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2019 Statewide Quality Reporting and Measurement System (SQRMS) Update

The Minnesota Department of Health (MDH) will not promulgate a Health Care Quality Rule for the 2019 reporting year because there are no significant changes to the reporting requirements for physician clinics and hospitals. In its place, MDH will issue technical guidance in November about any changes measure stewards have made to measure specifications and the removal of several hospital measures to maintain alignment with Centers for Medicare & Medicaid Services requirements.

In parallel, MDH expects to continue making progress in the development of the legislatively required quality measurement framework that will inform Minnesota’s approach to measurement in the future. MDH will provide a status update to the Legislature this year, continue developing the framework during 2019, and begin the implementation process in 2020.


Upcoming MNCM Reports

MNCM is launching a new report series this fall, organizing results by measurement focus area. These reports bring together performance results on both quality and health equity for measures relevant in each category.

The series is intended to provide a more in-depth, user-friendly view of measure results that can more effectively draw attention to the wealth of data that MNCM publishes, engage stakeholder audiences more effectively, inform discussions, and catalyze improvement.

The new reports present content more concisely using design, context, and streamlined visual displays. The 2018 series will include reports on the following themes:

  • The first report in the series will be on depression measures, scheduled for release in late October.
  • Other topic reports will focus on chronic and acute conditions, preventive health screenings, and child and adolescent health.
  • MNCM will continue to publish summary reports for cost, quality, health equity, and disparities.

Reducing the Burden of Data Reporting

Based on provider feedback, internal assessments, and market research, MNCM is in the process of developing a new suite of software to alleviate provider data reporting burden. The new approach will allow MNCM to implement automated data extraction methods with participating providers to retrieve encounter data necessary for measurement. Once encounter data is retrieved, MNCM will be able to apply measurement specifications centrally to determine the appropriate measure denominators and numerators reducing the burden of data reporting for medical groups.

Pilot Testing

MNCM is currently recruiting provider organizations to pilot this approach and expects to begin pilot testing in early 2019. Organizations that are interested in reducing their reporting burden can contact Will Muenchow, Director of Information Technology and Data Integrity, at


Annual Clinic and Provider Registration Opens November 1

The MN Community Measurement (MNCM) Data Portal will open November 1 for annual clinic and provider registration. Every year, all eligible Minnesota clinics and providers are required to register and update their information.

How to Register

To get started, draft instructions are available for download from the MNCM Data Portal Resources tab. If you have not registered with MNCM previously, please request a portal account. Registration is a prerequisite to submitting data for the clinical quality measures in 2019. Although the portal will be open for registration through February 8, 2019, we encourage you to register early.

There are no expected changes to the registration requirements this year. Please stay tuned for communication from MNCM when the portal is officially open. Final instructions and a recorded webinar will be available at that time as well.

MNCM’s New Helpdesk System

MNCM will be implementing a new helpdesk system for data submitters. The new system is being developed and will be launched in November. Data submitters will be able to submit and track questions as well as find answers to common technical questions about MNCM measures – all in one place.

Questions? Please contact MNCM at 612-746-4522 or


Other News and Events

National Affordability Summit logo

As part of the Network for Regional Healthcare Improvement (NRHI), MNCM invites you to participate in shaping the dialogue about, and solutions to, health care affordability at NRHI’s Annual National Affordability Summit on October 4.

NRHI’s first National Affordability Summit uncovered the reasons health care costs so much and what we can do about it. This year’s event will dig deeper, exploring how three key issues − health, price, and waste − influence affordability. The theme of this year’s summit is “Positive Disruption through Regional Multi-Stakeholder Solutions.”

In-Person Event Information:
Thursday, Oct. 4, 2018
Ronald Reagan International Trade Center
1300 Pennsylvania Avenue, NW
Washington, DC 20004
live event information >>

A live stream will also be available. live stream information >>


MNCM Board Updates

MNCM has recently welcomed two new members to its Board of Directors – Deb Krause, vice president of the Minnesota Health Action Group, and Mariam Mohmed, an independent consultant who will serve as a consumer representative.

Deb Krause

Deb Krause is vice president of the Minnesota Health Action Group, a coalition of public and private purchasers whose sole purpose is to represent the collective voice of those who write the checks for health care in Minnesota. Deb also represents employers/purchasers on MNCM’s Measurement and Reporting Committee (MARC), Measure Review Committee (MRC), and Cost Technical Advisory Committee (TAG), for which she is the 2017/2018 Chair.

Before joining the Health Action Group, Deb was a partner at Hewitt Associates and a principal at Mercer, where she provided strategic guidance to employers for over 25 years. Deb also served as director of social responsibility for UnitedHealth Group where her responsibilities included strategic planning, business unit consulting, measurement and reporting, and program development/management. Deb has been an active volunteer leader with nonprofit health and community organizations for more than 25 years. She is the 2018 Chair of the American Cancer Society’s Minnesota/Dakota Area Board, as well as past national, regional, and local volunteer leadership positions with the American Heart Association. Deb has a B.S. in business administration from Valparaiso University and an M.B.A. in finance from the University of Wisconsin—Madison.

Miriam Mohamed

Mariam Mohamed, a new consumer representative on MNCM’s Board of Directors, holds two master’s degrees, one from SUNY College of Environmental Science and Forestry and one from California State University, Fresno. Mariam has more than 30 years of board professional experience working with nonprofits, foundations, and public and private organizations. Mariam has worked with more than 30 organizations including international institutions. For the past 18 years Mariam has worked as an independent consultant with an expertise in program start-ups and turnarounds, assessments, plan implementation, strategic planning, and development systems implementations.

Undergirding Mariam’s work is her extensive experience of program analysis and evaluation in the private and nonprofit service arena. In addition to her extensive experience, Mariam is known as a trusted team member and builder of collaborative relationships among government, nonprofit, corporate, and community stakeholders. Mariam is currently serving as a yearly contract consultant for UCare. She is also a co-owner of Hoyo, a company founded on the goal of employing and empowering Somali women. Mariam is a much-called-upon consultant and advisor to government, nonprofit/profit agencies, and local communities.


Hospital Mortality and Readmission Measures Refreshed on MNHealthScores

MNCM recently refreshed several hospital measures on MNHealthScores:

  • 30-day Acute Myocardial Infarction (AMI) Mortality Rate
  • 30-day Heart Failure (HF) Mortality Rate
  • 30- day Pneumonia Mortality Rate
  • 30-day AMI Readmission Rate
  • 30-day HF Readmission Rate
  • 30-day Pneumonia Readmission Rate
  • 30-day Chronic Obstructive Pulmonary Disease (COPD) Readmission Rate
  • 30-day Total Knee or Hip Replacement Readmission Rate

The mortality measures have been refreshed for the period of April 1, 2014–March 31, 2017; the readmission measures reflect the period July 1, 2014–June 30, 2017 – accessed from data on CMS’s Hospital Compare website.

Hospitals are ranked for each measure compared to the national average. See the results at


New MNCM Cancer Care Measures, Symptom Control During Chemotherapy

While asking patients about their symptoms during chemotherapy is not a new concept for oncology care, measuring outcomes related to symptom control is new.
MN Community Measurement is excited to announce the development of new patient-reported outcome measures for the symptom control of nausea, pain and constipation during chemotherapy. The Symptom Control During Chemotherapy (SCDC) measures were successfully tested and approved for widespread implementation in oncology practices across Minnesota and surrounding communities. Implementation of the measures will include 2019 dates of service with data reported in 2020.

Collecting and submitting data for these measures will:

  • Support ongoing patient-centered care;
  • Provide data to help inform understanding of treatment tolerance enabling the continuation of therapy; and
  • Provide outcome rates that will support national endorsement of these measures.

To participate, the most important first step for oncology practices is to begin administration of the patient assessment tool prior to January 1, 2019. The tool needs to be integrated into clinical workflows to capture information reported by patients during Day 5 to 15 of each chemotherapy cycle; measurement occurs for cycles 1, 2 and 3. MNCM has obtained permission from the National Cancer Institute for the use of six individual questions from the Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) tool.

Educational Information and Resources:


Annual Seminar “Measurement Matters” Attended by Over 300

More than 300 attendees came together on September 12th at the Earle Brown Center to participate in MNCM’s Annual Seminar. Presentations included: Jan Malcolm, MDH Commissioner; Kevin Larsen, Director of Continuous Improvement and Strategic Planning at CMS; Daniel Wolfson, Executive Vice President and COO of the ABIM Foundation and “Choosing Wisely”; six breakout sessions featuring quality improvement and health care professionals sharing innovative quality improvement tools and practices, cross-sector collaboration efforts, and strategies to advance equity; and speakers from the MDH Sage program, which is advancing cultural competency through the use of International Medical Graduates to improve colorectal cancer screening rates in disparate populations. It was a great day of sharing relevant information and data!

If you attended, please remember to complete the evaluation to provide feedback and request either a CME or attendance certificate here.


MNCM Cancer Measures Approved for Implementation in the 2020 Report Year

MNCM’s Cancer Care Measure Development Workgroup recently completed pilot testing of four new patient reported outcome (PRO) based Symptom Control During Chemotherapy (SCDC) measures. The Workgroup concluded that the four measures tested are feasible to collect and demonstrate variation and opportunity for improvement. They recommended implementation of the measures for oncology practices in the 2020 report year (2019 dates of service).

The results of the pilot testing and the Workgroup’s measure recommendations were presented to the Measurement and Reporting Committee (MARC) at their meeting on February 14, 2018. MARC members had a thoughtful discussion and approved the recommendation as presented. The measures were approved by the MNCM Board on February 21, 2018. The measures include:

  1. Symptom Severity Assessment During Chemotherapy (process; PRO tool administration)
  2. Symptom Control During Chemotherapy: Pain (outcome)
  3. Symptom Control During Chemotherapy: Nausea (outcome)
  4. Symptom Control During Chemotherapy: Constipation (outcome)

These measures will support MNCM’s goals to include more specialty and patient reported outcomes (PRO) measures in our slate of measures for public reporting.

All oncology practices in Minnesota and surrounding communities are encouraged to begin implementing this symptom assessment tool in their practices in 2018 but no later than January 1, 2019. An educational webinar will be scheduled in the fall of 2018.

View Measure Development Workgroup Members, Chemotherapy Symptom Control Measure and Field Specifications, PRO-CTCAE tool, and Pilot Results.


Health Care Quality Report Highlights Improvements in Care

MN Community Measurement (MNCM), an independent non-profit organization that collects and reports health care data to drive statewide system improvement, today released its 2017 Health Care Quality Report. This 14th annual report provides data related to preventive and chronic care comparing statewide, regional, medical group and clinic performance.Health Care Quality Report

A highlight of this year’s analysis is improvement in quality measures related to mental health. The rate of Adolescent Depression and/or Mental Health Screening increased by nine percentage points since last year’s report, from 64 to 73 percent. Since 2015, the rate for this measure has improved 33 percentage points resulting in over 45,000 more adolescents across Minnesota receiving screening for depression during this time period.

Improvements were also seen in measures for adult depression care follow-up and outcomes. Depression is a common and treatable mental disorder. According to a recent National Health and Nutrition Examination Survey (NCHS), it is estimated that over 8 percent of American adults had an episode of major depression in a given two week period. MNCM’s suite of depression measures was developed to increase follow-up and improve depression outcomes.

This year’s report shows improvement in three of the depression measures:

  • The depression follow-up rate at 12 months increased by nearly five percentage points, from 22.8 to 27.3 percent;
  • The depression response rate at 12 months (fewer symptoms after starting treatment) improved by nearly two percentage points, from nine to 11 percent; and
  • The depression remission rate at 12 months (no symptoms or very few symptoms after starting treatment) improved by over one percentage point, from five to six percent. This represents over 5,800 patients with depression symptoms in remission.

Entira Family Clinics – West St. Paul had the top depression follow-up rate at 69 percent, the top response rate at 44 percent and the top remission rate at 39 percent.

These improvements reflect better follow-up with patients and improved communication between patients and their primary care providers, and between primary care providers and behavioral health providers. Most importantly, these numbers reflect overall better outcomes for patients with depression.

“We still have a long way to go, but it’s encouraging to see progress in screening, follow-up and outcomes for depression,” said Julie Sonier, MNCM President. “While the statewide improvements may appear small, they reflect tangible improvements for real people with a very challenging chronic disease. The most important news is that the hard work of follow-up is showing progress, and patients are benefiting with improved depression outcomes. The fact that all of these measures are trending upward shows that Minnesota health care providers’ efforts in this area are paying off.”

Other notable improvements in quality measures and trends over time included:

  • In the Colorectal Cancer Screening measure, the rate has increased nine percentage points since 2011 from 64 percent to 73 percent representing over 116,000 more patients being screened for colorectal cancer. Three medical groups had colorectal cancer screening rates at 90 percent or higher: Obstetrics, Gynecology and Infertility – Maple Grove, CentraCare Health Plaza – Internal Medicine and Catalyst Medical Clinic in Watertown.
  • Since 2012, the rate for adolescent immunization increased 33 percentage points from 53 to 86 percent. This means that 9,400 more adolescents in Minnesota received recommended immunizations (one dose of meningococcal vaccine and one tetanus, diphtheria toxoids and acellular pertussis vaccine) before their thirteenth birthday. Wayzata Children’s Clinic and Southdale Pediatrics Associates had the top adolescent immunization rate at 98 percent.

The report also highlights fifteen medical groups with consistent high performance on three or more quality measures over three years and 17 medical groups with consistent improvement on three or more quality measures over the same time period.

To read the full report and explore other measures statewide, visit The annual report is a compilation of all quality measures publicly reported by MNCM during the year. Individual clinic and medical group results are available at and updated as new data become available.

MNCM’s goal with the Health Care Quality Report and other initiatives is to provide reliable information to support both quality improvement in the medical community and health care transparency with the public. According to the 2017 Price Transparency and Physician Quality Report Card from Altarum Institute and Catalyst for Payment Reform, Minnesota was one of only two states that earned an “A” for our outstanding work in physician quality websites through

About MN Community Measurement

MN Community Measurement is a non-profit organization dedicated to improving health by publicly reporting health care information. A trusted source of health care data and public reporting on quality, cost and patient experience since 2003, MNCM works with medical groups, health plans, employers, consumers and state agencies to spur quality improvement, reduce health care costs and maximize value. Learn more at and