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GENERAL INFORMATION
Developer Name: CQM Tracker, a Division of Medsphere Systems Corporation
Plan Report ID Number: 20211018med
Product Name(s): CQM Tracker
Version Number(s): 11
Product List (CHPL) ID(s): 15.05.05.2806.MEDS.01.00.1.191014
ONC-ACB Certification ID: 15.05.05.2806.MEDS.01.00.1.191014
JUSTIFICATION FOR REAL WORLD TESTING APPROACH
At this time, CQM Tracker is marketed as solution to receive data from an EMR that would then perform data analytics to determine thresholds related to clinical quality measures and also provide the ability to create and transmit QRDA files to CMS. We currently only have the interface between the inpatient setting and CQM tracker. Therefore, the Real World Testing plan will apply to this care setting. We also understand that QRDA files may only be created during 1st quarter of each calendar year due to when clients are submitting the data as part of their attestation. We have incorporated results for QRDA analytics that would only be looked at during Q1. This Real World Testing plan documents how we intend to test 170.315(c)(1)-record and export, 170.315(c)(2)-import and calculate, and 170.315(c)(3)- report in the real world.
STANDARDS UPDATES (INCLUDING STANDARDS VERSION ADVANCEMENT PROCESS (SVAP) AND UNITED STATES CORE DATA FOR INTEROPERABILITY (USCDI))
This product utilizes all standards associated with the 2015 certification methods.
| Standard (and version) | Not applicable |
| Date of ONC-ACB notification | Not applicable |
| Date of customer notification (SVAP only) | Not applicable |
| USCDI-updated certification criteria (and USCDI version) | None |
MEASURES USED IN OVERALL APPROACH
The following outlines our measures that have been identified to best demonstrate how our product is in and maintains conformance to 170.315(c)(1)-record and export, 170.315(c)(2)-import and calculate, and 170.315(c)(3)-report.
Measure 1(Export Data File)
This measure will capture the number of successful and unsuccessful events of exporting QRDA Cat 1 files.
| Certification Criteria | Requirement |
| 170.315(c)(1) – record and export | Export a QRDA Cat 1 file |
Rationale: CQM Tracker gives clinicians the ability to create a QRDA Cat 1 file to submit to CMS for attestation given a particular reporting period. We feel that extracting the successful and unsuccessful events will give us a numeric representation as to what is happening in the real world.
Test Approach 1: (in the event we have an active client using the functionality) System logs will be used to extract data related to QRDA exports. Success rates of these types of exports will be trended over time. We do anticipate that most of these exports will occur during Q1 as this is when the clients will report to CMS.
Test Approach 2: (in the event we do not have an active client using functionality) Internal test systems will be used to create and export a QRDA Cat 1 file. Internal system logs will be reviewed to analyze success rates of the export function.
Expected Outcome(s): It is expected in either case that both internal and external clients will be able to export QRDA Cat 1 files without limitations and in compliance with the certification criteria, including the technical standards and vocabulary code sets. We do anticipate that most of these exports will occur during Q1 as this is when the clients will report to CMS.
Measure 2 (Aggregate Reports)
This measure will capture the success rate of producing aggregate reports
| Certification Criteria | Requirement |
| 170.315(c)(2) – import and calculate | Import a data file and calculate aggregate report |
Rationale: CQM Tracker gives clinicians the ability to import a data file and produce an aggregate report.
Test Approach 1: (in the event we have active customers using the product) System logs will be used to extract data related to QRDA exports. Success rates of these types of exports will be monitored and trended over time. We do anticipate that most of these exports will occur during Q1 as this is when the clients will report to CMS.
Test Approach 2: (in the event we do not have any active clients using the product) Using internal test systems, data files will be imported and aggregate reports will be created on a quarterly basis to ensure the product functionality still performs as previously certified. System logs will be used to track the success rates of the creation of aggregate reports.
Expected Outcome(s): In either case, It is expected that both internal and external clients will be able to import data and calculate aggregate reports without limitations and in compliance with the certification criteria, including the technical standards and vocabulary code sets. We anticipate that the aggregate reports will be successfully created with less than 5% error.
Measure 3 (Report Submissions)
This measure will capture the number of MIPS submissions.
| Certification Criteria | Requirement |
| 170.315(c)(3) – report | Report to CMS |
Rationale: CQM Tracker gives clinicians the ability submit their data to CMS in accordance to the standards. Tracking the number of successful submissions will give us a view of the real world instances in which this is at stake and will also help us identify communication efforts that could be sent out reminding those that have not yet submitted.
Test Approach 1: (in the event we have active client using the functionality) A manual survey will be conducted during Q1 to capture the amount of successful submissions to CMS.
Test Approach 2: (in the event we do not have an active client using the functionality) Internal test environments will be used to submit both file types to the external test system for validation on a quarterly basis to ensure the system functions as previously certified. The success /failures will be logged on a quarterly basis.
Expected Outcome(s): It is expected that either internal or external clients will be able to report to CMS or an external test system without limitations and in compliance with the certification criteria, including the technical standards and vocabulary code sets. We do anticipate that most of these submissions will occur during Q1 as this is when the clients will report to CMS. We anticipate that our clients will be able to report to CMS or an external test system with less than 1% error.
Care Setting(s)
CQM Tracker is only interfaced with our inpatient systems at this time, therefore, only inpatient settings will be used for Real World Testing.
SCHEDULE OF KEY MILESTONES
| Key Milestone | Date/Timeframe |
| Deployment of code allowing ability to capture additional information in system logs. | Jan/Feb 2022 |
| Work with clients to capture success rates of submission to CMS (if applicable) | Q1 |
| Begin collection of data laid out by plan | March 2022 |
| Data Collection and Review | Quarterly |
| End of Real World Testing for all measures. | December 2022 |
| Final data review and analytics, create results report | January 2023 |
| Submit Real World Testing Results Report to ACB | January 2023 |
ATTESTATION
This Real World Testing plan is complete with all required elements, including measures that address all certification criteria and care settings. All information in this plan is up to date and fully addresses the health IT developer’s Real World Testing requirements.
| Authorized Representative Name: | Nicki Anderson, Director, Compliance |
| Authorized Representative Email: | nicki.anderson@medsphere.com |
| Authorized Representative Phone: | 760.979.6531 |
| Authorized Representative Signature: | Nicki Anderson |
| Date: | October 8, 2021 |
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