No active measure groups appear for a patient - everything but MRF is grayed out.

When the Medical Record Found question is answered with anything other than Yes, then the patient is considered not qualified for the sample and all ranked measures will be disabled - you do not have to answer any further questions for that patient.

PREV-10 Tobacco Use -- What About E-Cigarettes?

In a  GPRO Support call, CMS had the following question:

"In relation to the measures that diabetes – non-tobacco use and Prevention – screening for tobacco use, how are we to answer these questions in relation to electronic


The answer: "The measure owner does not consider e-cigarettes tobacco use."

So, for the purposes of reporting 2016, list e-cigarette users as Non-Tobacco Users.

Yes/No Questions Showing Blank

There are a number of questions in the Registry that have Yes/No as the answer options. In most cases, the prepopulated data will only show an answer when that answer is Yes. This is because we will only have evidence in the patient data to support a Yes answer; lack of data is not sufficient to confirm a No answer. This gives the practice an opportunity to review the patient data and select the appropriate answer.

For example, if a patient is ranked (required) for the Diabetes measure group the first question is: DM Confirmed? The answer options are:

  • Yes
  • Not Confirmed - Diagnosis
  • No - Other CMS Approved Reason

If the patient is found to qualify for the diabetes measures by having a diabetes diagnosis or a medication indicative of diabetes, then the answer will be set to Yes.

If no diagnosis or medication is found, then the answer will be left blank and the practice will need to determine the correct answer in this instance. Lack of evidence from the clinical data is not determined to be sufficient to select a No answer.

When there is evidence in the patient data that can support both a Yes and No answer, then the system will select the appropriate answer based on that evidence.

For example, in the PREV measure group, PREV - 9 has 3 questions: BMI Calculated?,  BMI Normal? and Follow-up Plan?

  • For BMI Calculated? the answer will only prepopulate when the answer is Yes.
  • For BMI Normal? the answer will prepopulate as Yes when the patient's most recent BMI falls within the normal range (per CMS) and will prepopulate as No when the patient's most recent BMI falls outside the normal range.
  • For Follow-up Plan? the answer will only prepopulate when the answer is Yes.

CMS Other Approved Reason

New for 2017 in the Clinigence ACO Registry -- Clinigence Registry Users can enter the CMS help desk ticket number in the Clinigence ACO Registry that is required when selecting the "CMS Other Approved Reason" option available for some measures. The ACO personnel will still need to submit a help ticket to CMS with details on why a specific patient should be able to use that answer for a specific measure and once that help ticket has been approved, the user can enter that information directly into the Clinigence ACO Registry and it will be uploaded to CMS with the rest of the patient data files.

Performance Report - Explaining the Met/Not Met counts for the Diabetes measures

This entry in the Performance Report is somewhat complicated because there is one Higher Is Better measure and one Lower Is Better measure plus a composite that is combining the two scores.

DM-2 - HbA1c Poor Control (>9) is a Lower Is Better measure so a patient who has an HbA1c <=9 will show in the Not Met column. This agrees with the Meets Target Criteria/Outside Target Criteria in the Performance Dashboard for this same measure.

DM-7 - Eye Exam is a Higher Is Better measure, and the patient will show in the Met column when the answer is Yes.

DM-Comp. In the Performance Dashboard we combined the Complement of DM-2 with the Numerator of DM-7 to get the composite Numerator, because we are combining a Lower Is Better with a Higher is Better. In the Performance Report we see the same methodology: CM-COMP Met = DM-2 Not Met AND DM-7 Met


An FAQ from previous years’ CMS Support calls can be found here: