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Type: EC eCQMs
Resolution: Answered
Priority: Moderate
Component/s: None
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Thank you for your questions on Eligible Clinician eCQMs. While we are not able to respond to questions about attribution, in general, the CQL logic is not able to assign attribution to the provider. The measure determines whether the numerator requirements have been met, based on the information in the patient’s EHR. For patient-based measures, while a specific clinician may perform an intervention for a given patient, and by doing so meet the numerator requirements, any clinician who has a qualifying encounter with that same patient, who uses the same EHR and reports on that measure, can also receive credit.

Please find responses to your measure-specific questions below:

CMS117v11 (Childhood Immunization Status), CMS122v11 (Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)), CMS147v12 (Preventive Care and Screening: Influenza Immunization): The measure logic does not require that vaccines or diagnoses be tied to the same clinician who provided the initial population qualifying encounter. For CMS147, the patient can be attributed to the clinician via a qualifying encounter, hemodialysis or peritoneal dialysis, as per measure logic.
CMS145v11 (Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF) less than or equal to 40%): As it relates to the ‘Has History of Cardiac Surgery Prior to Encounter’ definition, the cardiac surgery does not have to be performed by the clinician performing the encounter. Unless there is a specific notation that a procedure, test, or examination should be performed by the same clinician, this is not a requirement. The patient meets the requirement as long as the procedure is documented prior to the encounter.
CMS69v11: The intervention does not need to be performed or ordered by the same provider as the qualifying encounter.
CMS50v11: This measure is clinician specific as the clinician who makes the referral is held accountable for the measure.

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Thank you for your questions on Eligible Clinician eCQMs. While we are not able to respond to questions about attribution, in general, the CQL logic is not able to assign attribution to the provider. The measure determines whether the numerator requirements have been met, based on the information in the patient’s EHR. For patient-based measures, while a specific clinician may perform an intervention for a given patient, and by doing so meet the numerator requirements, any clinician who has a qualifying encounter with that same patient, who uses the same EHR and reports on that measure, can also receive credit. Please find responses to your measure-specific questions below: CMS117v11 (Childhood Immunization Status), CMS122v11 (Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)), CMS147v12 (Preventive Care and Screening: Influenza Immunization): The measure logic does not require that vaccines or diagnoses be tied to the same clinician who provided the initial population qualifying encounter. For CMS147, the patient can be attributed to the clinician via a qualifying encounter, hemodialysis or peritoneal dialysis, as per measure logic. CMS145v11 (Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF) less than or equal to 40%): As it relates to the ‘Has History of Cardiac Surgery Prior to Encounter’ definition, the cardiac surgery does not have to be performed by the clinician performing the encounter. Unless there is a specific notation that a procedure, test, or examination should be performed by the same clinician, this is not a requirement. The patient meets the requirement as long as the procedure is documented prior to the encounter. CMS69v11: The intervention does not need to be performed or ordered by the same provider as the qualifying encounter. CMS50v11: This measure is clinician specific as the clinician who makes the referral is held accountable for the measure.
2024 Performance Period EC eCQMs:

Not measure related
2023 Performance Period EC eCQMs:

CMS0050v11, CMS0122v11
Impact:
Measure outcomes not evaluated correctly

First of all, thank you for taking the time walking these through with us.

In ~~CQM-6625~~, it is stated that a clinician is responsible for closing their own referral loop, which we understand would makes sense for the measure intent.

However, there can be a lot of different data elements in a measure. We are going to need clearer guidance on, how to attribute a clinician to a patient, and given a data element, and how to know whether to check that it is the same clinician (let's call it clinician specific) in the later logic.

For example, for CMS-117, a clinician is attributed to the patient if they have a qualifying encounter with the patient in the initial population. Clearly, we wouldn't expect every vaccination to be done by the same provider.

So our speculation was that only the data elements in the initial population is clinician specific.

But what about the diabetes measures like CMS-122? The clinician needs to have an qualifying encounter with the patient, to meet the initial population. But does the diagnosis needs to be entered by the same provider? The answer is most likely no.

Ok, maybe the initial population was not the only criteria. Maybe it only applies to certain QDM templates, like encounter performed, procedure performed, intervention performed.

Well, let's take a look at some more cases.

CMS-145 vs CMS-147

For CMS-147, part of the initial population is "Hemodialysis During the Measurement Period". That's a procedure performed and that's the only logic other than patient age. So obviously we will use it to determine which clinicians are attributed to the patient.

For CMS-145 though, part of the initial population logic is "Has History of Cardiac Surgery Prior to Encounter". The measure intent was that the encounter needs to be performed by the clinician but the cardiac surgery does not.

How do we know whether a procedure performed needs to be clinician specific?

CMS-50 vs CMS-69

For CMS-50, the initial population has an encounter and an intervention. It sounds like they both need to be performed by the same clinician, and that carries over to numerator, meaning the intervention performed in the numerator is clinician specific.

For CMS-69 though, there is also an intervention performed check in the numerator logic if the patient has high/low BMI. Does that need to be done by the provider from encounter on the initial population?

How do we make these kind of calls?

Our point is not to argue something should or should not count, and not about these specific examples. We are asking for a standardized way for us to tell these kind of distinctions.

If this is measure-specific, include it in the CQL logic, like checking the performer attribute on this procedure object against the encounter object. Or include it somewhere concrete, saying these valuesets in these measures are clinician specific.

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