBERD for MIPS reporting

1. Zero staff involvement, after set-up, for data collection and reporting to CMS
2. EMR independent data collection — no more extra “clicks”!
3. Meet 75% of the CPS with patient-reported outcomes (100% with other OBERD features)
4. Real-time dashboard to monitor and optimize performance
5. Pro-active notification of under-performing providers, to help focus your quality-improvement efforts
6. High compliance (over 85%) to form completion, increasing your opportunity for high CPS
7. CMS audit management on your behalf
8. A single data source to report to: CMS, AJRR, AAOS, and any other registry or organization
9. Benchmarking against over 4 million validated patient outcome forms
10. Research-validated data collection forms (license-paid by OBERD)

Talk to an OBERD expert to learn more about MIPS.

OBERD allows you to collect and report patient-reported measures, independent of your EMR, to meet 75% of the MIPS Composite Performance Score. After set-up, data collection and reporting requires no staff involvement! We do it all for you, including managing CMS audits.

Download a free recording of our recent EHR-Independent MIPS Reporting webinar.


Optimizing MIPS : real-time performance measurement

Our MIPS dashboard gives you real-time access to performance scores. We’ll continually monitor and notify you of under-performing providers’, so you can focus your quality-improvement efforts. We want you to exceed the baseline, and take advantage of the $500 million incentive payments set-aside for exceptional performance.

OBERD QCDR SUPPORTED MEASURES

All of the measures below qualify for MIPS credit. Those labeled “Non-MIPS” were developed by OBERD QCDR and approved by CMS for use in the 2017 MIPS reporting program.

  • NON-MIPS MEASURES

    All measures below were developed by OBERD QCDR and approved by CMS, and qualify for 2017 MIPS Reporting Program credit

     

    Post Stroke Outcome and Follow-Up

    TYPE: Outcome

    QUALITY DOMAIN: Effective Clinical Care

    DESCRIPTION: This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the “baseline” measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the “follow-up” measurement)

    NUMERATOR: Number of patients counted in the denominator for whom a follow-up score is obtained which is not less than the baseline score

    DENOMINATOR: Number of patients 18 or older, diagnosed with IS, ICH, or TIA, who received a baseline score, and who are eligible for a follow-up score during the measurement period.

    EXCLUSION: Patients unable or unwilling to provide a follow-up
     

    Health Related Quality of Life: Patient Defined Outcomes

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    DESCRIPTION: The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.

    NUMERATOR: Number of patients counted in the denominator who are asked to rate, on a scale of 0 to 10, the difficulty of performing the activity both before treatment and after treatment, and whose score has improved.

    DENOMINATOR: Number of patients 18 or older who are being treated for an impairment of the ability to perform a self-selected activity of importance to the patient’s quality of life.

    EXCLUSION: None

     

    Inflammatory Bowel Disease: Follow-up and Outcomes

    TYPE: Outcome

    QUALITY DOMAIN: Effective Clinical Care

    Type: Outcome

    DESCRIPTION: This measure is a translation of the recommendations of ICHOM for optimum IBD patient follow-up using an appropriate patient reported outcome (PRO) instrument to measure symptoms and activities of daily living. IBD-Control is such an instrument, available without license or fees provided the original paper is cited in any publication (see Bodger, et al, Gut 2014;63(7):1092-102). This measure requires that adequate disease control is demonstrated.

    NUMERATOR: Number of patients counted in the denominator who were assessed within 3-6 months of a prior assessment, both of which employed IBD-Control or equivalent PRO, and who showed no adverse change in score.

    DENOMINATOR: Number of patients 18 or older with a diagnosis of IBD.

    EXCLUSION: None

     

    Patient Satisfaction: CG-CAHPS Composite Tracking

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Process

    DESCRIPTION: Patient Satisfaction has become a recognized responsibility of the healthcare community that ultimately resides with the EC. This measure is intended to encourage the administration of CG-CAHPS to all patients at each visit and to ensure that attention is focused on the actionable items in the instrument, as summarized in four of the composites: Getting Timely Appointments, Care, and Information; How Well Providers Communicate With Patients; Helpful, Courteous, and Respectful Office Staff; and Follow-up on Test Results. This questionnaire is collected like any other patient reported outcome by the QCDR; it differs from the “CAHPS for MIPS” in that it is much shorter and does not require a special vendor.

    NUMERATOR: Number of patients 18 or older.

    DENOMINATOR: Number of patients counted in the denominator completing at least one CG-CAHPS instrument including responses to the questions comprising the above-mentioned composites.

    EXCLUSION: None

     

    Patient Satisfaction: Tracking Satisfaction Improvement with CG-CAHPS

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Outcome

    DESCRIPTION: This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.

    NUMERATOR: Number of patients who have two or more CG-CAHPS scores

    DENOMINATOR: Number of patients who have two or more CG-CAHPS scores

    EXCLUSION: None

  • MIPS MEASURES

    MIPS # Q001, Q110, Q111, Q113, Q128, Q130, Q134, Q181, Q226, Q236, Q317, Q318, Q373, Q374, Q402, Q412, Q431, Q438

    MIPS Q001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

    Measure Developer/Steward: NCQA

     

    MIPS Q110: Preventive Care and Screening: Influenza Immunization

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

    Measure Developer/Steward: AMA-PCPI

     

    MIPS Q111: Pneumococcal Vaccination Status for Older Adults

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

    Measure Developer/Steward: NCQA

     

    MIPS Q113: Colorectal Cancer Screening

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer

    Measure Developer/Steward: NCQA

     

    MIPS Q128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or duringthe previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter

    Normal Parameters:
    Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q130: Documentation of Current Medications in the Medical Record

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q181: Elder Maltreatment Screen and Follow-Up Plan

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within24 months AND who received cessation counseling intervention if identified as a tobacco user

    Measure Developer/Steward: AMA-PCPI

     

    MIPS Q236: Controlling High Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18 – 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period       

    Measure Developer/Steward: NCQA

     

    MIPS Q317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

    Measure Developer/Steward: QIP/QIO

     

    MIPS 318: Falls: Screening for Future Fall Risk

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

    Measure Developer/Steward: PCPI & NCQA

     

    MIPS Q373: Hypertension: Improvement in Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period

    Measure Developer/Steward: NCQA

     

    MIPS Q374: Closing the Referral Loop: Receipt of Specialist Report

    Type: Process

    Quality Domain: Communication and Care Coordination

    Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Developer/Steward: AMA, LOINC®, LOINC®

     

    MIPS Q402: Tobacco Use and Help with Quitting Among Adolescents

    Type: Process

    Quality Domain: Community / Population Health

    Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

    Measure Developer/Steward: NCQA

     

    MIPS Q412: Documentation of Signed Opioid Treatment Agreement

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Developer/Steward: American Academy of Neurology Institute

     

    MIPS Q431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

    Type: Process

    Quality Domain: Community/ Population Health

    Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Developer/Steward: AMA-PCPI

     

    MIPS Q438: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period:
    • Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
    • Adults aged ≥21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR
    • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

    Measure Developer/Steward: AMA, LOINC®, SNOMED CT®