Centers for Medicare & Medicaid Services
CMS eXpedited Life Cycle (XLC)
Quality Measures Assessment Tool (QMAT)
User Manual
Version 0.2
09/24/2013
Document Number: QMAT-UM-01
Contract Number: HHSM-500-2010-0019I, HHSM-500T0002
QMAT User Manual
Table of Contents
Table of Contents
Version History ..................................................................................................... vii
1. Introduction......................................................................................................... 8
2. Overview ............................................................................................................. 9
2.1 Conventions ....................................................................................................... 10
2.2
Cautions & Warnings .................................................................................... 10
3. Getting Started.................................................................................................. 11
3.1 Set-up Considerations ....................................................................................... 11
3.1.1 General Set-up Considerations................................................................ 11
Windows ............................................................................................................. 11
Mac OS .............................................................................................................. 11
Linux 11
3.1.2 Section 508 Compliance / Accessibility.................................................... 11
3.2 User Access Considerations .............................................................................. 11
3.3 Accessing the System ........................................................................................ 12
3.3.1 Signing Into the Portal ............................................................................... 13
3.3.2 User ID and Password ............................................................................. 15
3.4 Exiting the System ............................................................................................. 27
4.0 Using the System ........................................................................................... 28
4.1 QMAT Home Page............................................................................................. 28
4.1.1 Data Upload Link ....................................................................................... 29
4.1.2 Data Entry Link .......................................................................................... 29
4.1.3 Data Submission Link ................................................................................ 29
4.1.4 Measures Specs Link ................................................................................ 29
4.1.5 Help Docs Link .......................................................................................... 30
4.1.6 System Notification .................................................................................... 30
4.1.7 About QMAT .............................................................................................. 30
4.1.8 Help Desk .................................................................................................. 30
4.1.9 Completion Summary ................................................................................ 30
4.2 Data Upload ....................................................................................................... 31
4.2.1 Filter Files by Date Range ......................................................................... 35
4.2.2 Generate Reports ...................................................................................... 35
4.3 Data Entry .......................................................................................................... 42
4.3.1 Main Menu Bar .......................................................................................... 43
<Place holder for the ACO Info Bar> .................................................................. 43
4.3.2 Data Entry Bar ........................................................................................... 43
Figure 4-3.2 Data Entry Bar ................................................................................ 43
4.3.3 Patient Record ........................................................................................... 52
4.3.4 Consecutively Completed & Confirmed ..................................................... 83
4.4
Data Submission ........................................................................................... 86
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4.5 Measures Specs ................................................................................................ 87
4.6 Help Docs .......................................................................................................... 87
4.7 QMAT BI Reports............................................................................................... 87
4.7.1 Completion Status Report.......................................................................... 88
4.7.2 Pre-filled Comparison Report .................................................................... 90
4.7.3 Beneficiary Summary Report ..................................................................... 91
ACO Overall Status Report ................................................................................ 91
5. Troubleshooting & Support ............................................................................. 93
5.1 Error Messages.................................................................................................. 93
5.2 Support .............................................................................................................. 93
Acronyms .............................................................................................................. 94
Glossary ................................................................................................................ 96
Record of Changes ............................................................................................... 98
Approvals .....................................................................Error! Bookmark not defined.
List of Figures
Figure 3-3 CMS.gov | Enterprise Portal Home Page .............................................. 12
Figure 3-4 CMS .gov | Enterprise Portal Terms and Conditions Page .................... 13
Figure 3-4.1 Successful Login
15
Figure 3-5 CMS.gov | Login to CMS Enterprise Portal ........................................... 14
Figure 3-6 CMS Registration Page ......................................................................... 16
Figure 3-6.1 Your Information Page ....................................................................... 17
Figure 3-6.2 Verify Identity Page ............................................................................ 18
Figure 3-6.3 Choose User ID and Password .......................................................... 19
Figure 3-6.4 Registration Complete ........................................................................ 20
Figure 3-6.5. CMS.gov | Enterprise Portal – My Portal Page.................................. 21
Figure 3-6.6 Request Access
22
Figure 3-6.7 Request Access to QMAT
23
Figure 3-6.8 Add a Role
24
Figure 3-6.9 Select a Role
25
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Figure 3-6.10 Select an ACO
26
Figure 3-7. Log Out ................................................................................................ 27
Figure 4-1 QMAT Home Page ................................... Error! Bookmark not defined.
Figure 4-2 Data Upload Page ................................................................................. 31
Figure 4-2.1 Data Upload Page – Main Menu Bar .................................................. 32
Figure 4-2.2 Data Upload Page – Data Upload Bar................................................ 32
Figure 4-2.3 Expand Page to Upload a New File.................................................... 33
Figure 4-2.4 Data Upload Page – Uploaded Files .................................................. 34
Figure 4-2.5 Uploaded Files-Filter File Uploads by Date ........................................ 35
Figure 4-2.6 Expand Page to Select Report Type .................................................. 36
Figure 4-2.7 Data Upload Error Report ................................................................... 37
Figure 4-2.8 Submission Report ............................................................................. 39
Figure 4-2.9 QRDA Data Element Report .............................................................. 40
Figure 4-2.10 QRDA I Data Element Report .......................................................... 41
Figure 4-3 Data Entry Page ....................................... Error! Bookmark not defined.
Figure 4-3.1 Data Entry Page – Main Menu Bar ........ Error! Bookmark not defined.
Figure 4-3.2 Data Entry Bar ....................................... Error! Bookmark not defined.
Figure 4-3.3 Patient Record....................................... Error! Bookmark not defined.
Figure 4-3.4 Data Entry Advanced Search ............................................................. 44
Figure 4-3.5 Data Entry Search Results ................................................................. 45
Figure 4-3.6 Data Entry Completion Status Report ... Error! Bookmark not defined.
Figure 4-3.7 Completion Status Report – Total Ranked Beneficiaries.................... 47
Figure 4-3.8 Completion Status Report – Completed ............................................. 48
Figure 4-3.9 Completion Status Report – Incomplete ............................................. 49
Figure 4-3.10 Completion Status Report – Total Skipped Beneficiaries ................. 50
Figure 4-3.11 Completion Status Report – Total Beneficiaries Used for Analysis .. 51
Figure 4-4.1 Data Submission ................................................................................ 86
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Figure 4-4.2 Data Submission Confirmation Window ............................................. 86
Figure 4-4.3 Data Submission Complete ................................................................ 87
Figure 4-7.1 QMAT BI Reports tab ......................................................................... 87
BI Reports Page (Figure 4-7.2).................................. Error! Bookmark not defined.
Figure 4-7.3 Completion Status Report ..................... Error! Bookmark not defined.
Figure 4-7.4 Prefilled Comparison Report ................. Error! Bookmark not defined.
List of Tables
Table 1: Version History ......................................................................................... vii
Table 2. Demographics Field Description ............................................................... 56
Table 3. CAD Field Description .............................................................................. 60
Table 4. CARE-1 Field Description ......................................................................... 61
Table 5. CARE-2 Field Description ......................................................................... 62
Table 6. DM Field Description ................................................................................ 66
Table 7. HF Field Description ................................................................................. 68
Table 8. HTN Field Description............................................................................... 69
Table 9. IVD Field Description ................................................................................ 71
Table 10. PREV-5 Field Description ....................................................................... 72
Table 11. PREV-6 Field Description ....................................................................... 73
Table 12. PREV-7 Field Description ....................................................................... 74
Table 13. PREV-8 Field Description ....................................................................... 75
Table 14. PREV-9 Field Description ....................................................................... 77
Table 15. PREV-10 Field Description ..................................................................... 78
Table 16. PREV-11 Field Description ..................................................................... 80
Table 17. PREV-12 Field Description ..................................................................... 82
Table 18: Acronyms................................................................................................ 95
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Table 19: Glossary .................................................... Error! Bookmark not defined.
Table 20: Record of Changes ................................................................................. 98
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Version History
Table 1: Version History
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Introduction
1. Introduction
On October 20, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized new rules
under the Patient Protection and ACA to allow for Accountable Care Organizations (ACO). An
ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and
others involved in patient care) that will work together to coordinate care for the Medicare FeeFor-Service patients they serve. The goal of an ACO is to deliver seamless, high-quality care for
Medicare beneficiaries, instead of the fragmented care that often results from a Fee-For-Service
payment system in which different providers receive different, disconnected payments. As
required by the ACA, before an ACO can share in any savings created, it must demonstrate that
it met the quality performance standard for that year. The Pioneer ACO quality measures will be
reported through the Quality Measure Assessment Tool (QMAT), designed for clinical quality
measure reporting (22 measures).
The CMS Innovation Center (CMMI) has an objective of achieving better care for individuals,
better health for the population, and reducing expenditures for Medicare and Medicaid Program
Beneficiaries. CMMI is seeking to develop a system that efficiently enables an ACO to submit
both claims and clinical data for quality performance measures. Additionally, the QMAT provides
reporting functions that provide CMS and ACOs with feedback on their (ACO’s) performance.
The QMAT is a method of data submission that incorporates some characteristics and methods
from the CMS demonstration projects. The QMAT will be pre-populated with the assigned
beneficiary sample under each condition module (e.g., Diabetes, Heart Failure, etc.) serving as
a data collection tool for ACOs to use in collecting and submitting quality measures data to
CMS. In order for the Pioneer ACOs to report via the QMAT, Medicare beneficiary and claims
data from the CMS Integrated Data Repository (IDR) is necessary for identifying the
denominator populations in each condition module (or measure in some cases), random
sampling of such beneficiaries, and pre-filling within QMAT certain elements (such as service
dates, laboratory tests) that can be reliably obtained through claims to lessen the burden on the
Pioneer ACOs.
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Overview
2. Overview
The QMAT, a web based solution for ACO Pioneer Model, allows for the export of clinical quality
data directly from certified Electronic Health Records (EHR) systems and the calculation of
clinical quality measures via a standardized, rules-based, and scalable measures engine. The
QMAT will serve as a data collection and reporting solution that resides in a framework that
promotes re-use and collaboration.
The primary actors within the QMAT are:
 Pioneer ACOs interact with the QMAT application for reports and data exchanges
pertaining to clinical quality data
 The Program Analysis Contractor (PAC) interacts with the QMAT application for clinical
and scoring data, beneficiary modules, assignments, and associated claims data
 CMMI interacts with the QMAT for beneficiary alignment lists and program management
reports
The QMAT provides a secure interface for Pioneer ACOs, CMMI, and CMMI sub-contractors to
view progress and scoring dashboards. The system will be aligned and coordinated with future
CMS enterprise quality reporting systems. The QMAT supports the CMMI Pioneer ACO model
initiative and the tool includes the following modules:
Data Upload
1. Validate and process beneficiary module information from PAC
2. Assign patients by module
3. Validate and process QRDA I files from ACOs
4. Produce Submission reports
Data Entry
1. Manually enter or modify quality measures data
2. Produce Completion Status Report
Data Submission
1. Attest the data is correct
2. Submit the completed information
Measure Specifications
1. View the current version of Pioneer ACO QMAT EHR Data Upload specifications
QMAT BI Reports
1. Prefilled Comparison Report
2. Completion Status Report
3. Beneficiary Summary Report
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Help Docs
1. View QMAT Help Docs
2.1Conventions
This document provides screen shots and corresponding narrative to describe how to use the
QMAT. The term “user” throughout this document is in reference to a person who requires and/or
has acquired access to the QMAT.
2.2Cautions & Warnings
When signing into the application, a warning screen will appear with Terms and Conditions of
Use of the CMS.gov Enterprise Portal (ePortal), content and applications. The message
should be ready thoroughly; it explains the penalties and consequences of misusing the
system(s) and its contents. The screens that display in the system may differ slightly from the
sample images that appear in this document.
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3. Getting Started
3.1 Set-up Considerations
3.1.1
General Set-up Considerations
The minimum system requirements to effectively access the CMS Portal are:
Windows
1. 1.4GHz Intel® Pentium® 4 or faster processor (or equivalent) for Microsoft® Windows®
XP, Windows 7 or Windows 8; 2GHz Pentium 4 or faster processor (or equivalent) for
Windows Vista®
2. Windows 8 (32-bit/64-bit), Windows 7 (32-bit/64-bit), Windows Vista, Windows XP
3. 512MB of RAM (1GB recommended) for Windows XP, Windows 7 or Windows 8; 1GB of
RAM (2GB recommended) for Windows Vista
4. Microsoft Internet Explorer 8 or higher; Mozilla Firefox 15.0 or higher; Google
Chrome 17.0 or higher; Safari 5.0 or higher
5. JavaScript and cookies must be enabled
Mac OS
1.
2.
3.
4.
5.
1.83GHz Intel Core™ Duo or faster processor
512MB of RAM (1GB recommended)
Mac OS X 10.7.4, 10.8
Mozilla Firefox 15.0 or higher; Google Chrome 17.0 or higher; Safari 5.0 or higher
JavaScript and cookies must be enabled
Linux
1. Ubuntu 11.04, 12.04; Red Hat Enterprise Linux 6; OpenSuSE 11.3
2. Mozilla Firefox 15.0 or higher
3. JavaScript and cookies must be enabled
3.1.2
Section 508 Compliance / Accessibility
CMS.gov is committed to making its electronic and information technologies accessible to people
with disabilities. We strive to meet or exceed the requirements of Section 508 of the Rehabilitation
Act (29 U.S.C. 794d), as amended in 1998.
If any content or use of any features on this website cannot be accessed due to a disability, please
contact our Section 508 Team via E-mail at 508Feedback@cms.hhs.gov.
For more information on CMS.gov Accessibility and Compliance with Section 508, please go to:
https://www.cms.gov/About-CMS/Agency-Information/Aboutwebsite/Policiesforaccessibility.html.
3.2 User Access Considerations
CMS, Pioneer ACOs, and PAC users can access the QMAT through the CMS Enterprise
Web Portal. Authorized users have access to modules and functionality based on their assigned
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role. Security for the QMAT will confer to the CMS Information Services (IS) Acceptable Risk
Safeguard (ARS) guidelines and the system will comply with the CMS Minimum Security
Requirements. Security enforcement spans across tiers leveraging CMS infrastructure. The CMS
infrastructure provides network-layer security systems such as firewalls, intrusion detections
systems and link encryptions. The CMS infrastructure security will be maintained for the data
throughout the loading process onto the CMS mainframe and also throughout the loading
process into the QMAT. CMS mainframe system access is limited to users authorized to access
CMS computer services.
3.3 Accessing the System
To sign into the CMS Secure Portal, the user must have a CMS Enterprise Identity Management
(EIDM) authorized account. If an account has been established but the password has been
forgotten, refer to Section 3.3.1 of this document. To access the system, go to
https://portal.cms.gov/. The home page of the ePortal is displayed in the figure below.
Figure 1: CMS.gov Enterprise Portal Home Page
To access the CMS Secure Portal select the Login to CMS Secure Portal link located on the
CMS.gov Enterprise Portal page. This link is used to access the QMAT. The Terms and
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Conditions will display as illustrated in the figure below.
Figure 2: CMS.gov Enterprise Portal Terms and Conditions Page
3.3.1 Signing Into the Portal
To continue to the Welcome page, accept the terms and conditions associated with the portal.
Declining the Terms and Conditions will automatically cancel the ability to login. After accepting
the Terms and Conditions the Welcome to CMS Enterprise Portal displays, as seen in the figure
below.
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Figure 3: CMS.gov Login to CMS Enterprise Portal
Type the EIDM User ID and Password in the User ID and Password fields and click the Login
button. The figure below displays the page upon successful login.
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Figure 4: Successful Login
3.3.2
User ID and Password
If there is an established account but the Password has been forgotten, select the Forgot
Password? link to retrieve the user’s CMS Enterprise portal password.
If there is an established account but have forgotten the User ID, select the Forgot User ID? link
to retrieve the user’s CMS Enterprise portal User ID.
It is necessary for first time users to establish an account in order to access the system. Select
the New user registration link. The CMS Registration page displays, as seen in the figure below.
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Figure 5: CMS Registration Page
To begin the Registration process, follow the steps below:
1. Read the important Terms and Conditions information and accept the user’s agreement
by selecting the Checkbox next to the “I agree to the Terms and Conditions” verbiage.
(The Next button is not enabled until the “I agree to the Terms and Conditions” checkbox
is selected).
2. Click the Next button to enter the user’s Personally Identifiable Information (PII). PII is
information that can be used to uniquely identify, contact, or locate a single person or
can be used with other sources to uniquely identify a single individual.
3. Enter the information into the required fields.
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Figure 6: Your Information Page
4. Click the Cancel button to exit the Registration process.
5. Click the Next button. The Verify Identity page displays, as seen in the figure below.
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Figure 7: Verify Identity Page
6. Select the Radio button next to the appropriate answer for each question.
a. Only ONE attempt is allowed to answer the questions correctly. Users who fail
Identify Proofing will not be able to see the questions on another attempt.
b. A user who fails Identify Proofing is allowed to continue with the registration
process with limited access to EIDM functions.
7. Click the Next button to continue the registration process.
8. The next step of the Registration process is to choose a User ID and Password, as seen
in the figure below.
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Figure 8: Choose User ID and Password
Select three different questions from the drop-down menu and provide an answer for each.
The following CMS ARS Password Policy must be adhered to:


Be minimum of six and a maximum of 74 alphanumeric characters; and
Allowed special characters are dashes (-), underscores (_), apostrophes (‘), @ and
periods (.).
The CMS portal password must conform to the following CMS ARS Password Policy:
1.
2.
3.
4.
5.
6.
7.
8.
Be changed at least every 60 days
Be eight to 20 characters long
Be changed only once a day
Contain at least one letter and one number
Contain at least one upper case and one lower case letter
Not contain the User ID
Be different from the user’s previous six passwords
Not contain words: 1234, PASSWORD, WELCOME, CMS, HCFA, SYSTEM,
MEDICARE, MEDICAID, TEMP, LETMEIN, GOD, SEX, MONEY, QUEST, F20ASYA,
DOCTOR, 567890, 12345678, ROOT, BOSSMAN, JANUARY, FEBRUARY, MARCH,
APRIL, MAY, JUNE, JULY, AUGUST, SEPTEMBER, OCTOBER, NOVEMBER,
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DECEMBER, SSA, FIREWALL CITIC, ADMIN, UNISYS, PWD, SECURITY, 76543210,
43210, 098765, IRAQ, OIS, TMG, INTERNET, INTRANET, E
9. XTRANET & ATT; and may contain special characters except for =? < >( )’ ”/ \ &
10. Enter a Password based on the guidelines given.
11. Re-Enter the Password into the Confirm Password field making sure the entries match
12. Select a question (1-4) from the drop-down list for which the answer is known to the user
13. Click the Next button to complete the registration process
Things to Note:
1.
2.
3.
4.
The Help is available when scrolling over the selected field.
A unique answer should be entered for each of the four challenge questions.
Three unsuccessful attempts are allowed before the account is locked.
Password and Confirm Password fields always display the asterisk (*) characters when
typing this information for security reasons.
5. CMS terminates the registration session if the session is inactive for more than 15
minutes during the registration process.
The Registration Complete page indicates successful completion of the CMS registration
requirements, as seen in the figure below.
Figure 9: Registration Complete
Upon receiving the acknowledgment message, click the OK button to exit and return to the CMS
portal home page. The new User ID and Password can now be utilized to login. Upon
successful login, the CMS.gov Enterprise Portal page displays, as seen in the figure below.
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Figure 10: CMS.gov | Enterprise Portal – My Portal Page
Access to QMAT must be requested. Click the Request Access link to request access to the
QMAT, as seen in the figure below.
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Figure 11: Request Access
Select the QMAT from the Application Description list, as seen in the figure below.
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Figure 12: Request Access to QMAT
It is necessary to specify the role needed. Select the Add a Role link, as seen in the figure
below.
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Figure 13: Add a Role
Select a role from the Select the Role list, as seen in the figure below.
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Figure 14: Select a Role
It is necessary to identify the ACO with whom the user is associated. Select the ACO from the
list, as seen in the figure below.
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Figure 15: Select an ACO
Click the Submit button and the Request Acknowledgement page displays, as seen in the figure
below.
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Figure 16: Request Acknowledgment
Click OK and the page closes. An E-mail will be sent once the request has been processed.
3.4 Exiting the System
To log out of the portal, click the Log Out link in the upper right portion of the page, as seen in
the figure below.
Figure 17: Log Out
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4. Using the System
4. Using the System
The QMAT is set up with a Data Reporting flow in mind. Users can upload QRDA 1 files into the
QMAT, and run reports related to the files uploaded in Data Upload. Users can manually enter
patient data, update information previously entered or uploaded, and run a report related to the
overall completion of the minimum reporting requirement for the reporting period in Data Entry.
After all data has been entered and it is ready to be submitted to CMS, an authorized user will
have the ability to attest all data is correct and submit it through Data Submission. The Measures
Specifications and the overall Help information are accessible at any time through the QMAT.
The following sub-sections provide detailed step-by-step instructions describing how to use the
various functions or features of the QMAT Interface.
4.1 QMAT Home Page
The QMAT home page is the first screen that displays when the QMAT button is selected from
the CMS Portal ACO homepage. The QMAT home page provides a quick overview of the
reporting process and access to the various sections of the tool.
Figure 18: QMAT Home Page
The QMAT Home page displays the following (refer to the figure above):
1. QMAT Logo
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2. Data Upload Link
3. Data Entry Link
4. Data Submission Link
5. Measures Specs Link
6. Help Guide Link
7. System Notification
8. About QMAT
9. Help Desk
10. Completion Summary
11. ACO Info Bar
4.1.1 Data Upload Link
This icon provides a link to the Data Upload sections where users can upload
Quality Reporting Data Architecture (QRDA) 1 files and run reports related to
the files uploaded. The reports available are the Submission Report, Error
Report, and QRDA 1 Data Elements Report.
4.1.2 Data Entry Link
This icon provides a link to the Data Entry section where users can manually
enter patient data. Users can run the Completion Status Report to obtain
information identifying the overall completion of the minimum reporting
requirement for the reporting period. Additional detail can be obtained by
clicking links within the Completion Status Report to display the following
information: Incomplete, Total Skipped Beneficiaries, and Total Beneficiaries
Used for Analysis.
4.1.3 Data Submission Link
This icon provides a link to the Data Submission section. Once all data has
been entered and is ready to be submitted to CMS, an authorized user will
have the ability to attest all data is correct and submit it.
4.1.4 Measures Specs Link
This icon provides a link to the Pioneer ACO Electronic Health Records
(EHR) Data Upload Specifications document.
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4.1.5 Help Docs Link
This icon provides a link to this User Manual for the entire application.
Additional help information is provided by section on all the screens.
4.1.6 System Notification
This section displays important information in relation to the QMAT that needs attention, for
example, “the submission deadline is approaching.”
Figure 19: Due Date for Data Submission
4.1.7 About QMAT
At the bottom of the QMAT home page there is a quick intro to the tool in the About QMAT
Information box.
4.1.8 Help Desk
At the bottom of the QMAT home page there is a Help Desk box which provides information to
contact the Help Desk if further assistance is needed.
4.1.9 Completion Summary
The Completion Summary shows an overview of progress for reporting data. It contains the list
of modules, the group status, and whether or not they have met the minimum requirement.
Under Modules is each module’s name.
This is an example of one of the modules.
Under Group Status, this number indicates the number of consecutively completed
and confirmed patients for the module.
Under Minimum Requirements Met, this icon indicates the minimum reporting
requirement for the module has been met.
Under Minimum Requirements Met, this icon indicates the minimum reporting
requirement for the module has not been met.
< Place holder for the ACO Info Bar>
The ACO Info Bar displays the ACO Name and Identification Number. Authorized users that
have access to multiple ACOs can select an individual ACO and view their specific data.
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4.2 Data Upload
The QMAT Data Upload page is accessed by selecting the Data Upload link from the QMAT
Home page or the QMAT Main Menu bar, as seen in the figure below.
Figure 20: Data Upload Page
Data Upload contains the following:
1.
2.
3.
4.
Main Menu Bar
ACO Info Bar
Data Upload Bar
Uploaded Files
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Figure 21: Data Upload Page – Main Menu Bar
The Main Menu Bar, in the figure above, contains all the links to main sections for the
application. This bar will appear on all pages. The main sections include:
1. QMAT Logo
2. Home Link
3. Data Upload Link
4. Data Entry Link
5. Data Submission Link
6. Measures Specs Link
7. Help Guide Link
8. System Notification Icon
This icon will appear if there is a system notification available. To view the system
notification, click this icon and a slide-down area with the message details appears.
This is a Close icon. To hide the slide-down area, click the Notification icon or the
Close icon.
<Place holder for the ACO Info Bar>
The ACO Info Bar displays the ACO Name and ACO Identification Number.
Figure 22: Data Upload Page – Data Upload Bar
The Data Upload Bar displays the following:
1. Upload a New File Icon
2. Show the List of All Uploads Icon
3. Generate, Print and Download Reports Icon
4. Data Upload Help Icon
To upload an individual QRDA 1 file, select the Upload a New File Icon from the Data Upload
Bar. The page expands, as seen in the figure below.
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Figure 23: Expand Page to Upload a New File



Click the Browse button and select the QRDA I file to be uploaded.
Click the Upload button to upload the file.
Click the Cancel button to stop the file from being uploaded.
Refer to the Final 2013 Pioneer ACO QMAT EHR Supporting Documents posted on the ACO
Collaborative site. The QRDA Data Submission Specifications document includes specifications
for file format for the QRDA 1 files. The QMAT will validate each QRDA 1 file that is included in
a concatenated xml file. The QMAT will not reject the entire concatenated xml file if there are
individual files containing errors; rather the individual files are validated separately. The QMAT
will reject or accept each individual QRDA I files according to the validation rules outlined in the
QRDA Data Submission Specifications. To view a list of uploaded files click the List of All
Uploads Icon; the page is refreshed to display the list of uploaded files, as seen in the figure
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below.
Figure 24: Data Upload Page – Uploaded Files
The Uploaded Files section displays the following (refer to the figure above):
1. Filter Files by Date Range Icon
2. Uploaded Files Help Icon
3. Information Bar (Reporting Period, Last Upload, Last User)
4. Uploaded Files Data Table
5. Select Report Type
6. Generate, Print and Download Report for Selected File(s)
The following columns display on the page:
Import ID: System generated number given to the file upon submission
File Name: Name of the file submitted
File Type: QRDA 1
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File Status: Status of the file that was submitted, valid values are Complete, Processing,
Rejected
Date Received: Date the file was submitted
Date Processed: Date the file was processed
Number of Errors: The number of errors within the file
4.2.1 Filter Files by Date Range
The Uploaded files section displays the list of uploaded files, and can be filtered. Select the filter
files by the upload date icon and the page will expand, as seen in the figure below.
Figure 25: Uploaded Files-Filter File Uploads by Date
1. Select a Submission Start Date and/or Submission End Date.
2. Click the Filter button. The Uploaded Files Data Table displays the files that have been
uploaded for the specified Submission dates.
3. Click the Clear Filter button to clear the Submission Start and End Dates.
4. To further filter the rows that display, enter any field value in the Filter files by any field
box. Only those rows with the specified field value display.
5. The rows that display can also be limited by clicking the Select/Deselect All box that
corresponds to the pertinent row(s).
6. The up and down arrows on the column headers can be used to sort the information that
displays.
4.2.2 Generate Reports
To generate a report select the Generate, Print, and Download Reports Icon. The page is
expanded, as seen in the figure below.
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Figure 26: Expand Page to Select Report Type
This is the download button. To download any of the reports click on the
Download button. The report will be available for download in Excel format.
This is the print button. To print any of the reports click on the Print button. The
report will display in a browser window formatted for printing.
4.2.2.1 Error Report
Click the Error Report radio button to generate the Error Report. This report displays all errors
within QRDA 1 files that were rejected due to file validation issues. The report can be made
more specific by making a selection from the following fields:
1.
2.
3.
4.
5.
6.
7.
8.
Submission Start Date
Submission End Date
Provider Name
Provider TIN
Provider NPI
Import ID
File Name
Error Code
Click the View button and the report displays for the parameters selected, as seen in the figure
below.
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Figure 27: Data Upload Error Report
The Error Report displays information in the following columns:
1.
2.
3.
4.
5.
6.
7.
Import ID: System generated number given to the file upon submission
Import Name: System generated name of the imported file
File Name: Name of the file submitted
Provider TIN: Service provider’s Taxpayer Identification Number
Provider NPI: Service provider’s National Provider Identifier Number
Provider Name: Name of the service provider
Error Code: Validation Error Code within the submitted file
To sort the report in ascending or descending order, select the up or down arrow for any sort
able column header. The Error Report by default will show 10 entries per screen. The amount of
rows to be displayed in the data table can be increased to 25, 50, or 100 by selecting an option
in the Show entries drop-down menu.
Figure 28: Show Entries Drop-Down Menu
The slide box will show the total number of entries and how many are being shown on the
current view. Navigate between view of records by clicking on the ‘Previous’ and ‘Next’ links
located under the data table. When the Error Code link is selected the Error Report details
displays on the expanded page. (Figure 4-2.8 Error Report-Error code Details). The following
information displays:


Error ID: Validation Error Code number within the submitted file
Error Description: Explanation of the Validation Error Code within the submitted file
To download the Data Upload Error Report, click the Download button. The report will be
available for download in Excel format.
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To print the Data Upload Error Report click the Print button. The report will display in a browser
window formatted for printing.
Figure 29: Data Upload Error Report-Error Code Details
4.2.2.2 Submission Report
To generate the Submission report, select the Generate, Download or Print Icon. The page
expands, as seen in the figure below. Select the Submission Report radio button.
The report can be made more specific by making a selection from the following fields:
1.
2.
3.
4.
5.
6.
7.
Submission Start Date
Submission End Date
Provider Name
Provider TIN
Provider NPI
Import ID
File Name
Click the View button and the report displays for the parameters selected.
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Figure 30: Submission Report
The Submission Report displays information in the following columns:
1.
2.
3.
4.
5.
6.
7.
Import ID: System generated number given to the file upon submission
Import Name: System generated name of the imported file
File Name: Name of the file submitted
Provider Taxpayer Identification Number (TIN): Service provider’s TIN
Provider National Provider Identifier (NPI): Service provider’s NPI
Provider Name: Name of the service provider
File Status: Value indicates if the file was Rejected or Accepted
To sort the report in ascending or descending order, select the up or down arrow of any sort
able column header. The Submission Report by default will show 10 entries per screen. The
amount of rows to be displayed in the data table can be increased to 25, 50, or 100 by selecting
an option in the Show entries drop-down menu.
The slide box will show the total number of entries and how many are being shown on the
current view. Navigate between view of records by clicking on the ‘Previous’ and ‘Next’ links
located under the data table. To download the Submission Report click the Download button.
The report will be available for download in Excel format. To print the Submission Report click
the Print button. The report will display in a browser window formatted for printing.
4.2.2.3 QRDA Data Element Report
To generate the QRDA Data Element Report, select the Generate, Download, or Print Icon. The
page expands. Select the QRDA Data Element Report radio button.
The report can be made more specific by making a selection from the following fields:
1.
2.
3.
4.
5.
6.
7.
Submission Start Date
Submission End Date
Provider Name
Provider TIN
Provider NPI
Import ID
File Name
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Click the View button and the report displays for the parameters selected, as seen in the figure
below.
Figure 31: QRDA 1 Data Element Report
The QRDA Data Element Report displays information in the following columns:
1.
2.
3.
4.
5.
6.
7.
Import ID: System generated number given to the file upon submission
Import Name: System generated name of the imported file
File Name: Name of the file submitted
Provider TIN: Service provider’s TIN
Provider NPI: Service provider’s NPI
Provider Name: Name of the service provider
Data Entry Data Element: The Data Entry question corresponding to QRDA I data
To sort the report in ascending or descending order, select the up or down arrow of any sort
able column header. The Submission Report by default will show 10 entries per screen. The
amount of rows to be displayed in the data table can be increased to 25, 50, or 100 by selecting
an option in the Show entries drop-down menu.
The slide box will show the total number of entries and how many are being shown on the
current view. Navigate between view of records by clicking on the ‘Previous’ and ‘Next’ links
located under the data table. To download the QRDA 1 Data Element Report, click the
Download button. The report will be available for download in Excel format.
To print the QRDA 1 Data Element Report click the Print button. The report will display in a
browser window formatted for printing. When the Data Element link is selected the QRDA 1
Data Element Report displays on the expanded page (Figure 4.2.11 QRDA Data Element
Report-Reason Details). The following information displays:
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Data Entry Data Element: The Data Entry question corresponding to QRDA 1 data
QRDA Data Element Report Message: The reason the QRDA data was not used to
override the data already displaying on the Data Entry screen
Figure 32: QRDA Data Element Report-Reason Details
The QRDA Element Report by default will show 10 entries per screen. The amount of rows to
be displayed in the data table can be increased to 25, 50, or 100 by selecting an option in the
Show entries drop-down menu.
The slide box will show the total number of entries and how many are being shown on the
current view. Navigate between view of records by clicking on the ‘Previous’ and ‘Next’ links
located under the data table.
To download the QRDA Data Element Report-Reason Details click on the Download button.
The report will be available for download in Excel format. To print the QRDA Data Element
Report-Reason Details click the Print button. The report will display in a browser window
formatted for printing.
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This is the Help icon. The Data Upload bar help contains information explaining the
different buttons on this bar. To access the Data Upload bar help click on the Help
icon. The help icon is displayed in a separate window on top of the screen. The help
window can be dragged and moved around to the desired placement.
To close the help window click the close icon.
4.3 Data Entry
The QMAT Data Entry page is accessed by selecting the Data Entry link from the QMAT Home
page or the Main Menu Bar, as seen in the figure below.
Figure 33: Data Entry Page
Data Entry contains the following:
1. Main Menu Bar
2. ACO Info Bar
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3. Data Entry Bar
4. Patient Record
4.3.1 Main Menu Bar
The main menu bar contains all the links to main sections of the application. This bar will appear
in all pages, as seen in the figure below.
Figure 34: Data Entry Page – Main Menu Bar
The Main Menu Bar contains the following:
1. QMAT Logo
2. Home Link
3. Data Upload Link
4. Data Entry Link
5. Data Submission Link
6. Measures Specs Link
7. Help Docs Link
8. System Notification Icon
This icon will appear if there is a system notification available. To view the system
notification click on this icon and a slide-down area with the message details
appears.
Figure 35: Slide-Down area with Message Details
This is a Close icon. To hide the slide-down area, click on the Notification icon or the
Close icon.
<Place holder for the ACO Info Bar>
4.3.2 Data Entry Bar
The Data Entry Bar contains the following:
1.
2.
3.
4.
Patient Record Quick Search Form
Advanced Search Icon
Completion Status Report Icon
Data Entry Help Icon
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Figure 36: Data Entry Bar
4.3.2.1 Patient Record Filter
From left to right is a quick way of filtering patients:
1.
Filter the patients by module or by provider.
2.
Depending on the selection in the Filter by select box, this field will be prepopulated with the correct information. For example, if module is selected, the list of
available modules will be populated.
3.
In the third field the list of patients can be ordered by last name, first name,
Medicare ID, or rank number (rank number is only available if module was selected in
the ‘Filter by’ field).
4.
This field will display the list of patients that was generated by
the previous filter selections.
5. Clicking the ‘Go’ button
criteria.
will return a list of patients matching the quick search filter
4.3.2.2 Advanced Search
To find a specific patient click the Advanced Search Icon
box will display under the data entry bar.
. Once the icon is selected a slide
To close the advanced search box, click the Advanced Search icon or the close icon.
Figure 37: Data Entry Advanced Search
To use the advanced search:
1.
Filter the patients by module or by provider.
2.
Depending on the selection in the Search In select box, this field will be prepopulated with the correct information. For example, if Provider is selected, the list of
available providers will be populated.
3.
Next, select either All, Last Name, First Name, or Medicare ID to further define
the search criteria.
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4. In the fourth field enter the keyword(s) the search will match with the selected properties
of the previous fields selected.
5. Clicking the ‘Search’ button
search criteria.
Clicking the ‘Clear Search’ button
search form.
will return a list of patients matching the advanced
will clear out all selections on the advanced
If no patients are returned when performing a search, modify the search criteria and try again.
4.3.2.3 Search Results
When performing either a quick search or advanced search the system will return a list of
patients matching the search criteria.
Figure 38: Data Entry Search Results
The search results are displayed in a data table. The column headers of the data table are
clickable to re-sort the list of patients. Click any active link within the list of patients search
results table to access the data entry screens for a given patient.
To close the advanced search box with the Search Results, click the Advanced Search
icon or the close icon.
4.3.2.4 Completion Status Report
At all times during the reporting period the completion status report can be viewed, downloaded,
or printed from within the Data Entry section. Progress toward the minimum reporting
requirement for the reporting period as information is entered can be viewed in this report.
To view the completion status report click the Completion Status Report Icon from the Data
Entry Bar
. Once the icon is selected a slide box will display under the data entry bar.
To close the Completion Status Report box, click the Completion Status Report icon or
the close icon.
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Figure 39: Data Entry Completion Status Report
The Completion Status Report slide box displays a data table showing the following:
1. Reporting Period: The period during which the Pioneer ACO measures are to be
reported for covered professional services provided.
2. ACO: An ACO refers to a group of providers and suppliers of services (e.g., hospitals,
physicians and others involved in patient care) that will work together to coordinate
care for the Medicare Fee-For-Service patients they serve.
3. Module: a module represents one or more measures grouped together for reporting
that have the same or similar populations. Pioneer ACO includes 15 modules.
4. Total Ranked Beneficiaries: The total number of beneficiaries assigned to a module.
5. Completed: All required elements under a module have been supplied and there are
no invalid values for the module. Clicking on a value in this column will generate the
detailed beneficiary-level information.
6. Incomplete: At least one required element does not have a valid value for the
module. Clicking on a value in the column will generate the detailed beneficiary-level
information.
7. Total Skipped Beneficiaries: Number of beneficiaries who are skipped with a valid
reason code for a given Module and ACO. Reasons include: Medical Record not
Found, Diagnosis not Confirmed (if applicable), Not Qualified for Sample (In Hospice,
Moved out of Country, Deceased, Enrolled in MO, or Other CMS Approved Reason).
Clicking on a value in this column will generate the detailed beneficiary-level
information.
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8. Total Beneficiaries Used for Analysis: The number of consecutively completed
beneficiaries minus the total count of beneficiaries skipped prior to the first patient
marked as “incomplete”. Clicking on a value in the column will display how this was
calculated.
9. Minimum Requirement Met or Not: An indicator for reporting successfully based on
the sample method selected by the ACO or for the reporting period.
Additional information can be accessed for ‘Total Ranked Beneficiaries’, number ‘Completed’,
number ‘Incomplete’, ‘Total Skipped Beneficiaries and ‘Total Beneficiaries Used for Analysis’ by
clicking on the hyperlinked number in the given column for the chosen measure.
When clicking a hyperlinked number a slide box will be displayed within the completion status
report data table below the selected number showing details for the given column and measure.
To hide these reports, click the close icon.
To download the Completion Status Report, click the Download button. The Completion Status
Report will be available for download in Excel format. To print the Completion Status Report,
click the Print button. The Completion Status Report will display in a browser window formatted
for printing.
Figure 40: Completion Status Report – Total Ranked Beneficiaries
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Figure 41: Completion Status Report – Completed
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Figure 42: Completion Status Report – Incomplete
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Figure 43: Completion Status Report – Total Skipped Beneficiaries
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Figure 44: Completion Status Report – Total Beneficiaries Used for Analysis
Each ‘Total Ranked Beneficiaries’, number ‘Completed’, number ‘Incomplete’, ‘Total Skipped
Beneficiaries and ‘Total Beneficiaries Used for Analysis’ slide box by default will show 10 entries
per screen. The amount of records to be displayed in the data table can be increased to 25, 50
or 100 by selecting an option in the Show entries drop-down menu.
The select box will show the total number of entries and how many are being shown on the
current view. Navigate between view of records by clicking on the ‘Previous’ and ‘Next’ links
located under the data table.
To download the Completion Status Report-Total Beneficiaries Used for Analysis Report click
the Download button. The Completion Status Report will be available for download in Excel
format. To print the Completion Status Report-Total Beneficiaries Used for Analysis Report click
the Print button. The Completion Status Report will display in a browser window formatted for
printing.
4.3.2.5 Data Entry Bar Help
This is the Help icon. The data entry bar help contains information explaining the
different buttons on this bar. To access the data entry bar help click on the Help icon.
The help icon is displayed in a separate window on top of the screen. The help
window can be dragged and moved to the desired placement.
To close the help window click the close icon.
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4.3.3 Patient Record
Figure 45: Patient Record
The Patient Record includes the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Title Bar Selected Patient Medicare ID – Last Name, First Name
Title Bar Validate Icon
Information Bar
Progress and Modules Navigation
Timer
Modules Tabs
Modules Data Entry
Data Entry Save & Cancel Form Action Icons
Help Icons
4.3.3.1 Selected Patient Medicare ID – Last Name, First Name & Record Information Bar
Once a patient record has been selected the Patient Medicare ID – Last Name, First Name will
be displayed on the title bar. Below the title bar there is an info bar showing the reporting period
date range, who is currently using the file (shown as “Locked By: User”) which can be the
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current user or another user which locks the file from other users to enter data, when the patient
data was modified for the last time, and who was the last user that worked on this patient.
4.3.3.2 Module Progress, Navigation & Timer
On the left side of the patient record is the module progress and navigation showing the overall
status of each module. The module progress displays the number of consecutively completed
and confirmed patients (Group Status), whether this patient is ranked or Not Ranked (NR) for a
measure including his or her ranking (Patient Rank), and if the data within this measure is
complete or not (Patient Status).

Group Status: This number
patients.

Patient Rank: This number
module.
Patient Status:

indicates the consecutively completed and confirmed
indicates the rank assigned to the patient in the
This icon indicates data entry for the module has been entered and
completed.
This icon indicates data entry for the module has not been completed.
This icon indicates the patient is not ranked for that module.
To the right of the module progress is the navigation tabs. Clicking the navigation tab will load
the selected module’s data entry screen. All enabled fields are required for completion of this
module unless otherwise indicated-data MUST be saved before navigating to another module.
Module Tab
Description
Demographics. The dark blue background indicates this is the current
tab and the content for demographics is displayed on the right-side
module content area.
Coronary Artery Disease (CAD) Composite
CAD-2: Lipid Control
CAD-7: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy - Diabetes or Left
Ventricular Systolic Dysfunction (LVEF <40%)
Care Coordination/Patient Safety (CARE)
CARE-1: Medical Reconciliation
Care Coordination/Patient Safety (CARE)
CARE-2: Falls: Screening for Future Fall Risk
Diabetes Mellitus Composite & DM-2 (DM)
DM-2: Hemoglobin A1c Poor Control
DM-15: Hemoglobin A1c Control (<8%)
DM-13: High Blood Pressure Control
DM-14: Low Density Lipoprotein Control (LDL-C)
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Module Tab
Description
DM-16: Daily Aspirin or Antiplatelet Medication Use for Patients with
Diabetes and Ischemic Vascular Disease
DM-17: Tobacco NON-Use
Heart Failure (HF)
HF-6: Beta Blocker Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
Hypertension (HTN)
HTN-2: Controlling High Blood Pressure
Ischemic Vascular Disease (IVD)
IVD-1: Complete Lipid Profile and LDL-C
IVD-2: Use of Aspirin or Another Antithrombotic
Preventive Care & Screening (PREV-5)
PREV-5: Breast Cancer Screening
Preventive Care & Screening (PREV-6)
PREV-6: Colorectal Cancer Screening
Preventive Care & Screening (PREV-7)
PREV-7: Influenza Immunization
Preventive Care & Screening (PREV-8)
PREV-8: Pneumococcal Vaccination for patients 65 Years and Older
Preventive Care & Screening (PREV-9)
PREV-9: Body Mass Index Screening & Follow-Up
Preventive Care & Screening (PREV-10)
PREV-10: Tobacco Use
Preventive Care & Screening (PREV-11)
PREV-11: Screening for High Blood Pressure (BP) & Follow-Up
Preventive Care & Screening (PREV-12)
PREV-12: Screening for Clinical Depression & Follow-Up
Table 2: Modules Navigation Tabs
The timer will track the time spent within demographics or any of the modules,
starting when a field is selected, and will stop when data is saved or when the
session is cancelled. This time-tracking information will be available in
Business Intelligence (BI) reports.
4.3.3.3 Data Entry – Demographics
To access the data entry form for Demographics, click the ‘Demographics’ tab from the list of
modules, which are displayed on the left side of the screen. The ‘Demographics’ tab will change
to a dark blue background to indicate it is the active tab selected. Additionally, the heading of
‘Demographics’ will display in the content area.
The Demographics screen displays the Abstraction, Patient Demographics, Provider/Clinic
Information, Medical Record and a Comment field.
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Data Element
Abstraction Date
Description
MM/DD/YYYY Format
The Abstraction Date will default to the current date
the first time the patient data is saved. After the data
has been saved for the first time, the abstraction
date is not updated unless changed by the user.
Abstractor Notes (Optional)
Allows for additional notes from the abstractor. This
field is optional.
Medical Record Found
Valid Values: Yes or No
Select "No" if the patient’s medical record cannot be
found. The patient will be ineligible for ALL modules.
Medical Record Number (Optional)
This is a pre-filled field if the data is available.
Allows for input of the medical record number for the
specific patient. This field is optional.
Other ID (Optional)
Any other identifier used by the group for the patient.
This field is optional.
Is the patient disqualified from ALL
modules for one of the following
reasons
Select one of the listed options to indicate if the
patient is not qualified for the sample. The patient will
be ineligible for ALL modules unless "None of the
above" is selected.
In Hospice: Select this option if the patient is not
qualified for sample due to being in hospice care at
any time during the measurement period (this
includes non-hospice patients receiving palliative
goals or comfort care).
Moved out of Country: Select this option if the patient
is not qualified for sample because they moved out
of the country any time during the measurement
period.
Deceased: Select this option if the patient died
during the measurement period.
HMO Enrollment: Select this option if the patient was
enrolled in an HMO at any time during the
measurement period (i.e., Medicare Advantage, nonMedicare HMOs, etc.).
Date of Disqualification
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sample during the measurement period due to
hospice, deceased, enrolled in HMO, or moved out
of country (if date of death unknown enter
12/31/2013).
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Data Element
Description
Deselect the modules for which the
patient is not qualified for sample for
Other CMS Approved Reason:
Use this option to indicate if there is an "other" CMS
approved reason for patient disqualification from the
sample module. The modules the patient was
ranked in will already be selected. The patient is no
longer qualified for any module(s) that are deselected.
Medicare ID
Health Insurance Claim Number. This is a pre-filled
field and cannot be modified.
First Name
Patient’s first name. This is a pre-filled field, but can
be modified.
Last Name
Patient’s last name. This is a pre-filled field, but can
be modified.
Gender
This is a pre-filled field, but can be modified.
Valid values are: Female, Male and Unknown
Date of Birth
MM/DD/YYYY Format
This is a pre-filled field, but can be modified.
Valid values are between 01/01/1895 and
07/01/2012
Provider Name (Optional)
This is a pre-filled field if the data is available.
Allows for update or input of the provider name. This
field is optional.
Clinic Name (Optional)
This is a pre-filled field if the data is available.
Allows for update or input of the provider name. This
field is optional.
Physician NPI(s) with the largest
number of claims for the patient
These are pre-filled fields that cannot be modified.
Comments (Optional)
Allows for additional comments. This field is optional.
Table 3: Demographics Field Description
4.3.3.4 Data Entry – CAD
To access the data entry form for CAD, click on the ‘CAD’ tab from the list of modules, which
are displayed on the left side of the screen. The ‘CAD’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘CAD Composite’
will display in the content area.
The CAD screen includes CAD Confirmation, CAD-2, CAD-7, and General Comments.
Data Element
Coronary Artery Disease Diagnosis
Confirmed
Description
Valid Values: Yes or No
Diagnosis of CAD= (active or history of) can be at
any time in the patient’s history up through the last
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Description
day of the measurement period.
Synonyms for coronary artery disease may include:
AMI, angina, arteriosclerotic cardiovascular disease,
arteriosclerotic heart disease, ASCVD, ASHD,
atherectomy, atherosclerotic cardiovascular disease,
atherosclerotic heart disease, CABG, CAD,
cardiovascular (heart) disease, CHD, chronic
myocardial ischemia, chronic stable angina, coronary
arterio-sclerosis, coronary artery bypass graft,
coronary artery disease, coronary disease, coronary
endarteritis, coronary heart disease, coronary
insufficiency, coronary vascular disease, CVD,
ischemic heart disease, MI, myocardial infarction
(current or history), PCI, percutaneous transluminal
coronary angioplasty, post cardiac/coronary injury,
PTCA, rotablator, S/P MI, status-post myocardial
infarction, stent (coronary), unstable angina.
Coronary Artery Disease Diagnosis
Code
Diagnosis Code for CAD.
If no diagnosis code is available check the box for
“No diagnosis code available”
CAD-2: Composite (All or Nothing
Scoring): Coronary Artery Disease
(CAD): Lipid Control
Patients with a diagnosis of coronary artery disease
seen during the measurement period who have a
LDL-C result < 100 mg/dL OR patients who have a
LDL C result >=100 mg/dL and have a documented
plan of care to achieve LDL-C <100 mg/dL,
including at a minimum the prescription of a statin.
LDL-C documented
Valid Values: Yes or No
If there is more than one LDL-C performed, use the
value on the most recent date.
Most Recent LDL-C value
If the LDL-C was performed, but a result is not
documented, record a "0" (zero) value. If the
laboratory is unable to calculate the LDL-C value due
to high triglycerides, record "0" (zero). If the test
result is labeled "unreliable" and a result is provided,
also record "0" (zero).
Do not enter a ratio as a value (it is not a valid
value).
Most recent LDL-C date during the
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measurement period
Plan of care documented to achieve
LDL-C & 100 mg/dL
Valid Values: Yes or No
Includes the prescription of a statin and may also
include: documentation of discussion of lifestyle
modifications (diet, exercise) or scheduled re
assessment of LDL-C.
Statin Therapy
Valid Values:
 Prescription for statin
 Current medication list during the
measurement period included statin
 No statin during the measurement period.
Prescribed – May include prescription given to the
patient for a statin at one or more visits within the
measurement period OR patient already taking a
statin as documented in the current medication list.
• A prescribed statin (which is the minimum
requirement of a plan of care) meets the
requirements of this measure
• A prescribed statin combination drug (i.e.,
lovastatin/niacin [Advicor]) meets the requirements of
this measure
• Niacin alone does not meet the requirements of this
measure
• A plan of care without statin therapy does not meet
the requirements of this measure
If prescription for statin is selected, enter the statin
prescription order date within the measurement
period in MM/DD/YYYY format.
Did the patient not receive statin
therapy for one of the following
reasons?
Valid Values:
 Documentation of medical reason(s) for not
prescribing statin therapy (e.g., allergy,
intolerance to statin medication(s), other
medical reasons)
 Documentation of patient reason(s) for not
prescribing statin therapy (e.g., patient
declined, other patient reasons)
 Documentation of system reason(s) for not
prescribing statin therapy (e.g., financial
reasons, other system reasons)
 No medical, patient, or system reason
documented
CAD 7: Composite (All or Nothing
Scoring): Coronary Artery Disease
Patients with a diagnosis of coronary artery disease
seen during the measurement period who also have
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(CAD): Angiotensin-Converting
Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB)
Therapy - Diabetes or Left
Ventricular Systolic Dysfunction
(LVEF <40%)
diabetes OR a current or prior Left Ventricular
Ejection Fraction (LVEF) <40% who were prescribed
ACE inhibitor or ARB therapy during the
measurement period.
LVEF <40%
Valid Values: Yes or No
Documentation of moderate or
severe LVSD
Valid Values: Yes or No
Diagnosis of Diabetes Mellitus
Valid Values: Yes or No
Synonyms for diabetes may include: Diabetes
mellitus, diabetes, Type II diabetes, IDDM, insulin
dependent diabetes mellitus, NIDDM, non-insulin
dependent diabetes mellitus, Type I diabetes
Diabetes Mellitus Diagnosis code
Diagnosis code for Diabetes Mellitus
If no diagnosis code is available check the box for
“No diagnosis code available”.
ACE Inhibitor or ARB therapy
Valid Values:
 Prescription for ACE Inhibitor or ARB therapy
 Current medication list during the
measurement period included ACE Inhibitor
or ARB therapy
 No ACE Inhibitor or ARB therapy during the
measurement period
Prescribed – May include prescription given to the
patient for ACE inhibitor or ARB therapy at one or
more visits in the measurement period OR patient is
already taking ACE inhibitor or ARB therapy as
documented in current medication list.
If prescription for ACE Inhibitor or ARB therapy is
selected, enter the prescription order date within the
measurement period in MM/DD/YYYY format.
Did the patient not receive ACE
Inhibitor or ARB therapy for one of
the following reasons?
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Valid Values:
 Documentation of medical reason(s) for not
prescribing ACE Inhibitor or ARB therapy
(e.g., allergy, intolerance, other medical
reasons)
 Documentation of patient reason(s) for not
prescribing ACE Inhibitor or ARB therapy
(e.g., patient declined, other patient reasons)
 Documentation of system reason(s) for not
prescribing ACE Inhibitor or ARB therapy
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
Comments (Optional)
(e.g., lack of drug availability, other reasons
attributable to the health care system)
No medical, patient, or system reason
documented
Allows for additional comments. This field is optional.
Table 4: CAD Field Description
4.3.3.5 Data Entry – CARE-1
To access the data entry form for CARE-1, click on the ‘CARE-1’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘CARE-1’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Care
Coordination/Patient Safety (CARE-1)’ will display in the content area.
The CARE-1 screen includes CARE-1 and General Comments.
Data Element
Description
CARE-1: Medication Reconciliation
This measure should be reported for each confirmed
Inpatient discharge with an office visit within 30 days
of discharge during the measurement period.
Inpatient Discharge Date
The pre-filled discharge dates from claims cannot be
changed, or removed, and additional dates cannot
be added.
Inpatient discharge dates within the patient record
that are within two days prior or two days after the
pre-filled inpatient discharge date can be used to
confirm inpatient discharge dates.
Synonyms for inpatient facility include: Acute care
hospital discharges, psychiatric inpatient discharges,
skilled nursing facility discharges or rehabilitation
inpatient discharges
Discharge Date Confirmation
Valid Values: Yes or No
Office Visit within 30 days after
Discharge Date
Valid Values: Yes or No
Discharge Medications Reconciled
Valid Values: Yes or No
The intent of the measure is to ensure that the PCP
(physician, PA, NP) OR a clinical pharmacist
(pharmacist who has the authority to prescribe
medications) reviewed the discharge medications
from the inpatient facility. If others (i.e., nurse)
perform the medication reconciliation there must be
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documentation that the PCP or clinical pharmacist is
aware of the review.
Medical Record – Must indicate: The clinician is
aware of the inpatient facility discharge medications
and will either keep the inpatient facility discharge
medications or change the inpatient facility discharge
medications or the dosage of an inpatient facility
discharge medication.
Provider Name (Optional)
Optional Field. This field can be included in the
PROCEDURES section of the QRDA file.
Free text, up to 30 characters each for First Name
and Last Name.
Provider NPI (Optional)
Optional Field. This field can be included in the
PROCEDURES section of the QRDA file.
The NPI for the provider reconciling the discharge
medications, up to 10 characters.
Comments (Optional)
Allows for additional comments. This field is optional.
Table 5: CARE-1 Field Description
4.3.3.6 Data Entry – CARE-2
To access the data entry form for CARE-2, click on the ‘CARE-2’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘CARE-2’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Care
Coordination/Patient Safety (CARE-2)’ will display in the content area.
The CARE-2 screen includes CARE-2 and General Comments.
Data Element
Description
CARE-2: Falls: Screening for Future
Fall Risk
Patients are considered at risk for future falls if they
have had 2 or more falls in the past year or any fall
with injury in the past year.
Screened for Future Fall Risk
Valid Values: Yes or No
Screening for future fall risk may include:
Documentation of no falls in the past year or only
one fall without injury in the past year or
documentation of two or more falls in the past year
or any fall with injury in the past year.
Fall - Is defined as a sudden, unintentional change in
position causing an individual to land at a lower level,
on an object, the floor, or the ground, other than as a
consequence of a sudden onset of paralysis,
epileptic seizure, or overwhelming external force.
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Fall Risk screening date during the
measurement period
MM/DD/YYYY Format
Documentation of medical reason(s)
for not screening for future fall risk
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
Table 6: CARE-2 Field Description
4.3.3.7 Data Entry – Diabetes Mellitus (DM)
To access the data entry form for DM, click on the ‘DM’ tab from the list of modules, which are
displayed on the left side of the screen. The ‘DM’ tab will change to a dark blue background to
indicate it is the active tab selected. Additionally, the heading of ‘Diabetes Mellitus Composite &
DM-2’ will display in the content area. The DM screen includes Diabetes Mellitus Confirmation
DM-2 & DM-15, DM-13, DM-14, DM-16, DM-17 and General Comments.
Data Element
Select an option that applies to the
patient
Description
Valid Values:
 Diagnosis of polycystic ovaries at any time in
the patient’s history
OR
Diagnosis of gestational diabetes during the
measurement period or the year prior to the
measurement period.
OR
Diagnosis of steroid induced diabetes during
the measurement period or the year prior to
the measurement period.
 The patient does not have a diagnosis of
polycystic ovaries, gestational diabetes or
steroid induced diabetes during the specified
timeframes
Exclude from the denominator for all DM measures:
All patients with an active diagnosis of polycystic
ovaries at any time during the patient’s history (but
by the last day of the measurement period).
OR
All patients with an active diagnosis of gestational
diabetes or steroid induced diabetes during the
measurement period (but by the last day of the
measurement period) or the year prior to the
measurement period.
Diabetes Mellitus Diagnosis
Confirmed
Valid Values: Yes or No
Diagnosis of DM-documented history of DM during
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Description
the measurement period or year prior to the
measurement period OR who are taking a
medication indicative of diabetes during the
measurement period.
Synonyms for diabetes mellitus may include: Adult
onset diabetes mellitus, AODM, adult onset diabetes,
AOD, diabetes mellitus, diabetes, Type II diabetes,
IDDM, insulin dependent diabetes mellitus, NIDDM,
non-insulin dependent diabetes mellitus, Type I
diabetes.
Diabetes Mellitus Diagnosis Code
Diagnosis Code for DM.
If no diagnosis code is available check the box for
“No diagnosis code available”
DM-2: Hemoglobin A1c Poor Control
&
DM-15 Composite (All or Nothing
Scoring): Hemoglobin A1c Control
(<8%)
DM-2 Diabetes Mellitus: Hemoglobin A1c Poor
Control
Patients with diabetes mellitus or who are taking a
medication indicative of diabetes who had their most
recent HbA1c >9.0 percent.
DM-15 Composite (All or Nothing Scoring): Diabetes
Mellitus: Hemoglobin A1c Control (8%)
Patients with diabetes mellitus or who are taking a
medication indicative of diabetes who had their most
recent HbA1c <8.0 percent.
HbA1c Test Performed
Valid Values: Yes or No
Synonyms for HbA1c testing may include:
Glycohemoglobin A1c, HbA1c, Hemoglobin A1c,
HgbA1c, A1c
This is a pre-filled field, but can be modified.
Most recent HbA1c Value
If the HbA1c test was performed but the result is not
documented, record a “0” (zero) value.
If there is more than one A1c performed, use the
value on the most recent date.
Most recent HbA1c date during the
measurement period
MM/DD/YYYY Format
This is a pre-filled field, but can be modified.
DM-13: Composite (All or Nothing
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Scoring): High Blood Pressure
Control
medication indicative of diabetes who had their most
recent blood pressure <140/90 mmHg.
Blood Pressure measured
Valid Values: Yes or No
Both the systolic and diastolic blood pressure
measurements are required for inclusion. If there are
multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date
as the representative BP.
If there is more than one BP performed, use the
value on the most recent date.
Most recent Systolic BP in mmHg
0 (zero) to 350 (three hundred fifty)
Most recent Diastolic BP in mmHg
0 (zero) to 250 (two hundred fifty)
Most recent BP date during
measurement period
MM/DD/YYYY Format
DM-14: Composite (All or Nothing
Scoring): Low Density Lipoprotein
(LDL-C) Control
Patients with diabetes mellitus or who are taking a
medication indicative of diabetes who had their most
recent LDL-C 100 mg/dL.
LDL-C documented
Valid Values: Yes or No
A calculated LDL may be used for LDL-C screening
and control indicators.
If there is more than one LDL-C performed, use the
value on the most recent date.
Synonyms for LDL-C testing may include:
Cholesterol analysis, cholesterol panel, cholesterol
profile, fasting lipids, lipid analysis, lipid panel, lipid
profile, lipids, lipoprotein analysis, low density
lipoprotein (LDL), LDL-Cholesterol, LDL-C
This is a pre-filled field, but can be modified.
Most recent LDL-C value
0 (zero) to 600 (six hundred)
If the LDL-c was performed, but a result is not
documented, record a "0" (zero) value. If the
laboratory is unable to calculate the LDL-C value due
to high triglycerides, record "0" (zero).
If the test result is labeled "unreliable" and a result is
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Description
provided, also record "0" (zero).
Do not enter a ratio as a value (it is not a valid
value).
Most recent LDL-C date during
measurement period
MM/DD/YYYY Format
This is a pre-filled field, but can be modified.
DM-16: Composite (All or Nothing
Scoring): Daily Aspirin or Antiplatelet
Medication Use for Patients with
Diabetes and Ischemic Vascular
Disease
Patients with diabetes mellitus or who are taking a
medication indicative of diabetes AND with and
ischemic vascular disease with documented daily
aspirin or antiplatelet medication use during the
measurement year unless contraindicated.
Ischemic Vascular Disease Diagnosis
Confirmed
Valid Values: Yes or No
Ischemic Vascular Disease Diagnosis
Code
Diagnosis Code for DM-16 IVD.
If no diagnosis code is available check the box for
“No diagnosis code available”
Daily aspirin or antiplatelet
medication
Valid Values:
 Prescription for daily aspirin
o If value selected enter the Daily
aspirin prescription order date within
the measurement period in
MM/DD/YYYY format.
 Current medication list during the
measurement period included daily aspirin
 Prescription for antiplatelet medication
o If value selected enter the antiplatelet
medication prescription order date
within the measurement period in
MM/DD/YYYY format.
 Current medication list during the
measurement period included antiplatelet
medication
 No daily aspirin or antiplatelet medication
within the measurement period
Documentation of medical reason(s)
for not prescribing daily aspirin or
antiplatelet medication
Valid Values: Yes or No
ACCEPTED CONTRAINDICATIONS:
 Anticoagulant use, Lovenox (enoxaparin) or
Coumadin (warfarin)
 Any history of gastrointestinal (GI) or
intracranial bleed (ICB)
 Allergy to aspirin (ASA)
Gastroesophogeal reflux disease (GERD) is not
automatically considered a contraindication but may
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be included if specifically documented as a
contraindication by the physician.
The following may be exclusions if specifically
documented by the physician:
 Use of non-steroidal anti-inflammatory
agents
 Documented risk for drug interaction
 Uncontrolled hypertension defined as 180
systolic, 110 diastolic
Other provider documented reason for not being on
ASA therapy
DM-17: Composite (All or Nothing
Scoring): Tobacco NON-Use
Patients with diabetes mellitus or who are taking a
medication indicative of diabetes who indicated they
were tobacco non-users during the measurement
period.
Screened for Tobacco use
Valid Values: Yes or No
Tobacco screening date within the
measurement period
MM/DD/YYYY Format
Tobacco NON-User
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
Table 7: DM Field Description
4.3.3.8 Data Entry – Heart Failure (HF)
To access the data entry form for HF, click on the ‘HF-6’ tab from the list of modules, which are
displayed on the left side of the screen. The ‘HF-6’ tab will change to a dark blue background to
indicate it is the active tab selected. Additionally, the heading of ‘Heart Failure (HF)’ will display
in the content area.
The HF screen includes Heart Failure Confirmation, HF-6 and General Comments.
Data Element
Heart Failure Diagnosis Confirmed
Description
Valid Values: Yes or No
Diagnosis of HF= (active or history of) at anytime in
the patient’s history up through the last day of the
measurement period.
Synonyms for heart failure may include: Congestive
heart failure, CHF, left ventricular failure,
biventricular failure, cardiac failure, pump failure,
cardiac decompensation, Kerly B lines, pulmonary
vascular congestion, ischemic cardiomyopathy,
venous congestion, dilated cardiomyopathy,
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pulmonary edema, lung edema, interstitial edema,
perihilar edema/fluid, fluid or volume overload,
perihilar congestion, interstitial congestion,
cephalization or alveolar edema, left-sided heart
failure, right-sided heart failure, systolic heart failure,
diastolic heart failure, rheumatic heart failure
Heart Failure Diagnosis Code
Diagnosis Code for Heart Failure Diagnosis.
If no diagnosis code is available check the box for
“No diagnosis code available”
LVEF <40%
Valid Values: Yes or No
Documentation of moderate or
severe LVSD
Valid Values: Yes or No
HF-6: Beta Blocker Therapy for Left
Ventricular Systolic Dysfunction
(LVSD)
Patients with a diagnosis of heart failure (HF) with a
current or prior left ventricular ejection fraction
(LVEF) <40% who were prescribed beta-blocker
therapy either when seen in the outpatient setting
OR at each hospital discharge during the
measurement period.
LVEF <40% corresponds to qualitative
documentation of moderate dysfunction or severe
left ventricular systolic dysfunction.
Prescribed – Outpatient Setting: May include
prescription given to the patient for beta-blocker
therapy at one or more visits in the measurement
period OR patient already taking beta-blocker
therapy as documented in current medication list.
Prescribed – Inpatient Setting: May include
prescription given to the patient for beta-blocker
therapy at discharge OR beta-blocker therapy to be
continued after discharge as documented in the
discharge medication list.
Beta-blocker Therapy for Patients with Prior LVEF
<40% – Bisoprolol, carvedilol, or sustained release
metoprolol succinate are the ONLY beta-blockers
allowed for this measure.
Beta-Blocker therapy
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Valid Values:
 Prescription for beta-blocker therapy
o If value selected enter the Betablocker therapy prescription order
date within the measurement period in
MM/DD/YYYY format.
 Current medication list during the
measurement period included beta-blocker
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
therapy
No beta-blocker therapy during the
measurement period
Did the patient not receive betablocker therapy for one of the
following reasons?
Valid Values:
 Documentation of medical reason(s) for not
prescribing beta-blocker therapy (e.g., low
blood pressure, fluid overload, asthma,
patients recently treated with an intravenous
positive inotropic agent, allergy, intolerance,
other medical reasons)
 Documentation of patient reason(s) for not
prescribing beta-blocker therapy (e.g., patient
declined, other patient reasons)
 Documentation of system reason(s) for not
prescribing beta-blocker therapy (e.g., other
reasons attributable to the healthcare
system)
 No medical, patient, or system reason
documented
Comments (Optional)
Allows for additional comments. This field is optional.
Table 8: HF Field Description
4.3.3.9 Data Entry – Hypertension (HTN)
To access the data entry form for HTN, click on the ‘HTN-2’ tab from the list of modules, which
are displayed on the left side of the screen. The ‘HTN-2’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘HTN’ will
display in the content area. The HTN-2 screen includes Hypertension Confirmation, HTN-2 and
General Comments.
Data Element
Hypertension Diagnosis Confirmed
Description
Valid Values: Yes or No
Diagnosis of HTN= history of HTN at any time in the
patient’s history up through the last day of the
measurement period.
Synonyms for hypertension may include: Benign
hypertension, malignant hypertension, hypertensive
heart disease, hypertensive chronic kidney disease,
hypertensive heart and chronic kidney disease,
unspecified hypertension
Hypertension Diagnosis Code
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Diagnosis Code for Hypertension Diagnosis.
If no diagnosis code is available check the box for
“No diagnosis code available”
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Description
HTN-2: Controlling High Blood
Pressure
Patients who had a diagnosis of hypertension (HTN)
and whose most recent blood pressure (BP) was
adequately controlled (<140/90 mmHg) during the
measurement period.
Blood pressure (BP) measurement
Valid Values: Yes or No
Both the systolic and diastolic blood pressure
measurements are required for inclusion. If there are
multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date
as the representative BP.
If there is more than one BP performed, use the
value on the most recent date.
If there are multiple BPs on the same date of service,
use the lowest systolic and lowest diastolic BP on
that date as the representative BP.
Most recent Systolic BP in mmHg
0 (zero) to 350 (three hundred fifty)
Most recent Diastolic BP in mmHg
0 (zero) to 250 (two hundred fifty)
Most recent BP date during the
measurement period
MM/DD/YYYY Format
Documentation of medical reason(s)
for not recording a blood pressure
measurement (diagnosis for EndStage Renal Disease [ESRD] and
pregnancy are the only acceptable
exclusions):
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
Table 9: HTN Field Description
4.3.3.10 Data Entry – Ischemic Vascular Disease (IVD)
To access the data entry form for IVD, click on the ‘IVD’ tab from the list of modules, which are
displayed on the left side of the screen. The ‘IVD’ tab will change to a dark blue background to
indicate it is the active tab selected. Additionally, the heading of ‘IVD’ will display in the content
area.
The IVD screen includes IVD Confirmation, IVD-1, IVD-2 and General Comments.
Data Element
Ischemic Vascular Disease Diagnosis
Confirmation
Description
Valid Values: Yes or No
Diagnosis of IVD=history of ischemic vascular
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disease (IVD), or was discharged alive for acute
myocardial infarction (AMI), coronary artery bypass
graft (CABG), or Percutaneous Coronary
Interventions (PCI) at any time in the patient's history
up through the last day of the measurement period.
Ischemic Vascular Disease Code
Diagnosis Code for Ischemic Vascular Disease.
If no diagnosis code is available check the box for
“No diagnosis code available”
IVD-1: Ischemic Vascular Disease
(IVD): Complete Lipid Profile and
Low Density Lipoprotein (LDL-C)
Control
Patients with Ischemic Vascular Disease (IVD) who
received at least one lipid profile (or ALL component
tests) during the measurement period and whose
most recent LDL-C level was in control (less than
100 mg/dL).
Received at least one lipid profile (or
ALL component tests)
Valid Values: Yes or No
A calculated LDL may be used for LDL-C screening
and control indicators.
If there is more than one LDL-C performed, use the
value on the most recent date.
This is a pre-filled field, but can be modified.
Most recent LDL-C value
0 (zero) to 600 (six hundred)
If LDL-C could not be calculated due to high
triglycerides, count as complete lipid profile. If the
laboratory is unable to calculate LDL-C value due to
high triglycerides, record 0 (zero).
If the test result is labeled "unreliable" and a result is
provided, also record 0 (zero). Do not enter a ratio as
a value (it is not a valid value.) If the test was
performed, but the result is not documented, record
a "0" (zero) value.
Most recent lipid profile (or ALL
component tests) date during the
measurement period
MM/DD/YYYY Format
IVD-2: Ischemic Vascular Disease
(IVD): Use of Aspirin or Another
Antithrombotic
Patients with Ischemic Vascular Disease (IVD) with
documented use of aspirin or another antithrombotic
during the measurement period.
Aspirin or another antithrombotic
therapy
Valid Values:
 Prescription for aspirin
o If value selected enter the Aspirin
prescription order date within the
measurement period in MM/DD/YYYY
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Description




format.
Current medication list during the
measurement period included aspirin
Prescription for antithrombotic medication
o If value selected enter the
Antithrombotic medication prescription
order date within the measurement
period in MM/DD/YYYY format.
Current medication list during the
measurement period included antithrombotic
medication
No aspirin or another antithrombotic therapy
within the measurement period
Oral antithrombotic therapy includes: Aspirin,
clopidogrel or combination of aspirin and extended
release dipyridamole.
Comments (Optional)
Allows for additional comments. This field is optional.
Table 10: IVD Field Description
4.3.3.11 Data Entry – Preventive Care & Screening (PREV-5)
To access the data entry form for PREV-5, click on the ‘PREV-5’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-5’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-5)’ will display in the content area. The PREV-5 screen includes PREV-5
and General Comments.
Data Element
Description
PREV-5: Breast Cancer Screening
Patients with breast cancer screening performed
during the measurement period or year prior to the
measurement period. Documentation in the medical
record must include both of the following:
 A note indicating the date the breast cancer
screening was performed AND
 The result of the findings
Mammogram performed and
documented
Valid Values: Yes or No
Screening includes: Breast imaging, breast x-ray,
breast cancer screening, diagnostic mammography,
digital mammography, mammogram, screening
mammography.
If there is evidence of two separate mastectomies,
this patient may be excluded from the measure. The
bilateral mastectomy must have occurred by the end
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Data Element
Description
of the measurement period.
This is a pre-filled field, but can be modified.
Date mammogram performed during
the measurement period or the year
prior to the measurement period
MM/DD/YYYY Format
Mammogram result documented
Valid Values: Yes or No
Documentation of medical reason(s)
for not performing a mammogram
within 24 months
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
This is a pre-filled field, but can be modified.
Table 11: PREV-5 Field Description
4.3.3.12 Data Entry – Preventive Care & Screening (PREV-6)
To access the data entry form for PREV-6, click on the ‘PREV-6’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-6’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-6)’ will display in the content area. The PREV-6 screen includes PREV-6
and General Comments.
Data Element
PREV-6: Colorectal Cancer
Screening
Description
Patients with colorectal cancer screening current
during the measurement period.
Patients are considered to have appropriate
screening for colorectal cancer if any of the following
are documented:
 Fecal occult blood test (FOBT) during the
measurement period
 Flexible sigmoidoscopy during the
measurement period or the four years prior
to the measurement period
 Colonoscopy during the measurement period
or the nine years prior to the measurement
period
Colorectal cancer screening is current may include:
Documentation in the medical record indicating
colorectal screening is “up-to-date” or “current”
Colorectal Cancer screening
completed and documented
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Valid Values:
 FOBT
o If value selected enter the FOBT
during the measurement period in
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Data Element
Description



MM/DD/YYYY format.
Flexible Sigmoidoscopy
o If value selected enter the Flexible
Sigmoidoscopy during the
measurement period or the four years
prior to the measurement period in
MM/DD/YYYY format.
Colonoscopy
o If value selected enter the
Colonoscopy during the measurement
period or the nine years prior to the
measurement period in MM/DD/YYYY
format.
No Colorectal Cancer screening within
specified timeframes
This is a pre-filled field, but can be modified.
Documentation of medical reason(s)
for not performing colorectal cancer
screening (i.e. total colectomy)
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
Table 12: PREV-6 Field Description
4.3.3.13 Data Entry – Preventive Care & Screening (PREV-7)
To access the data entry form for PREV-7, click on the ‘PREV-7’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-7’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-7)’ will display in the content area. The PREV-7 screen includes PREV-7
and General Comments.
Data Element
PREV-7: Influenza Immunization
Description
Patients seen for a visit between October 1, 2012
and March 31, 2013 and received an influenza
immunization OR reported previous receipt of an
influenza immunization.
Previous Receipt – Receipt of the current season’s
influenza immunization from another provider OR
from same provider prior to the visit to which the
measure is applied (typically, prior vaccination would
include influenza vaccine given since August 1st).
Influenza immunization received
between 8/1/2012 and 3/31/2013
Valid Values: Yes or No
This is a pre-filled field, but can be modified.
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Data Element
Description
Date of the influenza immunization
received
MM/DD/YYYY Format
When entering the date, if only the month and year is
documented use "01" for the day of the month. For
example, if the documentation reflects March 2013,
enter "03/01/2013" for the date.
This is a pre-filled field, but can be modified.
Did the patient not receive an
influenza immunization during the flu
season 8/1/2012 - 3/31/2013 for one of
the following reasons?
Valid Values:
 Documentation of medical reason(s) for not
receiving an influenza immunization during
the flu season (e.g., patient allergy, other
medical reasons)
 Documentation of patient reason(s) for not
receiving an influenza immunization during
the flu season (e.g., patient declined, other
patient reasons) (e.g., patient declined, other
patient reasons)
 Documentation of system reason(s) for not
receiving an influenza immunization during
the flu season (e.g., vaccine not available,
other system reasons)
 No medical, patient, or system reason
documented
Comments (Optional)
Allows for additional comments. This field is optional.
Table 13: PREV-7 Field Description
4.3.3.14 Data Entry – Preventive Care & Screening (PREV-8)
To access the data entry form for PREV-8, click on the ‘PREV-8’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-8’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive
Care & Screening (PREV-8)’ will display in the content area. The PREV-8 screen includes
PREV-8 and General Comments.
Data Element
Description
PREV-8: Pneumococcal Vaccination
for Patients 65 Years and Older
Patients having ever received a pneumococcal
vaccination.
Pneumococcal vaccine ever received
Valid Values: Yes or No
This is a pre-filled field, but can be modified.
Documentation of medical reason(s)
for not ever receiving pneumococcal
vaccination
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Valid Values: Yes or No
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Data Element
Description
Comments (Optional)
Allows for additional comments. This field is optional.
Table 14: PREV-8 Field Description
4.3.3.15 Data Entry – Preventive Care & Screening (PREV-9)
To access the data entry form for PREV-9, click on the ‘PREV-9’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-9’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-9)’ will display in the content area. The PREV-9 screen includes PREV-9
and General Comments.
Data Element
PREV-9: Body Mass Index (BMI)
Screening and Follow-Up
Description
Percentage of patients aged 18 years and older with
a calculated BMI in the past six months or during the
current visit documented in the medical record AND
if the most recent BMI is outside of normal
parameters, a follow-up plan is documented within
the past six months or during the current visit.
Determine the most recent office visit, and look back
up to 6 months from that date to find the most recent
BMI. If the most recent BMI is outside of normal
parameters based on the patient's age on the first
day of the measurement period, a follow-up plan
must be documented within the past six months or
during the current visit.
Calculated BMI or follow-up plan for BMI outside of
normal parameters that is documented in the
medical record may be reported if done in the
provider’s office/facility or if obtained by the provider
from outside medical records within the past six
months.
The documented follow-up interventions must be
related to the BMI outside of normal parameters,
example: “Patient referred to nutrition counseling for
BMI above normal parameters”.
Body Mass Index (BMI) calculated at
the most recent visit or within the six
months prior to that visit
Valid Values: Yes or No
Most recent calculated BMI value
1 (one) to 300 (three hundred)
Body mass index (BMI) is expressed as
weight/height (BMI; kg/m2) and is commonly used to
classify weight categories.
Normal Parameters:
Age 18 – 64 years BMI 18.5 and 25
Age 65 years and older BMI 23 and 30
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Data Element
Description
Calculated BMI-Requires an eligible professional or
their staff to measure both the height and weight.
Self-reported values cannot be used. BMI is
calculated either as weight in pounds divided by
height in inches squared multiplied by 703, or as
weight in kilograms divided by height in meters
squared.
Follow-up plan documented when
most recent BMI is outside of normal
parameters:
Valid Values: Yes or No
Was the patient´s BMI not
documented as normal OR was the
documented BMI outside parameters
with a follow-up not performed for
one of the following reasons?
Valid Values:
 Documentation of medical reason(s) for not
having a BMI measurement performed during
the measurement period (e.g., patient is
receiving palliative care, patient is pregnant
or patient is in an urgent or emergent medical
situation where time is of the essence and to
delay treatment would jeopardize the
patient’s health status)
 Documentation of patient reason(s) for not
having a BMI measurement performed during
the measurement period (e.g., patient refuses
BMI measurement or if there is any other
reason documented in the medical record by
the provider explaining why BMI
measurement was not appropriate)
 No medical or patient reason documented
Follow-up Plan-Proposed outline of treatment to be
conducted as a result of a BMI out of normal
parameters. Such follow-up may include but is not
limited to: documentation of a future appointment,
education, referral (such as, a registered dietician,
nutritionist, occupational therapist, physical therapist,
primary care provider, exercise physiologist, mental
health professional or surgeon), pharmacological
interventions, dietary supplements, exercise
counseling or nutrition counseling.
Not Eligible/Not Appropriate for BMI Measurement or
Follow-Up Plan – A patient is not eligible if one or
more of the following reasons exists:
 Patient is receiving palliative care
 Patient is pregnant
 Patient refuses BMI measurement
 If there is any other reason documented in
the medical record by the provider explaining
why BMI measurement or follow-up plan was
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Data Element
Description

Comments (Optional)
not appropriate
Patient is in an urgent or emergent medical
situation where time is of the essence and to
delay treatment would jeopardize the
patient’s health status.
Allows for additional comments. This field is optional.
Table 15: PREV-9 Field Description
4.3.3.16 Data Entry – Preventive Care & Screening (PREV-10)
To access the data entry form for PREV-10, click on the ‘PREV-10’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-10’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-10)’ will display in the content area. The PREV-10 screen includes PREV10 and General Comments.
Data Element
Description
PREV-10: Tobacco Use: Screening
and Cessation Intervention
Patients with tobacco cessation counseling
intervention received if the patient was identified as a
tobacco user during the measurement period or the
year prior to the measurement period.
Screened for tobacco
Valid Values: Yes or No
Most recent tobacco screening date
during the measurement period or
the year prior to the measurement
period
MM/DD/YYYY Format
Tobacco User
Valid Values: Yes, No or Unknown
If there is more than 1 patient query regarding
tobacco use, use the most recent.
Includes use of any type of tobacco.
If tobacco use status of a patient is unknown, the
patient cannot be counted in the numerator and
should be considered a measure failure. Instances
where tobacco use status of “unknown” is recorded
include: 1) the patient was not screened; or 2) the
patient was screened and the patient (or caregiver)
was unable to provide a definitive answer. If tobacco
use status of “unknown” is recorded but the patient
has an allowable medical exception, then the patient
should be removed from the denominator of the
measure and reported as a valid exception.
Cessation counseling intervention
for tobacco users
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Valid Values:
 Counseling
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Data Element
Description



Prescription for smoking cessation agents
o If value selected enter the C Smoking
cessation agents prescription order
date within the measurement period
or the year prior to the measurement
period in MM/DD/YYYY format.
Current medication list during the
measurement period included smoking
cessation agents
No cessation counseling intervention
documented within the specified timeframe
Cessation counseling Intervention-Includes brief
counseling (3 minutes or less), and/or
pharmacotherapy.
Documentation of medical reason(s)
for not screening for tobacco use
Valid Values: Yes or No
Comments (Optional)
Allows for additional comments. This field is optional.
Table 16: PREV-10 Field Description
4.3.3.17 Data Entry – Preventive Care & Screening (PREV-11)
To access the data entry form for PREV-11, click on the ‘PREV-11’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-11’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-11)’ will display in the content area. The PREV-11 screen includes PREV11 and General Comments.
Data Element
PREV-11: Screening for High Blood
Pressure and Follow-Up Documented
Description
Patients seen during the measurement period,
screened for high blood pressure (BP) AND a
recommended follow-up plan is documented based
on the most recent blood pressure reading as
indicated.
This measure only needs to be reported once per
measurement period
Screened for high blood pressure
(BP)
Valid Values: Yes or No
Pre-Hypertensive BP Reading: SBP ≥ 120 and ≤ 139
OR DBP ≥ 80 and ≤ 89. Indicated Follow-Up:
Rescreen BP within a minimum of one year AND
Recommend Lifestyle Modifications OR Referral to
Alternative/Primary Care Provider
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Data Element
Description
First Hypertensive BP Reading: SBP ≥ 140 OR DBP
≥ 90. Indicated Follow-Up: Rescreen BP within a
minimum of ≥ 1 day and ≤ 4 weeks AND
Recommend Lifestyle Modifications OR Referral to
Alternative/Primary Care Provider
Second Hypertensive BP Reading: BP Reading:
SBP ≥ 140 OR DBP ≥ 90. Indicated Follow-Up:
Recommend Lifestyle Modifications AND one or
more of the Second Hypertensive Reading
Interventions OR Referral to Alternative/Primary
Care Provider
Both the systolic and diastolic blood pressure
measurements are required for inclusion. If there are
multiple BPs on the same date of service, use the
lowest systolic and lowest diastolic BP on that date
as the representative BP.
If there is more than one BP performed, use the
value on the most recent date.
Most recent Systolic BP in mmHg
0 (zero) to 350 (three hundred fifty)
Most recent Diastolic BP in mmHg
0 (zero) to 350 (three hundred fifty)
Most recent BP date during the
measurement period
MM/DD/YYYY Format
Recommended follow-up plan
documented
Valid Values: Yes or No
Recommended follow-up based on BP Classification
includes: Recommending screening interval followup, lifestyle modifications, and referrals to
alternative/primary care provider, anti-hypertensive
pharmacological therapy, laboratory tests, or an
electrocardiogram (ECG).
Lifestyle Modifications: The current JNC report
outlines lifestyle modifications which must include
one or more of the following as indicated: Weight
Reduction, DASH Eating Plan, Dietary Sodium
Restriction, Increased Physical Activity, or
Moderation in Alcohol Consumption
Indicated BP Follow-Up by BP Classification: Normal
BP Reading: Systolic Blood Pressure (SBP) < 120
AND Diastolic Blood Pressure (DBP) < 80. Additional
follow-up NOT indicated
Date recommended follow-up plan is
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MM/DD/YYYY Format
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Data Element
Description
documented
Did the patient not receive screening
for high blood pressure for one of
the following reasons?
Valid Values:
 Documentation of medical reason(s) for not
receiving screening for high blood pressure
(e.g., patient has an active diagnosis of
hypertension, patient is in an urgent or
emergent situation where time is of the
essence and to delay treatment would
jeopardize the patient’s health status. This
may include, but is not limited to severely
elevated BP when immediate medical
treatment is indicated)
 Documentation of patient reason(s) for not
receiving screening for high blood pressure
(e.g., patient refuses BP measurement)
 No medical or patient reason documented
Comments (Optional)
Allows for additional comments. This field is optional.
Table 17: PREV-11 Field Description
4.3.3.18 Data Entry – Preventive Care & Screening (PREV-12)
To access the data entry form for PREV-12, click on the ‘PREV-12’ tab from the list of modules,
which are displayed on the left side of the screen. The ‘PREV-12’ tab will change to a dark blue
background to indicate it is the active tab selected. Additionally, the heading of ‘Preventive Care
& Screening (PREV-12)’ will display in the content area. The PREV-12 screen includes PREV12 and General Comments.
Data Element
Description
PREV-12: Screening for Clinical
Depression and Follow-Up Plan
Patients that were screened for clinical depression
using an age appropriate standardized tool during
the measurement period AND if positive, a follow-up
plan is documented on the date of the positive
screen.
Screened for clinical depression
using an age appropriate
standardized depression screening
tool
Valid Values: Yes or No
Completion of a clinical or diagnostic tool used to
identify people at risk of developing or having a
certain disease or condition, even in the absence of
symptoms.
Standardized Clinical Depression Screening Tool – A
normalized and validated depression screening tool
developed for the patient population where it is being
utilized. Examples of depression screening tools
include but are not limited to:
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Data Element
Description
Adolescent Screening Tools (12-17 years)
Patient Health Questionnaire for Adolescents (PHQA), Beck Depression Inventory-Primary Care Version
(BDI-PC), Mood Feeling Questionnaire, Center for
Epidemiologic Studies Depression Scale (CES-D)
and PRIME MD-PHQ 2
Adult Screening Tools (18 years and older)
Patient Health Questionnaire (PHQ-9), Beck
Depression Inventory (BDI or BDI-II), Center for
Epidemiologic Studies Depression Scale (CES-D),
Depression Scale (DEPS), Duke Anxiety-Depression
Scale (DADS), Geriatric Depression Scale (GDS),
Cornell Scale Screening and PRIME MD-PHQ 2
Clinical Depression screening date
during the measurement period
MM/DD/YYYY Format
Clinical Depression screening result
Valid Values: Positive or Negative
Date follow-up plan is documented
MM/DD/YYYY Format
Follow-Up Plan – Proposed outline of treatment to be
conducted as a result of positive clinical depression
screening. Follow-up for a positive depression
screening must include one or more of the following:
 Additional evaluation
 Suicide Risk Assessment
 Referral to a practitioner who is qualified to
diagnose and treat depression
 Pharmacological interventions
 Other interventions or follow-up for the
diagnosis or treatment of depression
Did the patient not receive screening
for clinical depression using an age
appropriate standardized tool for one
of the following reasons?
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Valid Values:
 Documentation of medical reason(s) for not
having screening for clinical depression
performed during the measurement period
(e.g., patient is in an urgent or emergent
medical situation where time is of the
essence and to delay treatment would
jeopardize the patient’s health status,
situations where the patient’s functional
capacity or motivation to improve may impact
the accuracy of results of standardized
depression assessment tools [For example:
certain court appointed cases or cases of
delirium], or patient has an active diagnosis
of depression or bipolar disorder)
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Data Element
Description


Comments (Optional)
Documentation of patient reason(s) for not
having screening for clinical depression
performed during the measurement period
(e.g., patient refuses to participate)
No medical or patient reason documented
Allows for additional comments. This field is optional.
Table 18: PREV-12 Field Description
4.3.3.19 Data Entry Save & Cancel Form Action Icons
Each data entry screen content area displays a title/menu bar and a footer bar with a set of
Save and Cancel form action buttons.
This is the Save button. To save data entered for the selected data entry module
the save button must be selected prior to navigating away from the module or
exiting QMAT. The screen will be updated to display any errors and/or warnings
when the Save button is clicked. A success message will be displayed upon a
successful save, and an error message will be displayed if errors prevent the data
from saving.
This is the Cancel button. When the cancel button is clicked any data entered into
the selected data entry module will be cleared and no data will be saved. Any prepopulated editable data form fields will return to the original state.
4.3.3.20 Validate Patient Record
This icon represents the validation button. To validate the information manually
entered or uploaded (through the Data Upload functionality) select the Validate icon.
When the validate icon is selected the system will display a slide box under the Title
Bar. Warnings can be generated after cross module validation of shared data
elements or when a patient is no longer qualified for a module due to a change in the
patient’s date of birth or gender.
Figure 46: Validation Warnings
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This is the Warning Icon. If any warnings exist this icon will be displayed. To close the
Validation Warnings click this icon or the close icon.
To close the Validation slide box, click the Validate icon or the close icon.
The sortable column headers of the data table are clickable to re-sort the list of warnings. The
table includes the following information:
1. Type –Error or Warning
2. Module/Measure-The Module or Measure containing the validation warning
3. Element-The Data Entry Data element with the validation warning
4. Description-Details for the validation warning displayed
When a warning is present the data entered will be saved. To locate the warning click the
hyperlinked element to be taken directly to that module. To download the validation warnings
click the Download button. The validation warnings will be available for download in Excel
format. To print the Validation Warnings Report click the Print button. The validation warnings
will display in a browser window formatted for printing.
4.3.3.21 Patient Record Help Icons
The patient record area of the Data Entry screen contains two context sensitive help icons. The
first icon is located on the Title Bar and the second is located within the selected measure data
entry area.
The help icons represent help information for the items in the Title bar as well as all
elements in the Data Entry content area. Each help icon is displayed in a separate
window on top of the screen. The help window can be dragged and moved to the
desired placement.
To close the help window click the Close icon.
4.3.4 Consecutively Completed & Confirmed
All beneficiaries included in the sample for the module are ranked from one to the total number
of sampled beneficiaries. For the 2013 Program year, the minimum reporting requirement is 411
consecutively completed and confirmed beneficiaries, or 100% reporting if less than 411. Each
beneficiary should be removed from the sample due to a valid disqualification reason, the age or
gender not meeting the requirements for that module, or if the medical record cannot be found
must have data entered into QMAT to support removing the beneficiary, the beneficiary will
display as “complete” for the module(s). All beneficiaries that are not removed from the sample
will be “incomplete” until all required data elements have valid data entered and saved. The
number of consecutively completed and confirmed beneficiaries is displayed in the “Group
Status” and the “Total beneficiaries used for analysis.” The Group Status will show the number
of beneficiaries counting toward the minimum requirements for satisfactory reporting in each
module.
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Within the Completion Status Report, the Total Beneficiaries used for Analysis, contains the
number of consecutively confirmed and completed beneficiaries in the module. The count of
Total Beneficiaries used for Analysis starts with the beneficiary ranked #1 and increments until
an incomplete beneficiary is found. Any beneficiaries prior to the first incomplete beneficiary that
was removed from the sample for a valid reason will be subtracted to determine the number of
beneficiaries used for analysis.
Example #1
This example shows a scenario where there are less than 411 patients under a module. In
this example, there are 85 patients ranked under the DM module. One record is incomplete and
one completed record was skipped (DM not confirmed, Medical record not found, OR Patient
not qualified for sample). If a record is skipped, it is considered as “completed” but is not
included in the records used for analysis to meet the minimum requirement.
DM Rank
DM Status
DM Confirmed/ Patient Qualified for Sample/ &
Medical Record Found (aka Not Skipped)
1
Completed
Yes
2
Completed
Yes
3
Completed
Yes
4….80
Completed
Yes
81
Completed
No
82
Completed
Yes
83
Incomplete
Yes
84
Completed
Yes
85
Completed
Yes
Table 19: DM Rank and Status
Example #1 Calculation:
DM: Total Ranked
Beneficiaries
85
Completed
84
Incomplete
1
Total Beneficiaries Used
for Analysis
81 (DM rank 1 to 80 and 82 since 83 were incomplete and
81 were skipped)
Table 20: DM Total Ranked Beneficiaries
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In the above example, the minimum number of records required is not met since the total number
of completed records is not equal to the total number of all patients ranked under the DM
module. If the patient with DM rank of 83 is completed, the minimum requirement for this module
will be met because 100% of the patients would be completed.
Example #2
This example assumes there are 615 patients under the PREV-5 module. There is one
incomplete record and one completed record was skipped (DM not confirmed, Medical record not
found, OR Patient not qualified for sample). If a record is skipped, it is considered as
“completed” but is not included in the records used for analysis to meet the minimum
requirement. Note: 615 is the maximum number of patients that can be assigned under a
module.
PREV-1 Rank
PREV-1
Status
PREV-1 Confirmed/ Patient Qualified for Sample/ &
Medical Record Found (aka Not Skipped)
1
Completed
Yes
2
Completed
No
3
Completed
Yes
4….409
Completed
Yes
410
Completed
Yes
411
Incomplete
Yes
412
Completed
Yes
413
Completed
Yes
414…615
Incomplete
Yes/Blank
Table 21: PREV-1 Rank and Status
Example #2 Calculations
PREV-1 Total Ranked
Beneficiaries
615
Completed
412
Incomplete
202
Total Beneficiaries Used
for Analysis
409 (PREV-1 rank 1 and 3 to 410 since 2 were skipped and
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411 were incomplete)
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Table 22: PREV-1 Total Ranked Beneficiaries
In the above example the minimum requirement was not met because the total number of DM
patients that will be included in the analysis is 409. The total will increase to 412 if the patient
with DM rank of 411 is completed and his/her DM Confirmed is kept at "Yes." The value of "No"
under the DM Confirmed column for patient with DM rank of 2 excluded that record in the
analysis. The incomplete record of the patient with DM rank of 411 breaks the consecutive
completed records from 1 to 410. As a result, records with DM rank of 411 and above will not be
counted even if their DM condition has been confirmed. The records ranked 414 to 615 are
incomplete so they will not be considered in the analysis, even if their DM condition has been
confirmed. If the patient with DM rank of 411 is completed the minimum requirement for this
module will be met.
4.4
Data Submission
The QMAT Data Submission page is accessed by selecting the Data Submission link from the
QMAT Home page or the Main Menu Bar. The Data Submission Page displays the Main Menu
Bar and the ACO Info Bar. The Data Submission content area provides information about the
reporting period date range and provides a check box for authorized users to affirm the
information is correct and ready to be submitted. The Submit button is originally disabled. The
Submit button is enabled once the check box is checked.
Figure 47: Data Submission
Once the user clicks the “Submit” button a confirmation window will pop up with an alert that the
submission is final once submitted and there will no longer be the ability to make changes.
Figure 48: Data Submission Confirmation Window
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After clicking “Yes, Submit” the confirm pop-up window will close and the Data Submission page
will display a thank you message, the date and time the data was submitted and help desk
contact information is displayed.
Figure 49: Data Submission Complete
4.5 Measures Specs
The QMAT Measures Specs is accessed by selecting the Measures Specs link from the QMAT
Home page or the Main Menu Bar.
The current version of the Pioneer ACO QMAT EHR Data Upload Specifications can be viewed
by selecting the Measures Specs link.
4.6 Help Docs
The QMAT Help Docs is accessed by selecting the Help Docs link from the QMAT Home page or
the Main Menu Bar. The current version of the QMAT User Manual can be viewed by selecting
the Help Docs link.
4.7 QMAT BI Reports
The QMAT BI Reports are accessed by selecting the QMAT BI Reports tab on any QMAT page,
as seen in the figure below.
Figure 50: QMAT BI Reports tab
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4. Using the System
The Report options and information that displays within a report is determined by the user’s role.
If the user does not have the authority to view a report, the report will not be visible for the user
to select. Listed below are the QMAT Reports that are available:



Completion Status Report
Pre-filled Comparison Report
Beneficiary Summary Report
4.7.1 Completion Status Report
The Completion Status Report (in the figure below) is visible to both CMS and ACOs. An ACO
can only see information for their ACO when the report is generated. The report displays the
completion status of each module. The following data fields are present on the Report:
1. Reporting Period: The period during which Pioneer ACO measures are to be reported
for covered professional services provided.
2. ACO Name and ID: An ACO refers to a group of providers and suppliers of services
(e.g., hospitals, physicians and others involved in patient care) that will work together to
coordinate care for the Medicare Fee-For-Service patients they serve.
3. Module: a module represents one or more measures grouped together for reporting
that have the same or similar populations. Pioneer ACO includes 15 modules.
4. Total Ranked Beneficiaries: The total number of beneficiaries assigned to a module.
5. Completed: All required elements under a module have been supplied and there are no
invalid values for the module. Clicking on a value in this column will generate the
detailed beneficiary-level information.
6. Incomplete: At least one required element does not have a valid value for the module.
Clicking on a value in the column will generate the detailed beneficiary-level information.
7. Total Skipped Beneficiaries: Number of patients who are skipped with a valid reason
code for a given Module and ACO. Reasons include: Medical Record not Found,
Diagnosis not Confirmed (if applicable), Not Qualified for Sample (In Hospice, Moved
out of Country, Deceased, Enrolled in MO, or Other CMS Approved Reason). Clicking a
value in this column will generate the detailed beneficiary-level information.
8. Total Beneficiaries Used for Analysis: The number of consecutively completed
beneficiaries minus the total count of beneficiaries skipped prior to the first patient
marked as “incomplete.” Clicking a value in the column will display how this was
calculated.
9. Reporting Minimum Requirement Met or Not: An indicator for reporting successfully
based on the sample method selected by the ACO or for the reporting period.
To run the Completion Status Report
1.
2.
3.
4.
5.
6.
Hover over the Completion Status Report icon. Show completion status report displays.
Select the Completion Status Report icon
User roles with access to view multiple ACOs information will have the following
options display:
a. All ACOs
b. Choose an ACO
Check “Choose an ACO” to limit the report to an ACO or specific ACOs
Click the Cancel button will cancel report creation
Click the Run Report button to proceed
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7.
8.
9.
4. Using the System
Select the ACOs
Click the run Report button
The Completion Status Report displays for the selected ACOs
Figure 51: Completion Status Report
The QMAT Total Beneficiaries Used for Analysis can be identified by clicking on the Total
Beneficiaries Used for Analysis link. The QMAT Total Beneficiaries used For Analysis displays,
as seen in the figure below. The following fields are present on the report:
1. ACO Name and ID: An ACO refers to a group of providers and suppliers of services
(e.g., hospitals, physicians and others involved in patient care) that will work together to
coordinate care for the Medicare Fee-For-Service patients they serve.
2. Module: a module represents one or more measures grouped together for reporting that
have the same or similar populations. Pioneer ACO includes 15 modules.
3. Sample Method: The method used to determine the sample population, including the
minimum reporting requirements.
4. Total Ranked Beneficiaries: The total number of beneficiaries assigned to a module.
5. Max Consecutively Completed (beneficiary prior to the first ranked beneficiary
that is Incomplete (A): The rank number of the patient prior to the first patient with a
status of incomplete.
6. Total Number of Skipped beneficiaries before the first beneficiary that is
Incomplete (B): Number of patients who are skipped with a valid reason code for a
given Module and ACO. Reasons include: Medical Record not Found, Diagnosis not
Confirmed (if applicable), Not Qualified for Sample (In Hospice, Moved out of Country,
Deceased, Enrolled in MO, or Other CMS Approved Reason). Clicking a value in this
column will generate the detailed beneficiary-level information.
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7. Total Beneficiaries Used for Analysis (A-B): The number of consecutively completed
beneficiaries minus the total count of beneficiaries skipped prior to the first patient
marked as “incomplete.” Clicking a value in the column will display how this was
calculated.
8. Minimum Requirement Met or Not: An indicator for reporting successfully based on
the sample method selected by the ACO or for the reporting period.
<INSERT SCREEN SHOT HERE>
Figure 52: QMAT Total Beneficiaries Used for Analysis Report
4.7.2 Pre-filled Comparison Report
The Pre-filled Comparison Report is accessible to authorized users, as seen in the figure below.
The report lists the values that were pre-filled in the database during the beneficiary sampling.
This report shows all the fields that have been changed from their pre-filled values. The prefilled value displays, as well as the current value, and an indicator if the current value is different
than the pre-filled value. All possible pre-filled values are included on the report, but the report
will not contain values if the patient is not ranked in the associated module. The following data
fields are present in the report:
1.
Reporting Period: The period during which Pioneer ACO measures are to be
reported for covered professional services provided
2. ACO: An ACO refers to a group of providers and suppliers of services (e.g., hospitals,
physicians, and other involved in patient care) that will work together to coordinate
care for the Medicare Fee-For-Service patients they serve.
3. Beneficiary Name: Name of the Beneficiary
4. Measure: Measure used by CMS to determine quality of care using nationally
recognized measures in four key domains:
a. Care coordination/patient safety
b. Preventive health
c. At-risk population: Diabetes Mellitus, Hypertension, Ischemic Vascular Disease,
Heart Failure, and Coronary Artery Disease, Pioneer ACO included 22 measures
for 2013 reporting period
5. Element: Represents the data element name that was populated by pre-filled data
received from PAC
6. Pre-filled Source: Source of the data element value received from PAC before the
update by the ACO
7. Pre-filled Value: Data element value received from PAC before the update by the
ACO
8. New Value: Data element value after the update by the ACO
9. Changed: An indicator whether the data element value was changed by the Abstractor
for the ACO
10. Consistency Check Verification: The process of determining if the values of two
closely related elements under different modules are the same.
To run the Pre-Filled Comparison Report
1.
2.
3.
4.
Hover over the Completion Status Report icon. The following options display:
Select the Pre-Filled Comparison Report icon
Select the ACO from the ACO drop down list
Select the beneficiary from the Beneficiary list
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4. Using the System
The Report displays
Figure 53: Prefilled Comparison Report
4.7.3 Beneficiary Summary Report
The Beneficiary Summary Report is accessible to authorized users, as seen in the figure below.
The Beneficiary Summary report displays all the information provided for the selected
beneficiary. The beneficiary’s demographic data is displayed at the top of the report; beneath it
is the data from each tab of the patient’s record. The source of data will be displayed for each
data element. Refer to the Data Entry section of the User Guide for field definitions for each field
value.
To run the Beneficiary Summary Report
1. Hover over the Completion Status Report icon. The following options display:
2. Select the Beneficiary Summary Report icon
Figure 54 shows the Beneficiary patient ranked in CAD.
<Insert Screen shot of Beneficiary Summary Report>
Figure 54: Beneficiary Summary Report
4.7.2 ACO Overall Status Report
The ACO Overall Status Report is accessible to authorized users (Figure 4.7.6 ACO Overall
Status Report). This report shows the actions performed by each ACO of the QMAT that are
recorded and stored in the database. Actions recorded include any changes to beneficiary
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records. The log stores dates and times of all actions along with the username of the user who
performed them, and the Beneficiary name, if the action was on a specific beneficiary. Users
can display the actions taken by a specific user, by all users on a single beneficiary, or by all
actions for all users on all beneficiaries. The following data fields are present in the report.
1. Reporting Period: The period during which Pioneer ACO measures are to be reported
for covered professional services provided
2. ACO: An ACO refers to a group of providers and suppliers of services (e.g., hospitals,
physicians, and others involved in beneficiary care) that will work together to coordinate
care for the Medicare Fee-For-Service beneficiaries they serve
3. ACO Primary TIN: ACO Primary Tax Identification Number (TIN)
4. # of Times TIN Connected to Submission Portal: Number of Connections per ACO to
QMAT Application Portal
5. # of NPIs in TIN During Qualification: Number of National Provider Identifier
associated with a TIN during Measurement Period
6. Current # of Accepted File Submissions : Number of accepted File submissions per
ACO
7. Current # of Rejected File Submissions : Number of Rejected File submissions per
ACO
8. Current # of Beneficiaries with accepted file Submission: Number of unique
Beneficiaries with accepted file submissions per ACO
9. Date Last Record Updated: Most Recent Date of Manual Submission Recorded as
Complete by Submitter for a measurement period
10. Current % of Sample Complete: Percentage of Sample completed for an ACO for a
measurement period
11. Avg Time Spent/Login (MM:SS): Total time spent on QMAT tool/Total Logins.
12. Avg Time Spent/Beneficiary (MM:SS): Total Time Spent on QMAT tool/Total
beneficiaries
13. Approved Unlock Request? (Y/N): An Indicator to identify whether an ACO had an
unlock request granted by CMS after the attestation
14. Total Unlocked Beneficiary Record Updated: Number of Beneficiaries whose records
have been updated after the approval of Unlock request
To run the ACO Overall Status Report
1. Hover over the ACO Overall Status Report icon. The following options display:
Select the ACO Overall Status Report icon
<Insert Screen shot of Overall Status Report>
Figure 55: ACO Overall Status Report
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5. Troubleshooting & Support
5. Troubleshooting & Support
5.1 Error Messages
A pop-up warning will display when there has been 24 minutes of inactivity on the website. The
user can react to the warning before the Portal session becomes inactive.
Error messages regarding invalid data, backend being down, etc. have to be determined.
5.2 Support
The QualityNet Help Desk is available from 7 am – 7 pm (CT), Monday through Friday.
1.
2.
3.
4.
Phone: (866) 288-8912
TTY: (877) 715-6222
Fax: (888) 329-7377
QNet E-mail: QNetSupport@SDPS.org
.
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Acronyms
Acronyms
Acronym
Literal Translation
ACO
Accountable Care Organization
ARS
Acceptable Risk Safeguard
CAD
Coronary Artery Disease
CMMI
Center for Medicare & Medicaid Innovation
CMS
Centers for Medicare & Medicaid Services
EIDM
Enterprise Identity Management
HF
Heart Failure
HICN
Health Insurance Claim Number
HTN
Hypertension
IDR
Integrated Data Repository
IS
Information Services
ISG
Information Systems Group
NPI
National Provider Identifier
OCSQ
Office of Clinical Standards and Quality
OIS
Office of Information Systems
PAC
Program Analysis contractor
PHI
Protected Health Information
PII
Personally Identifiable Information
PY
Performance Year
QMAT
Quality Measures Assessment Tool
TIN
Taxpayer Identification Number
XLC
Expedited Life Cycle
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Acronyms
Table 23: Acronyms
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Glossary
Glossary
Term
Definition
Accountable Care Organization
Accountable care organization (ACO) refers to a group
of providers and suppliers of services (e.g., hospitals,
physicians, and others involved in patient care) that will
work together to coordinate care for the Medicare FeeFor-Service patients they serve.
PAC
The CMS contractor that is responsible for beneficiary
assignment, beneficiary sampling and extracting
Medicare claims information on health care services for
the purpose of pre-populating the QMAT.
Beneficiary Assignment
Medicare beneficiaries who are retrospectively or
prospectively assigned to, aligned with, or otherwise
deemed affiliated with the ACO due to specified and
established algorithm, usually based on the plurality of
services. ACOs are accountable for the expenditure and
quality of care associated with their assigned/aligned
beneficiaries.
NPI
The National Provider Identifier referred to in this
document is the individual, not organizational, NPI. This
provider identification is unique to each Medicare
provider and will be used by the ACO PAC to pre-fill the
provider table with the provider information (e.g., names,
credential, etc). The ACO PAC will also identify the
primary care provider fo reach patient sampled for the
QMAT based on the plurality of service algorithm.
Pre-population/Pre-fill
Beneficiary information from Medicare claims or
enrollment data that will be pre-filled into the QMAT.
Information will include names and unique identifiers of
the sampled beneficiaries, rank order number for the
consecutive completion purpose, their date of birth,
provider information, specific services received and
dates of such service.
QMAT
The data collection platform available through an internet
connection developed by CMS and the Quality
Measures Tool Contractor. ACOs will analyze and
submit patient information to the Quality Measures Tool
contractor to input into the QMAT during late
Winter/early Spring each year. Results obtained through
the QMAT will be used for further quality scoring by the
ACO PAC for financial settlement. The QMAT is referred
as the ‘target’ system.
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Sampling
Glossary
Pioneer ACOs will not be required to do medical record
abstraction for all of their assigned beneficiaries. Pioneer
ACOs are only required to report a minimum of 411
consecutively completed beneficiaries (or 100%) if fewer
than 411 beneficiaries remain) in each module to be
deemed “successfully completed.” ACOs also have the
option to report above and beyond the 411 minimum
patients. The ACO PAC will conduct random sampling of
beneficiaries meeting the denominator criteria in each
condition module and provide a random sample of 616
beneficiaries in each module (411 + a 50% oversample).
Table 24: Glossary
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Record of Changes
Record of Changes
Date
Version
Description
Name
09/12/2013
0.1
First Draft
Sue Baer, Liz
Reese
9/23/2013
0.2
Incorporated feedback from internal review
sessions throughout document
Sue Baer
9/25/2013
0.3
Technical Edit Review
Sarah Fooks
Table 25: Record of Changes
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Approvals
Approvals
The undersigned acknowledge that they have reviewed the User Manual and agree with the
information presented within this document. Changes to this User Manual will be coordinated
with, and approved by, the undersigned, or their designated representatives.
Signature:
Date:
Print Name:
Title:
Role:
Submitting Organization’s Approving Authority
Signature:
Date:
Print Name:
Title:
Role:
CMS’ Approving Authority
Signature:
Date:
Print Name:
Title:
Role:
CMS Business Owner
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