Data Collection and PQRS

MNCM has been helping health care providers in primary care and across all specialties to collect, analyze and report clinical data since 2004, and we can help you, too. How can MNCM ease your path to reporting?

  • By offering a wide range of quality measures
  • By applying our robust data validation policies and procedures
  • By performing clear, helpful reporting
  • By giving you reliable advice and support

MIPS and the Physician Quality and Reporting System (PQRS)

MN Community Measurement has been helping health care providers in primary care and across all specialties to collect, analyze and report clinical data for more than 10 years. This includes supporting eligible providers in meeting requirements for the Centers for Medicare and Medical Services (CMS) Physician Quality Reporting System (PQRS) and Meaningful Use programs. MNCM serves Minnesota, North Dakota and South Dakota.

CMS Registry Application

MNCM submitted an application to become a Qualified Clinical Data Registry (QCDR). Currently and in the past, submitting to MNCM has allowed clinicians to attest they are meeting some of their CMS meaningful use requirements. With some modifications to our system, making this transition as a MIPS registry is feasible and a natural next step.

QPP Measures

Several MNCM developed measures have a CMS QPP (Quality Payment Program) number and can be used locally and nation-wide. Additionally, data elements from the Diabetes (A1C) and Vascular (Ischemic IVD) measures also have a QPP number.

Potential Penalties

Those who report satisfactorily for the 2016 program year (2017 report year) will avoid the 2018 PQRS negative payment adjustment. More importantly, MNCM can help you meet the reporting requirements to avoid penalties.

The PQRS negative payment adjustment applies to all of the individual eligible professionals (EP’s) or PQRS group practice’s Medicare Part B covered professional services under the Medicare Physician Fee Schedule (MPFS).

In 2017, individual EPs and PQRS group practices receiving a payment adjustment will be paid 2.0% less than the Medicare PFS amount for that service. The 2017 payment adjustment is based on 2015 PQRS reporting. Please note that this adjustment is separate from any additional adjustment that may be applied to EPs who are physicians under the Value Modifier program and the Medicare EHR Incentive Program in 2017.

How MNCM Can Help

MNCM can facilitate data submission to meet your PQRS e-clinical quality measure (eCQMs) requirements. Contact for details.

Data Collection

MNCM has collected data from health plans, medical groups, clinics and survey firms since 2002. During that time, the depth and breadth of our work has expanded dramatically. For example with HEDIS measure aggregation, we started out working with a few of the largest health plans in our market to submit data for one measure. Today, we have 10 participating health plans submitting data for 10 HEDIS measures.

The methods we use to collect data have also evolved during the past dozen years. In addition to measures that use data from health plans, we developed a ground-breaking new process called direct data submission (DDS) that allows clinics and medical groups to submit data directly from their electronic medical records systems to MNCM through a custom-built, secure web portal. What began in 2008 with 62 medical groups, encompassing 339 clinics submitting data, has grown to more than 203 medical groups, encompassing over 1,000 clinics, submitting data annually. The impact of DDS continues to spread since it became the data collection platform for the Minnesota Department of Health’s Statewide Quality Reporting and Measurement System (SQRMS) in 2009.

However, systems alone do not make our data collection processes successful; they must be paired with educated users.

MNCM is uniquely experienced in the creation of data collection guides – which translate measure specifications into practical, understandable and feasible ‘how to’ guides for clinics and medical groups to submit data. MNCM has created more than 60 data collection guides and has evolved them over time to be the ideal balance of enough information to execute data submission successfully without overwhelming the user.

We also collect data for other regions throughout the United States, including 10 other communities for our work on the DOCTOR project. We can also collect data for national programs, to meet CMS requirements for PQRS and Meaningful Use. We not only have the structures in place, but we also have the systems and validation processes to assist organizations nationally.

Data Validation

MNCM has developed rigorous and thorough data validation processes. We use at least one method to validate each and every medical group that submits data to MNCM through the DDS process. Those methods include:

  • Pre-submission validation of each medical group’s patient population and complete quality checks of submitted data.
  • Validation audits, which occur for a random number of medical groups on established measures and all medical groups for brand new measures.
  • All medical groups are given the opportunity to review their results and the statewide results before they are publicly reported.

MNCM utilizes the National Committee for Quality Assurance’s (NCQA) “8/30” process for validation audits, developed in consultation with Johns Hopkins University. The procedure involves reviewing an initial sample of eight files, then reviewing an additional sample of 22 files if any of the original eight fails the review (a total of 30 records). Our validation processes are paramount to our measurement work, by ensuring that data is collected and reported consistently and accurately.

Medicare EHR Incentive program (Meaningful Use)

CMS provides financial incentives for “meaningful use” of certified electronic health record technology through its EHR Incentive Program. To receive the incentive payment, eligible professionals (EPs), must demonstrate “meaningful use” of their EHR by meeting certain measurement thresholds. The program includes three stages:

  • Stage 1 – requires meaningful use of EHRs for a 90-day period
  • Stage 2 – requires meeting requirements for two full years
  • Stage 3 – begins in 2017 and will focus on improved outcomes

MNCM can assist you in meeting meaningful use stage 2 requirements in two ways:

  1. Submitting quality data to MNCM for any measure may fulfill the Stage 2 menu objective of Reporting Specific Cases to a Specialized Registry
  2. MNCM can submit your e-clinical quality measures (eCQMs) via PQRS data submission to fulfill the eCQM component of Stage 2.

Meaningful Use Requirements

17 Core Objectives – These are objectives everyone who participates in Stage 2 must meet. Some of the core objectives have exclusions, but many do not.

3 of 6 Menu Objectives – You have to report on three of the six available menu objectives for Stage 2. You can choose objectives that make sense for your workflow or practice. Again, some of these objectives have exclusions.

Visit to view the full list of the Meaningful Use objectives. >>

Submitting quality data to MNCM for any measure may fulfill the Stage 2 menu objective of Reporting Specific Cases to a Specialized Registry.

EPs considering selecting this menu objective based on data submission to MNCM should verify that your organization and national provider identifier (NPI) is registered with MNCM and that one of the following is true:

  • Data submission for applicable measure(s) occurred during 2015 or 2016; or
  • Your organization intends to submit data within 60 days of the start of the next applicable measure and reporting period; or
  • Your organization submitted data by the deadline and is currently engaged in testing and validation of that electronic submission.

Additionally, MNCM can facilitate data submission to meet eCQM requirements for meaningful use through our PQRS process. The list below includes measures offered by MNCM that meet these requirements and is organized by the six National Quality Strategy Domains that eCQMs can fall into.

1. Patient and Family Engagement

No MNCM measures.

2. Patient Safety

  • Use of High-Risk Medications in the Elderly NQF 0022 (Recommended Adult)
  • Falls: Screening for Future Fall Risk NQF 0101

3. Care Coordination

  • Closing the referral loop: receipt of specialist report CMS50v1 (Recommended Adult)

4. Population and Public Health

  • Preventive Care & Screening: Tobacco Use: Screening & Intervention NQF 0028 (Recommended Adult)
  • Preventive Care & Screening: Influenza Immunization NQF 0041
  • Preventive Care & Screening: Screening for Clinical Depression and Follow-up Plan NQF 0418 (Recommended Adult)
  • Preventive Care & Screening: Body Mass Index Screening and Follow-up NQF 0421/CMS69v1 (Recommended Adult)
  • Preventive Care & Screening: Screening for High Blood Pressure and Follow-up Documented NQF TBD

5. Efficient Use of Healthcare Resources

  • Low Back Pain: Use of Imaging Studies NQF 0052 (Recommended Adult)

6. Clinical Processes/Effectiveness

  • Controlling High Blood Pressure NQF 0018 (Recommended Adult)
  • Breast Cancer Screening NQF 0031
  • Colorectal Cancer Screening NQF 0034 / PQRI 113
  • Pneumonia Vaccination Status for Older Adults NQF 0043 / PQRI 111
  • Diabetes: Hemoglobin A1c Poor Control NQF 0059 / PQRI 1
  • Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic NQF 00068 / PQRI 204
  • Depression Remission at 12 Months NQF 0710
  • Depression Utilization of the PHQ-9 Tool NQF 0712
  • Hypertension: Improvement in Blood Pressure NQF TBD

Other Data Collection Methods

MNCM has experience in claims data collection and analysis, as well as data aggregation.

Healthcare Effectiveness Data and Information Set (HEDIS)

MNCM collects claims data from health plans and produces and publicly reports HEDIS measures. HEDIS is a national set of standardized performance measures originally designed for the managed care industry that use the data collected from health plan claims data. Measures using health plan data follow the National Committee for Quality Assurance’s HEDIS specifications. The measures have been adopted for use by MNCM to evaluate the performance of medical groups.

MNCM began publicly reporting health care performance results in 2004 with a vision of improving health and health care in Minnesota and neighboring communities by driving change in the cost, quality and patient experience of care. That inaugural effort utilized HEDIS measures, aggregating data from

10 health plans and reporting results at a medical group level. In 2005, we put the results online for the first time and still continue to publicly report on the following HEDIS measures today:

  • Breast Cancer Screening
  • Immunization for Adolescents
  • Avoidance of Antibiotics in the Treatment of Adult Bronchitis
  • Use of Spirometry Testing in the Assessment and Diagnosis of COPD
  • Appropriate Treatment for Children with Upper Respiratory Infection
  • Controlling High Blood Pressure
  • Appropriate Testing for Children with Pharyngitis
  • Chlamydia Screening in Women
  • Follow-up Care for Children Prescribed ADHD Medication
  • Childhood Immunization Status (Combo 3)

Data Aggregation

As a result of the unique technical infrastructure we have created to securely collect data, MNCM is a go-to partner for organizations and initiatives that want to aggregate data from many entities.

One of the most notable examples is our selection to lead, manage and aggregate data for the national Doctor Project, an initiative launched in 2014 by the Robert Wood Johnson Foundation. The goal of the project is to develop consumer-friendly reports that measure how clinics and medical groups in 10 communities across the country perform in delivering high-quality health care. The Doctor Project is focusing on performance in diabetes, heart disease, cancer screenings, and patient safety. The organizations selected to participate in the project are:

  • Center for Improving Value in Health Care (Colorado)
  • Greater Detroit Area Health Council (Detroit, Mich.)
  • Healthcare Collaborative of Greater Columbus (Columbus, Ohio)
  • Integrated Healthcare Association (California)
  • Maine Health Management Coalition (Maine)
  • Massachusetts Health Quality Partners (Massachusetts)
  • MN Community Measurement (Minnesota)
  • The Health Collaborative (Cincinnati, Ohio)
  • Washington Health Alliance (Washington State)
  • Wisconsin Collaborative for Healthcare Quality (Wisconsin)

MNCM educates the groups about our data collection processes and requirements and collect the data from the nine other communities. The results will be aggregated and are expected to be published by Consumer Reports in early 2016.

Contact for details.