Run the Clinical Quality Measures Report

The Clinical Quality Measures report in PCC EHR calculates your clinicians’ performance on CMS Clinical Quality Measures.

Follow the procedure below to use the report.

More About PCMH, CQMs, Meaningful Use Measures and Incentive Programs: For more information, check out the PCMH, CQMs, Measures, and Incentive Programs section of PCC Learn.

CQM Criteria Have Changed: Criteria and qualifying procedures for CQMs have changed. This report is still a useful way to measure how your practice addresses these measures:
• Children Who Have Dental Decay or Cavities
• Appropriate Testing for Children with Pharyngitis
• Chlamydia Screening for Women
• Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
For other CQMs, you should review your activity in the Practice Vitals Dashboard, order reports in the PCC EHR Report Library, or use another method.

Configure Your System and Adjust Chart Policies

The Clinical Quality Measures report depends on charting and coding in PCC EHR. You may need to adjust how you code and chart visits in order for PCC EHR to properly evaluate your CQM percentages.

Read Clinical Quality Measures with PCC EHR to learn more.

Time Period: After your practice makes configuration and workflow changes, you may need to wait 90 days in order for the Clinical Quality Measures report to fully reflect how your office addresses each measure.

Click “Reports” and Select “Clinical Quality Measures”

The Clinical Quality Measures report is in the Reports menu.

Select Measures, Reporting Period, Eligible Professionals, and Report Layout

On the Clinical Quality Measures report criteria screen, you can adjust options for output before you generate the report.

2014 or 2011 Edition: You can select either the 2014 or 2011 Edition CQM rules by clicking on a tab at the top of the screen. Note that the 2011 CQM rules have been retired and that practices can no longer apply for the EHR Medicaid Incentive Program or for PCMH recognition using the 2011 rules.
Limit Measures: By default, the Clinical Quality Measures report will evaluate your practice’s data for the nine CMS recommended pediatric CQMs. You can click “Edit” in the Measures criteria section to limit measures that will appear on the report. These nine measures are appropriate for both the EHR Medicaid Incentive program and for PCMH applications.
Reporting Period: For 2015, your EHR Medicaid Incentive Program application or PCMH application will probably use a 90-day reporting period. For 2016 and beyond, a full calendar year may be required. You can set any 90-day period, any calendar year, or input a custom reporting period.
- Do not use a reporting period that extends before the date you went live with PCC EHR. Some of the data needed to properly calculate CQMs can not be obtained through data conversions.
- If you have added chart note components or made charting policy changes at your practice in order to record data for CQMs, you should use a reporting period after you made those changes.
Eligible Professionals: Click “Edit” in the Eligible Professionals criteria section to select providers for the report. For example, for the EHR Medicaid Incentive Program, you will run reports for professionals that perform at least 20% Medicaid visits. Contact PCC Support for help determining the Medicaid volume of the clinicians at your practice. For PCMH, you should select all providers (NP, PA, MD, DOs, etc.) However, for both PCMH and EHR Medicaid Incentive Program applications, you should use this criteria to exclude generic or “nurse” provider entries.
Report Layout: The EHR Medicaid Incentive program application requires data for each eligible professional. A PCMH recognition application requires a practice aggregate report.

Once you set the report criteria and generate the report, PCC will remember your settings and restore them each time you open the Clinical Quality Measures Report.

Who Did What in PCC EHR?: As you review data for each eligible professional, keep in mind that 2014 Clinical Quality Measure calculations use the “Provider of Encounter” for each visit. The PoE appears at the top of each chart note, and by default is the scheduled provider. 2011 calculations were based on the clinician who signed the visit.

Click “Generate Report”

After you make your selections, click “Generate Report”.

The Clinical Quality Measures report examines details from hundreds or thousands of charts and may take several minutes to run. You may prefer to run it after-hours, when your system is less busy.

Review Report Results

The Clinical Quality Measures report will calculate and display your practice’s numbers for each measure, either as an aggregate report or per-provider.

For each Clinical Quality Measure, you can see the CMS and NQF code, a description of the measure and any components that make up the measure, followed by your practice’s results.

Numerator and Denominator: Most CQM results display a number of patients who meet the requirements or goal of the measure (the “Numerator” column), as well as the total number of patients who were billed a visit code during the reporting period (the “Denominator” column).
Performance Rate: Next, the “Performance Rate” column displays your practice’s percentage for the measure, calculated by dividing the numerator by the denominator.
Exclusions or Exceptions: The final two columns display the total number of any patients who met certain CQM-specific exclusions or exceptions. For example, if a patient was pregnant during the reporting period, they will show up in the Denominator but appear in the Exclusions column instead of the Numerator for the Weight Assessment CQM.

Interpreting Your Results: The philosophical goal of Clinical Quality Measures is to improve them over time. A low score or a zero score does not indicate that your practice or an eligible professional have failed to meet the measure–there is no success threshold. A higher percentage may mean that your practice is doing better at meeting the goals of the measure, but an improved percentage over time is the true goal. One exception to the “higher is better” rule is the “Children Who Have Dental Decay or Cavities” measure, for which a smaller percentage is desirable.

How Do I Chart and Configure PCC EHR to Affect Each Line? How Is Each Line Calculated? What Are the Exceptions and Exclusions?: Clinical Quality Measures compare activity during a visit, including how medical issues are recorded in a chart note, patient prescriptions, etc., with the diagnoses and procedures you record for a visit. For more information on how each line of the Clinical Quality Measure report is calculated, and to learn what changes you can make in your PCC workflow to improve your percentile score, read the Clinical Quality Measures in PCC EHR article.

Optional: Drill-Down to Per-Patient Details

Click “Details” for any measure to review patient-level details for the results.

Details for the report and the selected measure appear at the top. On the left, you can specify what portion of the patient population you wish to review (Numerator, Denominator, or All patients).

Click on any patient on the left to review what occurred for them to be counted in the denominator or the numerator on the right.

By reviewing patient records to see why they were or were not included in a measure’s calculation, you can address potential problems in your patient workflow or PCC configuration that may alter your final percentage.

Optional: Output the Report

Click “Save as PDF” or “Print” to output a copy of the CQM results.

What is eReporting?: Click “eReporting” to create a digital file containing your CQM results in QRDA Category 3 format. Some agencies may support uploading results so you do not have to retype them in order to apply for an incentive program. This feature is in pilot testing. Please consult PCC Support if you’d like to try this feature.

Here are some related articles in Other Pediatric Practice Resources > PCMH, CQMs, Measures, and Incentive Programs > Clinical Tasks > Generate Clinical Reports:

Run Reports in the PCC EHR Report Library
The Report Library in PCC EHR is an expanding suite of reports designed to give you useful and meaningful access to information in the EHR.
How to Chart for Each Clinical Quality Measure in PCC EHR
How can you use PCC EHR to calculate the Clinical Quality Measures (CQM) numbers required for PCMH and other incentive programs? How should you chart, and configure your system, in order to record medical information so that the reports are accurate?
Meet Meaningful Use Measures with PCC
How can you use PCC EHR to meet the statistical Meaningful Use measures required for the second and third year of your ARRA EHR incentive application? How should you chart, and configure your system, in order to record medical information so that your numbers are accurate?
Become a Patient Centered Medical Home (PCMH)
Depending on the state you live in, you can receive per-patient reimbursement from payors by becoming a Patient Centered Medical Home. When you meet PCMH standards, originally designed by the AAP, you help your patients and families gain access to care and you gain additional benefits for your practice.
ARRA Report
The ARRA report calculates Medicaid plan utilization at your practice. You can use it to see the percentage of patient visits that are medicaid or medicaid eligible, broken out by physician. This report is designed to help your office determine if you may qualify for the ARRA incentive program. You can run the report from a command prompt or from a custom Partner window location.
Patient Visit Summary Report
The Patient Visit Summary is an "end-of-visit" clinical summary report. It details everything that happened during an appointment. The report also includes an overview of other patient medical information. You can also customize what appears on the report and configure special components which will include patient instructions and other information.
Run the Meaningful Use Measures Report
The Meaningful Use Measures report calculates your office's performance on the Meaningful Use standards indicated in the EHR Medicaid Incentive Program guidelines and co-referenced in the PCMH requirements. Use this report to see your office's Meaningful Use statistics.
Find and Share Patient Education and Handouts
PCC EHR has built-in access to two libraries of patient education resources. The AAP’s Pediatric Patient Education library and the NLM’s MedlinePlus library give you instant access to handouts and current medical information on a wide range of topics.
Phone Encounter Performance Report
You can use the Phone Encounter Performance report to track phone note response time, report on phone tasks, and gather data for PCMH purposes.
Health Information Summary Report
You can generate a paper or electronic copy of a patient's health record with the Health Information Summary Report.
Patient Lists
PCC EHR can create lists of patients based on complex criteria. You can save those criteria as special reports that you can re-run at any time.
Patient Reminders
PCC EHR can create reminder lists of patients based on complex criteria. You can save those criteria as Patient Reminders that you can re-run at any time, and generate a contact file.
Get Started with Direct Secure Messaging
PCC EHR includes Direct Secure Messaging. Direct Secure Messaging is a communication technology for the transmission and exchange of private health information. Your practice can use Direct Secure Messaging for transitions of care, and patient portal users can use Direct Secure Messaging to send their visit information to other medical practitioners.
Summary of Care Record Report
The Summary of Care Record report produces a C-CDA-formatted chart summary for a patient. Your practice can use the report as a transition of care document. Optionally, if your practice uses Direct Secure Messaging, you can transmit the report to another clinician or practice.
The PCC EHR Audit Log
Use the PCC EHR Audit Log to review details about system events pertaining to a patient's chart.
Vaccine Lot Report
You can run the Vaccine Lot report in PCC EHR, to identify all patients who received a particular vaccine within a date range.
Report on Lab Test Results in PCC EHR
Contents1 Run the Test Results Report2 Customize the Test Results Report3 Schedule the Test Results Report4 When to Use the Test Results Report You can report on lab test results in the Report Library in PCC EHR. Run the Test Results Report In the Report Library in PCC EHR, open the Test Results report from […]
Washington State C-CDA Submission for Apple Care Patients
Use PCC reports and tools to send patient chart records to the Washington Medicaid Link4Health Clinical Data Repository.
Use Orders to Track Clinical Measures for Reporting, Mandates, and Incentive Programs
Whether you are tracking something for PCMH, pay for performance, or another incentive program, you can use an order in PCC EHR to record medical information that meets reporting requirements. Learn how to set up your orders, and special tips and techniques to help your practice workflow.
Create a Custom Report
You can generate and save custom reports and report categories in PCC EHR.
Find and Recall Patients Who Are Overdue for Vaccines
Which 13-year-olds at your practice never came in for an HPV shot? Can you quickly find all the six-year-olds who never made it in for their final IPV, MMR, and Varicella? PCC can find all of your patients that are due or overdue for vaccines and produce customizable reports.
Send and Receive Direct Secure Messages
Contents1 Send a Direct Secure Message to Another Healthcare Provider1.1 Attach a Patient Document to a Direct Secure Message1.2 Attach a File to a Direct Secure Message2 Receive a Direct Secure Message and Add It to a Patient’s Chart2.1 Add a Custom Summary to a Direct Secure Message2.2 Review and Work With a Direct Secure […]
Create a Custom Report
How to use PCC EHR's Report Library to create custom reports.
Restrict Access to Reports in the Report Library
Contents0.1 Reports Without a Category1 Restrict Access to Customize Report and Manage Categories When you want to limit access to certain report categories to one or more user roles, click the “Manage Categories” button in the Report Library window. To manage access, select a category and click the “Edit” button, then select one or more […]
Recall Patients Who Are Overdue for Vaccines
PCC EHR can create custom lists of patients who are overdue for any vaccine, or who are due soon. Watch this video to learn how to use the Overdue Vaccine Recall report.
Schedule Reports in PCC EHR
Contents1 Schedule a Report to Run Automatically2 Preview Results and Save Output Settings3 View Scheduled Report Results4 Edit Scheduled Reports5 Stop and Start Reports6 Delete Scheduled Reports You can schedule reports to run in the future in PCC EHR. Schedule a Report to Run Automatically Use scheduled reports to automate recall lists, billing oversight reporting, […]
Video: Schedule Reports in PCC EHR
Schedule a report to run automatically, periodically
Information Blocking in the 21st Century Cures Act for Pediatric Practices
How should a pediatric practice respond to the new Information Blocking rules in the 21st Century Cures Act? Watch this video to learn about Information Blocking and how the new regulations may impact your practice. You'll get an overview of the legal details, see some real-world examples, and understand what a pediatric practice can do to prepare for the new rules. Presentation File: https://wp.me/a8UHhr-auQ
Information Blocking in the 21st Century Cures Act FAQ
PCC created this FAQ to help pediatric practices learn about Information Blocking in the 21st Century Cures Act.
How to Report on Your Practice’s Use of Provider Relief Funds
If your practice received Provider Relief Fund payments, you may need to report on quarterly revenue loss to indicate your use of those funds. Read this article to learn about a new custom report in your PCC system.
Send, Receive, and Reconcile Direct Secure Messages
Learn how to send, receive, and reconcile Direct Secure Messages, a HIPAA-compliant method in PCC EHR that empowers practices to communicate and share records with other healthcare providers.
Clinical Document Exchange: The Responder Role
Learn how to exchange clinical information with health care providers through Clinical Document Exchange, how to configure settings for patient consent, and how to get started with the Responder Role at PCC.

Related Articles