Implementing a QCDR Reporting Program in Your Practice

January 12, 2016

Emily Richardson, M.D.,

Chair Committee on Practice Quality Improvement, AQI

Chief Quality Officer, Encompass Medical Partners

The Qualified Clinical Data Registry (QCDR) reporting mechanism was introduced for the Physician Quality Reporting System (PQRS) beginning in 2014. A QCDR is a CMS-approved entity that collects medical and/or clinical data for the purpose of patient and disease tracking to foster improvement in the quality of care provided to patients. Individual eligible professionals (EPs) who satisfactorily participate in 2015 PQRS through a QCDR may avoid the 2017 -2.0 percent payment adjustment.(ref. 1) Successful PQRS participation of >50 percent of your group’s EPs is also necessary to avoid an additional -4 percent penalty under the Value-Based Payment Modifier program.(ref.2)
There are several important differences between the claims-based and QCDR reporting methods under the PQRS (Table 1).(ref.3) In contrast to both claims-based and traditional registry reporting, a QCDR is not limited to measures within PQRS. For the 2015 reporting year, a QCDR may submit a maximum of 30 non-PQRS measures. The data submitted to CMS via a QCDR covers quality measures across multiple payers and is not limited to Medicare beneficiaries. Once a QCDR is selected, the EP will be required to enter into and maintain an appropriate legal agreement. Such arrangements provide for the QCDR’s receipt of patient-specific data and allow the QCDR to release quality measure data to CMS on the EP’s behalf.(ref.4) Additionally, CMS is seeking to move the PQRS program away from claims reporting.(ref.2) Practices can set themselves apart by being leaders in quality reporting and engaging in early adoption of the CMS preferred reporting mechanism, the QCDR.(ref.3)

Several important differences between the claims based QCDR reporting methods under the PQRS
Table 1.

There are several QCDRs available for anesthesiology measure reporting.5 Regardless of the QCDR you choose, collecting data and implementing quality capture systems in your practice early will improve your chances of success. Due to the complexity of the QCDR reporting process and differences between the QCDRs themselves, detailed instructions for participation are beyond the scope of this article. The purpose of this article is to provide a broad overview of the QCDR reporting process and tips for a successful implementation.


Step One: Practice Assessment and Information Gathering
There are many variables that will shape your group’s QCDR reporting process. The following questions will need to be answered in order to plan and implement a successful QCDR reporting program:

  • What is your practice model?
    • Affects cost, workflow and compliance.
  • How many providers do you have?
    • Affects both financial risk and cost of program implementation.
  • Do you have administrative support?
    • Affects provider workflow and implementation.
  • Who does your billing? Are they responsive to your needs?
    • Affects implementation and results.
  • Does your workflow vary between facilities?
    • Affects implementation and compliance.
    • Different facilities may require different data collection solutions.
  • What type of anesthesia record do you use?
    • Affects provider workflow, implementation and results.


Step Two: Define Your Data Collection Process or Processes
There are several questions that should be addressed when defining your data collection process. For example, do your providers have different workflows at different facilities? Will you need more than one collection process? You may have an AIMS system at one facility, a different AIMS in another facility and a paper record at a third facility. Due to reporting threshold requirements, differing case volumes at various facilities may dictate where and how the collection process is implemented. Subsequently, the data collection tool will need to be defined. Some practices have constructed their own collection tools. Depending on which QCDR you are reporting, there may be commercially available data collection tools, including paper forms versus electronic/digital submission via Web access or mobile app. If participating in the ASA QCDR, consult the AQI website for a list of approved QCDR-Ready Vendors.6 Ask the vendors which PQRS/QCDR measures are offered and how data collection may affect provider workflow. Consider your organization’s long-term goals when choosing a vendor. Are you building a quality program? Are there additional outcomes you would like to capture outside of the QCDR measure set? Are you considering launching a perioperative surgical home model? Once the collection process or processes are defined, create an implementation timeline and assign tasks to project participants.

Step Three: Engage External Players
Because the QCDR reporting process has many interdependent and moving parts, you may need to engage several external players, such as your billing vendor. Patient-specific demographic data is required for participation in the QCDR. You also may consider integrating your data capture system with your billing software, AIMS or enterprise EHR. In this case, other external players including EHR vendors, facility administrations and IT departments will be involved. Some quality data capture platforms can function as stand alone products and work with multiple EHRs while others are completely integrated within enterprise systems. When meeting with external players, be ready to describe the value proposition. Consider offering to share the data if others will help share the cost. Alternatively, offer to share the data in return for sharing the work of data collection, interface construction and/or system integration. Depending on your group’s relationship with facility administration and/or the hospital system, additional legal documents, such as business agreements, may need to be executed. If you are using external IT vendors, administrators may also request IT security documentation.

Step Four: Educate Your Providers
Thoroughly review the PQRS and QCDR measure definitions and denominators in order to choose the measures that will be applicable to your practice. Different EPs within the same group may choose to report different measures. For example, a provider doing pediatric cases at an ambulatory surgery center may not report the same measures as a cardiac anesthesiologist. Be able to clearly describe the requirements and definition for each measure and provide ample resources to your partners. Train anesthesia providers and nursing staff, if applicable, on the use of data collection tools and software. Consider multiple communication and training modalities, such as online resources, hard copy manuals and webinars.

Step Five: Go Live
Consider on-site support, especially if utilizing a digital data capture system. If you are not able to be on site, be available by phone and/or text.

Step Six: Assess Results
When the data are ready for review, you can assess compliance rates and give feedback to providers. Gross compliance rates for provider-reported quality measures can be calculated by comparing billed case volumes with number of cases with accompanying quality data. Review the data at regular intervals to monitor the number of providers who are successfully participating. Put in the time and effort to validate your vendor’s data processing logic. Look closely at the data your vendor is producing. Do the data make sense? Are your providers reporting accurately? Are they reporting what they think they are reporting? It is not uncommon to uncover several learning opportunities after the first data processing pass. There may be issues with file formatting or data integrity that need to be addressed.

Potential Pitfalls
One of the biggest risks for a failed implementation is lack of provider engagement. Be able to clearly describe your organization’s goals and be able to answer the question “Why are we doing this?”  Clearly define the benefits, including the financial implications of Medicare payment adjustments. Focus on improving care while avoiding payment penalties. Additional problems may arise due to the lack of knowledgeable and prepared support staff. For the best chance at success, you should fully understand the measures and how to report them correctly.

The addition of the QCDR reporting method under the PQRS is an important step toward better and more meaningful quality reporting. While the implementation process can be complex, there are many resources available for both providers and administrators who are up to the challenge.



Qualified clinical data registry reporting. Centers for Medicare & Medicaid Services. Accessed October 13, 2015.
Medicare Program; Revisions to payment policies under the Physician Fee Schedule and other revisions to Part B for CY 2016; Proposed rule. Fed Regist. July 15, 2015;80(135):41868.
ASA QCDR: measures that matter. American Society of Anesthesiologists website. Accessed October 10, 2015.
2015 Physician Quality Reporting System (PQRS): Qualified Clinical Data Registry (QCDR) Participation Made Simple. Baltimore, MD: Centers for Medicare & Medicaid Services; 2015:2. Published January 9, 2015. Accessed November 12, 2015.
2015 Physician Quality Reporting System Qualified Clinical Data Registries. Centers for Medicare & Medicaid Services. Published June 26, 2015. Accessed November 13, 2015.
QCDR-ready vendors, . Anesthesia Quality Institute website. Accessed October 10, 2015.

ASA Monitor “Implementing a QCDR Reporting Program in Your Practice” (Richardson E. [2016; 80(1): 36-38]) is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173.

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