Easing the Burden of Quality Reporting

Rick Newell

Rick Newell , MD, MPH

Chief Transformation Officer
Bradford Tinloy

Bradford Tinloy , MD

Director of CMS Programs

Published April 12, 2016

One unintended consequence of healthcare reform is the growing administrative burden on physicians.

Researchers from Weill Cornell Medical College and Medical Group Management Association (MGMA) recently surveyed doctors at 394 practices across the country. They found that:
  • The average physician spends 2.6 hours per week on CMS quality reporting.
  • When staff time is included, the number rises to 15.1 hours per week, or 785.2 hours per year.
  • The estimated annual cost of quality reporting is $40,000 per physician.

As leaders of our practice's CMS program, we're troubled by these findings. The overarching goal of healthcare reform is to drive value: maximum quality delivered at minimum cost. But value almost certainly suffers when practices spend tens of thousands to millions of dollars on CMS compliance.

Fortunately, there is a more user-friendly pathway for reporting quality data. In 2015, Vituity launhed two Qualified Clinical Data Registries (QCDRs). As a result, Vituity is able to satisfy our quality data reporting requirements while spending less than 2 percent of the above-cited costs per physician.

In this post, we'll discuss the benefits of QCDRs and how they can help all practices add value to their care.

The Quality Landscape

Since 2007, CMS has incentivized quality reporting by individual providers and group practices. The current iteration of the program includes the Physician Quality Reporting System (PQRS) and Value Modifier (VM), which mandate that:
  • Each eligible provider must report at least 9 CMS-approved quality measures covering three national quality strategy domains.
  • Depending on the reporting mechanism, providers must also report on outcome and "cross-cutting" measures.
  • To be deemed "satisfactory," reporting must capture at least 50 percent of patients for each measure.
  • Individual providers who do not successfully report receive a negative payment adjustment to their Medicare reimbursement (2 percent based on 2015 data).
  • Groups of providers (based on tax ID number) that do not successfully report also receive a negative payment adjustment to their Medicare reimbursement (4 percent based on 2015 data).

PQRS reporting can be an onerous process. Considerable staff time is required for compiling data from claims, chart abstraction, data capture, conducting audits, and completing and submitting forms. Meanwhile, physicians must painstakingly input EHR data for each patient to ensure metrics are properly captured downstream.

In 2014, CMS approved the creation of a new reporting mechanism, the qualified clinical data registry (QCDR). In addition to gathering data for reporting, QCDRs are intended to foster quality improvement. Unlike traditional registries that only deal with Medicare data, they gather information on all patients from all payers.

QCDRs allow providers and practices to:
  • Access a wealth of clinical data that can be used to inform care decisions and improve outcomes.
  • Review and compare individual physician performance.
  • Access best practices and improvement tools.
  • Report data on non-PQRS measures, CMS-approved specialty measures (i.e. anesthesia, hospitalist medicine, emergency medicine, etc.), allowing providers to report on measures that are most relevant to their practices.

Experts believe CMS is positioning the QCDR to become its preferred reporting mechanism. But as of this writing, relatively few have been approved. Which is where we come in …

An In-House Solution

In 2015, our practice management company Vituity gained approval to establish two QCDRs. Our Emergency Clinical Performance Registry (E-CPR) became one of two emergency medicine QCDRs in the country, and our Hospitalist Clinical Performance Registry (H-CPR) became the only hospital medicine QCDR in existence.

We were fortunate that Vituity was uniquely positioned for early QCDR approval. As early as 2002, we anticipated a growth in CMS' quality reporting programs that would eventually link reimbursement to performance. As a result, Vituity has steadily upgraded their data infrastructure and established an in-house traditional registry.

These previous investments were quite helpful when Vituity applied for QCDR approval. Additional factors such as the strength of our continuing education, in-house quality programs and collaboratives, and our ability to disseminate best practices throughout the organization allowed us to meet CMS’ goals for a QCDR.

How It Works

QCDR reporting has allowed us to design a workflow that’s user-friendly for physicians. Instead of battling through multiple EHR screens, they simply complete their regular clinical documentation.

Next, our billing company abstracts the relevant measures from patient charts and documents performance in our data warehouse. Because the QCDR allows us greater choice in measures, we're able to track those that are most relevant to each practice. Examples include patient safety, ED and hospital throughput, Surviving Sepsis Campaign compliance, Choosing Wisely compliance, and other hospital-based quality measures.

Finally, Vituity’s data team analyzes this wealth of information for actionable intelligence, reports findings back to our providers and practice leadership, and submits performance data to CMS. Vituity’s hospital-based practices can use the data to inform clinical decisions and improve care delivery, which adds a lot of value for our hospital partners. At the organization-wide level, we use this data to inform risk management and strategic planning.

This program has many benefits for our organization:
  • Robust reporting. In 2015, we met PQRS and VM reporting requirements, avoiding millions in penalties.
  • Cost savings. With the optimized infrastructure and workflow, we saved millions in reporting fees, staff time, and lost provider productivity.
  • Specificity. Our data infrastructure allows us to capture quality metrics at the provider level. This aids our clinical leaders in evaluating, comparing, and driving physician performance.
  • Patient experience. Because our physicians spend less time documenting in EHR-specific fields, patients can get more face time.
  • Agility. The QCDR can adapt quickly to keep quality measures consistent with the most up-to-date medical evidence.
  • Physician engagement. As a group, our physicians tend to be more open to quality improvement. As shared owners in the practice, they already realize that there are real dollars tied to CMS programs. They know they'll be held accountable to the quality measures but feel assured that the measures will be relevant to their specialty, practice, and patients.

Making the Transition

This year, a number of organizations applied to CMS to become a certified QCDR. Could this be the answer for your organization?

We think for most practices, becoming their own QCDR isn't the ideal solution. Approval requires significant investments in data infrastructure and personnel. QCDRs are also quite complex to run. At Vituity, we have a robust "team of teams" overseeing the process, including dedicated CMS, IT, data, analysis, reporting, compliance, and billing company teams.

A better alternative for many practices is to participate in an existing QCDR. As noted above, there could be considerable cost savings and benefits to doing so. The number of options available will likely grow over the next few years. In the meantime, if you have questions about our emergency/urgent care or hospital medicine QCDRs, feel free to contact us at


[Image credit: laptop and stethoscope by jfcherry licensed under CC BY 2.0]

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