• Physicians who receive sufficient clinical performance data from approved sources
• Physician who have recently completed or plan to complete QI projects in their practices using nationally recognized quality measures

*Physicians can use performance data they receive from approved sources to complete this module or can collect their own data using nationally recognized quality measures.

Approved Sources for Performance Data and Measures

The currently approved sources for quality improvement data are:

I. MEDICAL SOCIETIES
A number of medical societies provide quality improvement data as part of ongoing projects, measures derived from evidence-based guidelines or they provide members with a clinical registry.

Some examples of current medical society projects are:

• American College of Cardiology: National Cardiovascular Data Registry (ACC-NCDR)

  Measures collected for the ACC-NCDR can be used to complete this PIM. Data from any of the following four (4) registries currently available can be used:

  • ACTION Registry (for NSTEMI/STEMI patients)
  • CARE Registry (for carotid stenting procedures)
  • CathPCI Registry (percutaneous coronary interventions)
  • ICD Registry (implantable cardioverter defibrillators)



• American Society of Clinical Oncology (ASCO): Quality Oncology Practice Initiative (QOPI)
  Visit the ASCO website and select "Practice Resources" from the left menu.

  Measures collected for QOPI, an oncologist-led, practice-based, quality improvement initiative can be used to complete this PIM. While registration is open throughout the year, data collection occurs in March and September. The ASCO website provides detailed information on the program.

  Click here to see a sample Self-Directed PIM utilizing QOPI data (pdf). Included are five examples of measures, a feedback report (Performance Data Summary), and an Improvement Plan.
  
  

• American Society of Hematology (ASH)
  Visit the ASH website.

  ASH has developed measures related to the diagnosis and treatment of myelodysplastic syndrome (MDS), multiple myeloma and idiopathic thrombocytopenic purpura (ITP).

II. HEALTH PLANS OR MANAGED CARE PLANS
Many health plans collect quality data for individual physicians, especially if the health plan has a pay-for-performance program. You may call your participating health plans if you are unsure whether they provide such reports.

III. STATE QUALITY IMPROVEMENT ORGANIZATION (QIO)
These state organizations are charged by the Center for Medicaid and Medicare Services (CMS) to improve the care of Medicare and Medicaid beneficiaries. QIOs collect quality performance data on a yearly basis. They are anxious to partner with physicians like yourself to improve quality of care and offer valuable educational resources to physicians.
Visit the CMS website.

IV. QUALITY IMPROVEMENT ACTIVITY BY A GROUP PRACTICE (including community health clinics, federally-qualified health centers, etc.)
Many group practices are engaged in quality improvement projects and are actively collecting data. If you are part of a group practice, check with your medical director about what quality information might be available from your own practice. However, the group practice must use accepted, evidence-based quality measures and not quality measures created by the group practice.

V. QUALITY REPORTS FROM INDEPENDENT PRACTICE ASSOCIATIONS (IPO) OR PREFERRRED PROVIDER NETWORKS (PPO)
IPOs and PPOs collect data on individual performance. If you are part of a group practice, check with your medical director about what quality information might be available from your own practice. Any performance data used for this module must be measures derived from nationally-recognized, evidenced-based guidelines.

VI. HOSPITAL QUALITY REPORTS FOR INDIVIDUAL PHYSICIANS
If you work in a hospital practice, check with your clinic director or hospital quality improvement office about quality performance reports. However, the hospital must use accepted, evidence-based quality measures and not quality measures created by the hospital.

VII. PHYSICIAN RECOGNITION AND PAY-FOR-PERFORMANCE PROGRAMS
If you participated in an officially-recognized physician recognition program (such as the National Committee on Quality Assurance's Diabetes or Heart/Stroke program), or are enrolled in a pay-for-performance program with a health plan or other group, you may use the data for this module.

VIII. NATIONAL OR REGIONAL REGISTRIES
If you provide data to a national registry such as the Cystic Fibrosis Foundation registry or the Vermont Cancer Registry, you may be able to use your performance data to complete this module.