Epic quality reporting workflows can generate QRDA files to the local file system. The main purpose of these files is for upload to CMS in accordance with various quality reporting programs.
The QRDA documents generated will comply with one of the following specifications:
- QRDA I – Patient-level document
- QRDA III – Population-level document
QRDA I generation
Epic’s Green Book offers step-by-step instructions on how to generate, access, and decrypt QRDA I files in the section titled Optionally Generate XML Files in QRDA I Format, a subsection of Report Setup for EC Quality Measures. These instructions include references to using subsets to specify both patient groups and provider groups.
Before exporting CQMs in QRDA I format, it is important to make sure your organization
has all CQM data mapping set up properly. Luckily, Epic has many resources available to
customers on Galaxy (galaxy.epic.com), the Epic documentation repository. For guidance
on CQM, QRDA I, and data mapping setup, refer to the following Epic resources:
Epic’s Regulatory and Quality Reporting Configuration Guide (Blue book), (accessible by
searching “blue book” in Galaxy, referenced here as Blue Book) is a comprehensive guide
to all things related to regulatory reporting setup and contains several QRDA I relevant
sections:
- Shared Build for QRDA I and QRDA III Reporting
-
Initial Setup for Reporting in QRDA I Format
Epic’s Outpatient Quality Measures Reporting for Promoting Interoperability (MU) and MIPS (Green Book) has several sections relevant to data mapping CQMs, CQM specifications, details any recent updates to each specification, and Epic furnished CQM specific resources for each measure. The guide (henceforth referred to as the “Green Book”) can be found on Galaxy by searching for “green book”.
Step 1: Accessing the Quality Reporting Module
- Log into Epic.
- Navigate to Reports or Quality Reporting Measures depending on your system configuration.
- Select the option for Quality Measure Reporting or QRDA Extraction.
Step 2: Selecting EC Quality Measures
- Choose the EC Quality Measures (PQRS/UDS) option.
- Confirm that the quality measures relevant to your practice are listed.
- If needed, select additional measures for reporting.
Step 3: Generating Patient-Level XML Reports
- Locate the option to export data in XML format.
- Ensure that QRDA I is selected as the output format.
- Choose Generate Report to extract the patient-level QRDA data.
Step 4: Selecting Performance Year
- Use the dropdown menu to select the appropriate performance year.
- Ensure that the selected year matches the reporting period for submission to CMS.
Step 5: Defining the Data Date Range
- Enter the start and end dates for the reporting period.
- Confirm that the date range aligns with the performance year.
Step 6: Selecting Group SER Records
- If submitting as a group, ensure that the correct Group SER (Service Entity Record) is selected.
- If reporting as an individual provider, skip this step.
Step 7: Provider Selection
- Choose the providers whose data needs to be included.
- Select all applicable providers within the reporting group.
Step 8: Choosing Quality Measures
- Select the specific quality measures that need to be included in the QRDA I file.
- Verify that the selected measures match the CMS reporting requirements.
Step 9: Reviewing Data
- Before generating the report, review the data for completeness.
- Ensure that all required fields are populated.
- If necessary, fix any missing or incorrect data before proceeding.
Step 10: Generating the QRDA I XML File
- Click on Generate QRDA I Report.
- Save the XML file to a secure location.
- Encryption - Epic generates encrypted XML files. It is okay to upload these files to MDinteractive, but please provide us with the password.
- Epic may generate thousands of QRDA 1 XML files; these will need to be zipped into a single zip file before uploading them to MDinteractive.
Trouble shooting
QRDA I is a format created for use in MIPS reporting. As such, QRDA I generation will create a patient file for each provider with whom the patient had an encounter. This is because, for the purpose of MIPS, any eligible provider who saw the patient during the reporting period is equally responsible for the patient’s CQM success or failure. If a patient sees multiple providers, the QRDA I CQM generation process may result in multiple files for the same patient.
References:
https://www.oregon.gov/oha/HPA/OHIT/Documents/CQMR_VendorGuide_Epic.pdf