32.4.2.1.1CMS QPP Important References

32.4.3.0.1QPP Workflow on DQM UI

1. Run FHIR Authored Quality Measures using $evaluate-measure operation and generate results for your desired patient population in FHIR Measure Report resources.

2. Build QPP Quality Reporting per performance year for your respective Organization or Practice by building a measurement-set for your selected specialty and quality program.

   • Select Measure Reports to add to measurement-set for specialty profiles
   • Preview performance metrics by using Pre-Score to simulate CMS scoring

3. Authenticate to CMS using your CMS login or Registry token

4. Submit Reporting to CMS via API.

5. Manage and Edit submitted Reporting.

   • View Submitted reporting
   • Edit or Replace submitted reporting

6. Store and save CMS Submissions in CDR for Provenance

32.4.5.0.0.1Organization Parameter

Organization parameter represents a profile for a qpp-build submitting entity and is leveraged by $qpp-buld to source required identifiers for qpp submission and report building, the key critical pieces used by QPP are the following

• NPI
• TaxID (TIN)
• EntityId

This Organization resource would be referenced by $qpp-build by referencing its id, which in this example below would be organization-1.

This specific example represents how all three identifiers would be represented for an organization so that $qpp-build could locate them. EntityId specifically can be passed in from the operation request or sourced from the Organization identifier field, as shown below.

32.4.5.0.0.1.1Connecting Organization to MeasureReports

32.4.5.0.0.1.2Example Organization Resource

{
   "resourceType" : "Organization",
   "id" : "organization-1",
   "identifier" : [
      {
         "use": "official",
         "type": {
            "coding": [
               {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "XX",
                  "display": "CMS QPP EntityId"
               }
            ]
         },
         "value": "abc123456"
      },
      {
         "use": "official",
         "type": {
            "coding": [
               {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "TAX",
                  "display": "Tax ID Number"
               }
            ]
         },
         "value": "000000001"
      },
      {
         "use": "official",
         "type": {
            "coding": [
               {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "NPI",
                  "display": "National Provider Identifier"
               }
            ]
         },
         "value": "1234567893"
      }
   ],
   "active" : true,
   "type" : [
      {
         "coding" : [
            {
               "system" : "http://terminology.hl7.org/CodeSystem/organization-type",
               "code" : "pay"
            }
         ],
         "text" : "Payer"
      }
   ],
   "name" : "Reporting Payer",
   "telecom" : [
      {
         "system" : "phone",
         "value" : "(+1) 555-555-5555"
      },
      {
         "system" : "email",
         "value" : "hq@acme.org"
      }
   ],
   "address" : [
      {
         "line" : [
            "100 Insurance Avenue"
         ],
         "city" : "Amherst",
         "state" : "MA",
         "postalCode" : "01002",
         "country" : "USA"
      }
   ]
}

32.4.5.0.0.2QualityProgramLibraryId Parameter

The QualityProgramLibraryId references a FHIR Library resource Id and is meant to define a Quality Program Library of all available measures that can be used for CMS QPP submission.

32.4.5.0.0.2.1QualityProgramLibraryId Profile Required Data Points

32.4.5.0.0.2.2QualityProgramLibraryId RelatedArtifacts

• This should contain an entire catalog of CMS QPP authored measures available in CDR for a given performanceYear. This can contain Measures from a variety of programs like (mips, app1, or mvp Id's).
• $qpp-build parameters for programName and submissionMethod will act as the enforcement points to ensure that a compliant report can be built.

32.4.5.0.0.2.3QualityProgramLibraryId RelatedArtifacts Example

{
  "relatedArtifact": [
    {
      "type": "composed-of",
      "display": "CMS130",
      "resource": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003"
    }
  ]
}

32.4.5.0.0.2.4Quality Program Library Full Resource Example

This is an example of a Program Library Resource.

{
   "resourceType": "Library",
   "id": "qpp-quality-program-mips-ehr-1",
   "meta": {
      "profile": [
         "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/quality-program-cqfm"
      ]
   },
   "url": "http://hl7.org/fhir/us/cqfmeasures/Library/ep-ec-quality-program",
   "identifier": [
      {
         "use": "official",
         "system": "http://example.org/fhir/cqi/ecqm/Library/Identifier",
         "value": "Mips Test Quality Program"
      }
   ],
   "extension": [
      {
         "url": "http://hl7.org/fhir/StructureDefinition/cqf-quality-program",
         "valueString": "QPP"
      }
   ],
   "version": "0.1.0",
   "name": "MeasurementSet MIPS EHR Measures",
   "title": "qpp-mips-ehr-program",
   "status": "active",
   "experimental": true,
   "type": {
      "coding": [
         {
            "system": "http://terminology.hl7.org/CodeSystem/library-type",
            "code": "asset-collection"
         }
      ]
   },
   "date": "2019-09-03",
   "publisher": "Smile Digital Health",
   "description": "This library is an example of a quality program specification",
   "approvalDate": "2019-08-03",
   "lastReviewDate": "2019-08-03",
   "relatedArtifact": [
      {
         "type": "composed-of",
         "display": "CMS130",
         "resource": "http://ecqi.healthit.gov/ecqms/Measure/ColorectalCancerScreeningsFHIR|0.0.003"
      },
      {
         "type": "composed-of",
         "display": "CMS124",
         "resource": "http://ecqi.healthit.gov/ecqms/Measure/CervicalCancerScreeningFHIR|0.0.005"
      },
      {
         "type": "composed-of",
         "display": "CMS157",
         "resource": "http://content.alphora.com/fhir/dqm/Measure/CMS157|2.0.0"
      },
      {
         "type": "composed-of",
         "display": "CMS138",
         "resource": "http://content.alphora.com/fhir/dqm/Measure/CMS138"
      }
   ]
}

32.4.5.0.0.2.5Example Measure Resource with CMS MeasureId reference

In order for $qpp-build to correctly produce a CMS QPP report, it requires a Measure Resource with specific identifiers to be populated.

These required identifiers act as the connection between FHIR Measure Report resources passed into the $qpp-build operation, and the CMS specification.

32.4.5.0.0.3EntityType Parameter

• Supported values for entityType parameter for qpp-build are listed below, these values are used to define the type of entity you are submitting to CMS for.

  • individual - One of several MIPS participation options, where MIPS data is collected and submitted on behalf a single clinician (identified by TIN/NPI combination).
  • group - One of several MIPS participation options, where MIPS data is collected, aggregated and submitted on behalf all the clinicians in the TIN.
  • virtualGroup - A participation option available to solo practitioners and practices with 10 or fewer clinicians that allows them to join forces and submit aggregated data for all the clinicians in the TINs.
  • apm - An entity that participates in an Alternative Payment Model or other payer arrangement through a direct agreement with CMS, other payer, or through federal or state law or regulation.
  • subgroup - A subgroup in the Quality Payment Program (QPP) is a group of clinicians within a practice that is used to report MIPS Value Pathways (MVPs).

for more information on what entityType your organization is, reach out to your known CMS contact or representative.

32.4.5.0.0.4EntityId Parameter

• The unique identifier for the virtualGroup, subgroup, and apm entityType associated with the submission. This value should be supplied to you from CMS and can be appended to your qpp json report via this parameter or by storing on Organization resource used in OrganizationId parameter.

32.4.5.0.0.5QPP Structure Type Parameter

• This optional parameter is a way that qpp-build operation can construct different elements of qpp json to conform to a specific workflow need in the submission process.

Initial Report Submission Replace MeasurementSet Replace Measurement

• Submission-- this will force the user to generate reports for each Measure specified in the "Quality Program Profile", and will assume no submission was created before it. If this parameter is left blank, this will be the default behavior of qpp-build operation.

• MeasurementSet-- this will force the user to generate a single MeasurementSet that matches the measures in Specialty MeasurementSet Profile, this will require a single MeasurementSet, so any profile with multiple measurementSets will not work.

  • This operation generates a whole measurementSet with measurements within, as a resource intended to overwrite/replace a fully populated measurementSet posted in CMS.

• Measurement-- this will force the user to generate a single Measurement json body that is inside the "Quality Program Profile", this will only create one measurement resource. This will overwrite existing measurement with the same id and requires the measurementSetId parameter to be populated with the value from CMS server.

  • Main use case is to edit/add/replace existing submission's measurement by replacing it within the measurementSet on CMS server. This avoids resubmitting all elements again.

32.4.5.0.0.6MeasurementSetId Parameter

• This parameter is a CMS sourced value from a posted MeasurementSet and is only required for qpp-build when qppStructureType parameter is set.
• When this value is set for designed use case, it adds it to the qpp json body generated from qpp-build operation.

32.4.5.0.0.7PerformanceYear Parameter

• This parameter represents the performance year that an organization is submitting reporting to CMS for. The value populated for this parameter is used to populate the qpp reporting dates for the year selected and will default the period interval to first day of year and last day of performance-year for the measurmentSet. This value also is used to validate that the reports added into the measureReportIds parameter are from the same year as the performanceYear.
• The format required for this value is YYYY or as an example value 2023, this will store as start of 2023-01-01 and end at 2023-12-31.

32.4.5.0.0.8MeasureReports Parameter

• Once reporting is generated from the $evaluate-measure operation, and an output MeasureReport exists in CDR, you would reference the "id" of the MeasureReport(s) and add to the $qpp-build operation parameter as a comma separated list.

  • For the example below, the "id" that would be used for $qpp-build would be
    • single report =

    measureReportIds=measurereport-QPP-130
    

    • multiple reports =

    measureReportIds=measurereport-QPP-130&measureReportIds=measurereport-QPP-124&measureReportIds=measurereport-QPP-138
    

32.4.5.0.0.8.1MeasureReports Parameter Rules

• These reports populated in this parameter must have membership in the Quality Program Library resource referenced by the parameter qualityProgramLibraryId.
  • Matching is done by Measure canonical url defined in measurementSet to the Measure url in the MeasureReport
  • Reports selected must have a Measurement Period defined in the report that matches year defined in the PerformanceYear parameter.
    • Correct Example
      • MeasurementPeriod on MeasureReport (2023-01-01 - 2023-12-31) matches PerformanceYear '2023'
    • Bad Example
      • MeasurementPeriod on MeasureReport (2023-01-01 - 2024-12-31) matches PerformanceYear '2024'
      • MeasurementPeriod must be within the same year of PerformanceYear

32.4.5.0.0.9Quality Program Parameter

qualityProgram parameter is a required parameter for $qpp-build that allows for passing in the qpp program that you would like to build a report for.

The purpose of this parameter is to enforce compliance of selected Measure Reports in the measureReportIds parameter to meet compliance for a specific cms quality program.

32.4.5.0.0.10Submission Method Parameter

32.4.5.0.1User Rights and Dependencies in CDR

If executing $qpp-build operation from the backend, ensure the user has the correct rights and modules on CDR.

• License -- premium DQM license key is required to use DQM and this operation
• DQM module -- operation is exposed within the DQM module, along with configuration.
• UserRole Fhir -- FHIR Client Super user and above will also allow this to be accessed.
• Operation -- toggle Activate QPP_build toggle inside user management if user is below FHIR_SuperUser role

32.4.6.0.0.1QPP Submission Method Configuration

This configuration is found within the DQM Module under qpp category, the user will be able to change the type of qpp-build output required for performing CMS qpp submissions. This accepts only values of electronicHealthRecord or registry. The default value is electronicHealthRecord.

This means only Measures that are compliant with the chosen submission method are able to be added to the $qpp-build operation for submission.

This also controls behavior of the operation by building either a Submission or MeasurementSet for posting to CMS within the DQM UI.

32.4.6.0.0.2Evaluate Measure Configurations

$qpp-build relies on the output MeasureReport resources that are created from the $evaluate-measure operation and is a configurable to help users identify and correlate to Organization resources used for $qpp-build.

This correlation is especially helpful when building reporting for multiple Providers, Practices, or/and Organizations that may simultaneously store data in the same CDR server. This will allow you to append references to a reporting Organization into MeasureReport resources to delineate which report created belongs to which Organization.

32.4.6.0.0.2.1Default Evaluate Measure Reporter

When running Distributed Evaluate Measure, you have the option to populate a MeasureReport.reporter value by setting this configuration to point at an Organization FHIR resource reference.

32.4.6.0.0.2.2Use Group Resource for Reporter

When this config is enabled, the user will be able to populate MeasureReport.reporter when running Distributed Evaluate Measure with a reference to an Organization sourced from a Group resource used as a subject or practitioner parameter value to represent the subject population.

The operation would take the priority of looking for a pre-defined field on the passed in Group called managingEntity as a reference to extract Organization. If no reference exists, then it will use the Default Reporter config setting instead.

32.4.6.0.0.2.2.1Example Group Resource

Patient Group

{
   "resourceType": "Group",
   "id": "demo-group-patients-1",
   "type": "person",
   "actual": true,
   "name": "Demo Group 1",
   "identifier": [
      {
         "use": "usual",
         "type": {
            "coding": [
               {
                  "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                  "code": "MR",
                  "display": "Medical Record Number"
               }
            ]
         },
         "system": "http://hospital.smarthealthit.org",
         "value": "demo-group-1"
      }
   ],
   "member": [
      {  "entity": {  "reference": "Patient/denom-EXM130" } },
      {  "entity": {  "reference": "Patient/neg-ip-EXM130" } },
      {  "entity": {  "reference": "Patient/numer-EXM130" } }
   ],
   "managingEntity": "Organization/organization-1"
}

32.4.7.0.0.0.1Example Build Submission Request

GET http://localhost:8000/MeasureReport/$qpp-build?organizationId=org-acme-payer-1&qualityProgramLibraryId=QPP-quality-program&measureReportIds=measurereport-QPP-157&measureReportIds=measurereport-QPP-130&measureReportIds=measurereport-QPP-124&performanceYear=2023&entityType=group

32.4.7.0.0.0.2Example Build Submission Response

{
   "measurementSets": [
      {
         "performanceEnd": "2023-12-31",
         "performanceStart": "2023-01-01",
         "programName": "mips",
         "category": "quality",
         "submissionMethod": "electronicHealthRecord",
         "measurements": [
            {
               "measureId": "113",
               "value": {
                  "eligiblePopulation": 2,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 1,
                  "performanceNotMet": 1,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "309",
               "value": {
                  "eligiblePopulation": 2,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 1,
                  "performanceNotMet": 1,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "143",
               "value": {
                  "eligiblePopulation": 27,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 13,
                  "performanceNotMet": 14,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "226",
               "value": {
                  "strata": [
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 10,
                        "performanceNotMet": 0,
                        "eligiblePopulationException": 2,
                        "stratum": "screened"
                     },
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 5,
                        "performanceNotMet": 1,
                        "eligiblePopulationException": 2,
                        "stratum": "overall"
                     },
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 7,
                        "performanceNotMet": 1,
                        "eligiblePopulationException": 4,
                        "stratum": "combinedPopulations"
                     }
                  ],
                  "isEndToEndReported": true
               }
            }
         ]
      }
   ],
   "performanceYear": 2023,
   "entityType": "group",
   "taxpayerIdentificationNumber": "000000001"
}

32.4.7.0.0.0.3Example Build MeasurementSet Request

GET http://localhost:8000/MeasureReport/$qpp-build?organizationId=org-acme-payer-1&qualityProgramLibraryId=QPP-quality-program&measureReportIds=measurereport-QPP-157&measureReportIds=measurereport-QPP-130&measureReportIds=measurereport-QPP-124&performanceYear=2023&entityType=group&qppStructureType=measurementSet

32.4.7.0.0.0.4Example Build MeasurementSet Response

Requires only one measurementSet be provided

{
   "measurementSets": [
      {
         "performanceEnd": "2023-12-31",
         "performanceStart": "2023-01-01",
         "programName": "mips",
         "category": "quality",
         "submissionMethod": "electronicHealthRecord",
         "measurements": [
            {
               "measureId": "113",
               "value": {
                  "eligiblePopulation": 2,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 1,
                  "performanceNotMet": 1,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "309",
               "value": {
                  "eligiblePopulation": 2,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 1,
                  "performanceNotMet": 1,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "143",
               "value": {
                  "eligiblePopulation": 27,
                  "eligiblePopulationExclusion": 0,
                  "performanceMet": 13,
                  "performanceNotMet": 14,
                  "isEndToEndReported": true,
                  "eligiblePopulationException": 0
               }
            },
            {
               "measureId": "226",
               "value": {
                  "strata": [
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 10,
                        "performanceNotMet": 0,
                        "eligiblePopulationException": 2,
                        "stratum": "screened"
                     },
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 5,
                        "performanceNotMet": 1,
                        "eligiblePopulationException": 2,
                        "stratum": "overall"
                     },
                     {
                        "eligiblePopulation": 12,
                        "eligiblePopulationExclusion": 0,
                        "performanceMet": 7,
                        "performanceNotMet": 1,
                        "eligiblePopulationException": 4,
                        "stratum": "combinedPopulations"
                     }
                  ],
                  "isEndToEndReported": true
               }
            }
         ]
      }
   ],
   "performanceYear": 2023,
   "entityType": "group",
   "taxpayerIdentificationNumber": "000000001"
}

32.4.7.0.0.0.5Example Build Measurement Request

requires measurementSetId parameter

GET http://localhost:8000/MeasureReport/$qpp-build?organizationId=org-acme-payer-1&qualityProgramId=QPP-quality-program&measureReportIds=measurereport-QPP-130&performanceYear=2023&entityType=group&qppStructureType=measurement&measurementsetid=1234567

32.4.7.0.0.0.6Example Build Measurement Response

{
  "measurementSetId": "1234567",
  "measureId": "113",
  "value": {
    "eligiblePopulation": 2,
    "eligiblePopulationExclusion": 0,
    "performanceMet": 1,
    "performanceNotMet": 1,
    "isEndToEndReported": true,
    "eligiblePopulationException": 0
  }
}