In this episode, Dr. Dan Mingle answers some common questions about MIPS CQM APP submissions and QRDA I files, FHIR requirements for eCQM APP submissions, and measure options for MIPS Value Pathways (MVPs).

Click play on the video to listen to this episode now, or scroll down for the written summary.

Question One: QRDA I Files for MIPS CQM APP Submission

John asks: “I’m confused about quality reporting. We’d like to do a MIPS CQM quality submission for our ACO. Our EHR produces QRDA I files that we think will be easy to share with you to build our submissions. But QRDA is designed to support eCQMs. And I know that eCQMs have different specifications than MIPS CQMs. Will they lead to a flawed submission if we try to use our QRDA I?”

Great question, John.

The answer is no. We can build a solid submission for you on the foundation of your QRDA I data.

And I can understand the confusion. You are in good company.

To get everyone on the same page here. Let me briefly explain QRDA:

• QRDA stands for Quality Reporting Data Architecture. It is just one of many different specifications within the universe of HL7.
• HL7, of course, is the standard for health care data exchange. HL7 specifies file structure, language, and the range of acceptable content for a wide range of data exchange use-cases.
• They all fall under the category “Clinical Data Architecture”, or “CDA” and the category of “CDA” includes:
  • CCD: Continuity of Care Document
  • FHIR: Fast Healthcare Interoperability Resources
  • QRDA: Quality Reporting Data Architecture

QRDA is further subdivided into QRDA I and QRDA III file types.

QRDA I: A single QRDA I file contains all of the data pertaining to one patient needed to calculate the quality measure or measures targeted by the QRDA I file. It can contain anything between one to all available eCQM measures.

QRDA I contains patient-specific data. One file equals one patient.

It can be identified to a specific patient, or it can be stripped of the data that identifies it to a specific patient. But the data in a QRDA I all has to reflect one single patient, whether we can tell who the patient is or not.

QRDA III: The performance report calculated from the whole set of QRDA I files.

A QRDA III:

• Is specific to one practice.
• Can represent a single quality measure or many quality measures.
• Can only include measures that are eCQM specified.
• References many patients.
• And patients are represented into the pertinent counts of patients.
• No patient identifiable data is included.
• And cannot be combined with others to calculate performance across many practices, like ACOs need to do for the APM Performance Pathway (APP).

Back to the question:

Can you use QRDA I to report MIPS CQMs?

The answer is yes.

You are right that QRDA was created specifically to address eCQMs, and that eCQM specifications are usually different than the specification for the corresponding MIPS CQM measure.

But the clinical data required for each measure type is identical, one to the other. We can apply either or both the eCQM specifications or MIPS CQM specifications to your QRDA I files. And we can generate either or both eCQM and MIPS CQM submissions from your QRDA I files.

Question Two: FHIR Requirements for eCQM APP Submissions

Greg asks: “We are an ACO planning to use MIPS CQMs to report the APP (the APM Performance Pathway) for 2025. We know we need to be working toward eCQM submissions. We are concerned that we can’t get FHIR (Fast Healthcare Interoperability Resources) out of the EHRs used by our ACO members. Is this going to hurt us?”

The answer is no.

You don’t need to use FHIR to build eCQMs. That is true today and I expect it to stay true tomorrow.

FHIR is emerging as the preferred standard for EHR interoperability. It is not yet an exclusive requirement and may never be the requirement for quality reporting.

QRDA remains the HL7 standard for quality reporting.

QRDA I is the format for exchanging patient specific data about quality measures.

QRDA III is the standard for exchanging the aggregate quality measurements identified to a practice but not to any patients.

But the most important things to recognize about HL7 standards is:

• You have to use Certified EHR Technology (CEHRT) in order to be scored in MIPS for Promoting Interoperability or to be compliant with your APM (Alternative Payment Model) contract.
• To be fully certified, the EHR product you use has to show the capacity to do quality performance measurement.
  • It can either be available directly from the EHR, or through an add-on product from another vendor.
• To be certified in quality reporting functions, the vendor has to show the ability to read and to write both QRDA I and QRDA III files.
• BUT you, the practice, do not have to use those HL7 files to create your eCQM performance measures.
• The only requirement is that your performance data exchange and analysis be all electronic.
  • There is no manual chart abstraction.
  • There are no manual compilations or calculations.

If you have good HL7 format files you can provide to us, we can use them for your quality analytics.

QRDA I, CCD, FHIR, others we can read, we can use in your analytics.

We often find two common problems with HL7 file usability:

• Certification does not always translate to accuracy and usability. Many things can block the effective flow of data and population of standard data fields. These blocks include:
  • Coding: differences in coding between the implementation you are using and the one your vendor used for certification.
  • Configuration: the unique characteristics of your implementation in your environment.
  • Workflows: variations in clinical documentation workflows.
• And there is some inefficiency to address:
  • HL7 files are built per patient.
  • It’s an inefficient medium for data exchange.
  • It can consume a lot of processing time to create a complete set of patient specific files.
  • It can consume a lot of bandwidth to exchange those files.
  • It can take a lot of processing time for the vendor to ingest those files.

We prefer to use flat files for the exchange of data for clinical quality analysis. They are easier and quicker to produce, and they don’t require as much technical expertise.

Rather than one file for each patient, with a comprehensive set of patient-specific data in each file, flat files are one file for each data element, with one row for each instance and distinct columns linking the data element to patients and encounters.

It’s dramatically more efficient to build and to exchange these files. Instead of one file per patient, a typical data set might be:

• Claims file
• Results file
• Vital signs file
• Orders file
• Immunizations file

As long as it is all electronically generated and exchanged, submissions based on flat file analysis are equally valid as eCQMs as are submissions based on FHIR, QRDA or any other HL7 compliant files.

Question Three: High-Priority vs. Outcome Measures for MIPS Value Pathways

Sheila asks: “We are planning to do an MVP (MIPS Value Pathway) submission for 2025. We understand that MVPs require one of our selected measures to be an outcomes measure, and if there are no available or appropriate outcomes measures, we must choose a high-priority measure. The MVP that is appropriate for us doesn’t offer a MIPS CQM outcome measure, only high-priority measures. It does have outcome measures, but we’d have to use a QCDR (Qualified Clinical Data Registry) to be able to choose any of the offered outcomes measures. We don’t want to leave Mingle Health, we’ve got our quality measurement system reliably down pat with your help. Can we trust Medicare to accept a MIPS CQM high-priority measure when there are outcome measures we could use by changing registry vendors?”

Great question, Sheila. And thanks for your vote of confidence.

The rules for MVPs include the text: “At least one measure must be an outcome measure (or a high priority measure if an outcome is not available or applicable).”

By everything I know and have experienced, I believe you to be safe by choosing a MIPS CQM high-priority measure.

But I have to have a shred of insecurity, simply because MVPs are new to all of us. We haven’t seen all the rules and choices tested and challenged yet.

There are a lot of reasons to be confident.

• Medicare’s use of the phrase, “if an outcome measure is not available” applies to this situation.
  • I expect “not available” will cover:
    • Not offered as a choice in the MVP.
    • Not available from your registry vendor.
      • This assumes that your vendor’s qualification by Medicare is up to date and in good standing, as we are.
      • And your vendor is compliant with the requirement that they offer all available MIPS CQM measures, which we do.
      • Medicare does not require registries like us to provide any QCDR measures.
• We have never seen Medicare individually question the choice of a MIPS participant who says a measure or set of measures is not appropriate for them. I’ve never seen them overrule or even audit your choices.
• With one exception, I’ve never seen Medicare require engagement of a specific vendor. That would be the case if they were to require the choice of a QCDR outcomes measure.
  • The exception is that there was a time that there was a single source of patient satisfaction measurement. But that limitation was repaired many years ago.

On the other hand: I have seen Medicare representatives make mistakes in the application of their own rules.

But that is part of the rationale behind the focused review you can request after MIPS scoring is announced and distributed for review.

Send us your value-based care questions!

If you’d like to ask a question about the APP transition, MIPS, ACO quality reporting, or any other Alternative Payment Model, you can reach out to us in three ways:

You can leave your questions in a YouTube comment under any episode of Ask Dr. Mingle.

On LinkedIn, leave your questions in a comment on any of our posts.

And you can reach out directly by sending an email to hello@minglehealth.com.

Want to learn more about quality reporting for ACOs in 2025?

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