15. Report Clinical Quality Measures (CQMs) to CMS/States

This lesson will demonstrate the steps necessary to meet the Meaningful Use Core Measure for reporting Clinical Quality Measures to CMS/States.


SOAPware 2011 or later must be used.

Note: To determine the version of SOAPware being used, Click on Help > About SOAPware. This will open a window which will show the version and build of SOAPware currently in use.


This statistics for this measure can be exported and monitored through the CMS Quality Reporting Dashboard.

SOAPware 2011/2012 has been tested and certified on ALL Clinical Quality Measures.  Click here to view the official ONC-ATCB Certification Listing.

A listing of all 44 Clinical Quality Measures is below.

Measure Criteria

Objective:  Report ambulatory clinical quality measures to CMS or, in the case of Medicaid eligible providers, the States.  In total, eligible providers must report on 6 total measures: 3 core measures (substitute the alternate core measures if necessary) and 3 additional measures. A maximum of 9 measures would be reported if the eligible provider needed to attest to the 3 required core, the three alternate core, and the 3 additional measures.  For more information, please visit the CMS website by clicking here.

Measure:  Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS.

For more detailed information on this measure, please click on the "Reference" link below. This CMS documentation includes information on exclusions, attestation requirements, a definition of terms and important additional information.


Reference CMS: Clinical Quality Measures

CMS Stage 1 Changes

Beginning in 2013, there will no longer be a separate objective for reporting clinical quality measures; however, EPs are still required to report on clinical quality measures in order to achieve meaningful use.

For more information on the Stage 1 changes, please see: Stage 1 Changes Tipsheet.

Measure Calculation

This measure is not tracked within the SOAPware Meaningful Use dashboards. This Meaningful Use measure requires that the eligible professional must attest YES to reporting to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS to meet the measure.

For more information on the attestation requirements for this measure, please see: CMS: Clinical Quality Measures (CQMs).

Clinical Quality Measures User Manual

This measure requires very specific documentation in the patient's chart. Please see the Clinical Quality Measures Manual for documentation instructions on each measure.  

In order to export a report that provides users with the statistics for the numerator, denominator and percentage met for each clinical quality measure, users must document using specific structured SMARText items that have been created for each quality measure.

For assistance in capturing this data in a structured manner, a the above manual is provided with shortcuts to use for inserting the quality measure items.

CQMs: Core Measures

Note: It is required that eligible providers report on all 3 core measures

NQF 0421 / PQRI 128: Adult Weight Screening and Follow-Up

NQF 0028: Preventative Care and Screening Measure Pair (includes a. and b. shown below)

*0028(a): Tobacco Use Assessment

*0028(b): Tobacco Cessation Intervention

NQF 0013: Hypertension: Blood Pressure Measurement

CQMs: Alternative Core Measures

Note: It is required that eligible providers substitute one Alternative Core Measure for every Core Measure where the denominator is 0.

NQF 0024: Weight Assessment and Counseling for Children and Adolescents

NQF 0041 / PQRI 110: Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old

NQF 0038: Childhood immunization Status:=

CQMs: Additional Quality Measures

Note: It is required that eligible providers also select 3 additional CQMs from the list of 38 shown below (this excludes the core and alternate core measures).  It is acceptable to have a '0' denominator provided the EP does not have an applicable population.

NQF 0001: Asthma Assessment

NQF 0002: Appropriate Testing for Children with Pharyngitis

NQF 0004: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement

NQF 0012: Prenatal Care:  Screening for Human Immunodeficiency Virus (HIV)

NQF 0014: Prenatal Care:  Anti-D Immune Globulin

NQF 0018:Controlling High Blood Pressure

NQF 0027: Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing Smoking and Tobacco Use Cessation Strategies

NQF 0031: Breast Cancer Screening

NQF 0032: Cervical Cancer Screening

NQF 0033: Chlamydia Screening for Women

NQF 0034: Colorectal Cancer Screening

NQF 0036: Use of Appropriate Medications for Asthma

NQF 0043: Pneumonia Vaccination Status for Older Adults

NQF 0047: Asthma Pharmacologic Therapy

NQF 0052: Low Back Pain: Use of Imaging Studies

NQF 0055: Diabetes: Eye Exam

NQF 0056: Diabetes: Foot Exam

NQF 0059: Diabetes:  HbA1c Poor Control

NQF 0061: Diabetes: Blood Pressure Management

NQF 0062: Diabetes: Urine Screening

NQF 0064: Diabetes: LDL Management & Control

NQF 0067: Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD

NQF 0068: Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic

NQF 0070: Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI)

NQF 0073: Ischemic Vascular Disease (IVD): Blood Pressure Management

NQF 0074: Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol

NQF 0075: Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control

NQF 0081: Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

NQF 0083: Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

NQF 0084: Heart Failure (HF) : Warfarin Therapy Patients with Atrial Fibrillation

NQF 0086: Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

NQF 0088: Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

NQF 0089: Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care

NQF 0105: Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment

NQF 0385: Oncology Colon Cancer:  Chemotherapy for Stage III Colon Cancer Patients

NQF 0387: Oncology Breast Cancer:  Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer

NQF 0389: Prostate Cancer:  Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients

NQF 0575: Diabetes: HbA1c Control (<8%)