Measure Overview
Use in CMS Programs
- Finalized through rulemaking for inclusion in the Merit-based Incentive Payment System (MIPS) in 2016.
- Implemented in MIPS starting with Performance Year (PY) 2017.
Description
Percentage of visits for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter.
Measure Specification
Eligible clinician attests to documenting, updating, or reviewing the patient's current medications using all immediate resources available on the date of the encounter.
N/A
N/A
All visits occurring during the 12-month performance period.
None
N/A
Measure Information
Endorsement History
While this clinical quality measure (CQM) has not undergone consensus-based entity (CBE) endorsement, the electronic clinical quality measure (eCQM) collection type for this measure has gone through the CBE process and is outlined below.
- Initial endorsement, 2008
- Measure retired and endorsement removed, Patient Safety, Spring Cycle 2020
Link to endorsement measure record: Documentation of Current Medications in the Medical Record
Measure Performance in Program
Measure Score by Performance Year
Impact Summary: This measure supports the Merit-based Incentive Payment System (MIPS) goals of improving the quality and safety of care for patients and promoting higher-value care by ensuring clinicians document a current and complete medication list at each visit, which supports accurate clinical decision-making and helps reduce preventable medication errors and adverse drug events.
Clinician performance has consistently increased from 2021 to 2024, but highlighted improvement is needed among lower-performing clinicians. The analysis showed that a medication documentation rate of 100% is achievable. Based on the PY 2024 data, only 7.7% of the assessed visits lacked documentation of medications. While performance for this measure in MIPS continues to be high, there continues to be instances of poor performance as seen by Decile 1: 3.65 - 78.37.
For this measure, Battelle reviewed the following publicly available datasets at Benchmarks - QPP:
- 2026 MIPS Quality Benchmarks.csv (which is referred to as year 2024 in this assessment)
- 2025 MIPS Quality Benchmarks.csv (which is referred to as year 2023 in this assessment)
- 2024 MIPS Quality Benchmarks.csv (which is referred to as year 2022 in this assessment)
- 2023 MIPS Quality Benchmarks.csv (which is referred to as year 2021 in this assessment)
Battelle analyzed benchmark values for “Measure_ID”=130 and “CMS eCQM ID”=N/A to generate CQM benchmark data.
About Figure 1: Figure 1 is a boxplot that shows how rates have changed based on the most recent 4 years of data available. For each year, the boxplot displays a box with lines and dots to help visualize the range and distribution of rates. The dots represent the minimum and maximum rates, and the line connecting them shows the range of the rates. The box itself covers the middle 60% of the rates, from the 20th to the 80th percentile. A “+” sign shows the average rate. This type of graph makes overall trends in rates over time as well as the consistency and spread of the results easier to visualize.
Figure 1. Boxplot of Performance Rate by Year
Figure 1 Interpretation: Although each year there are some clinicians with very low performance, the 20th percentile has consistently increased from 87.26% in 2021 to 96.34% in 2024. For this measure, a higher rate indicates better quality of care.
Score Distribution for Most Recent Years
About Table 1: Table 1 illustrates the distribution of rates across deciles for the most recent year with data available.
Table 1. Importance (Decile by Performance Rate, 2024)
| Mean | Decile 1 | Decile 2 | Decile 3 | Decile 4 | Decile 5 | Decile 6 | Decile 7 | Decile 8 | Decile 9 | Decile 10 | |
| Performance Rate | 92.3 | 3.7-78.4 | 78.4-96.3 | 96.3-99.5 | 99.5-100 | 100 | 100 | 100 | 100 | 100 | 100 |
Table 1 Interpretation: More than 80% of clinicians have a performance rate greater than 95%, and more than 60% of clinicians have a rate of 100%. If Decile 8 performance (100%) is used as a plausible, achievable benchmark, and clinicians in Deciles 1 through 4 improved to that level, the estimated percentage of visits with current medications documented in the medical record would increase by about 7.7% (from 92.3% to 100%), potentially leading to better health outcomes for patients.
Meaningfulness
Importance
The Meaningfulness criterion will be evaluated as part of the full Preliminary Assessment available in September.
Data Stream Burden Reduction
Data Stream Burden Reduction
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Alignment with the Patient Health Care Journey
Alignment with the Patient Health Care Journey
This criterion will be evaluated as part of the full Preliminary Assessment available in September.
Public Comment
Enter a comment below