Clinical Quality Measures — Record & Export, Import & Calculate, Report

This page documents the end-user workflow for the Retinex Clinical Quality Measures (CQM) capability certified to 45 CFR §170.315(c)(1) (Record & Export), (c)(2) (Import & Calculate), and (c)(3) (Report). Every step described here is performed by an authorized end user, on-demand, through the Retinex MIPS dashboard — without any assistance from Retinex developers or staff. QRDA files conform to the standard adopted at §170.205(h)(2) (QRDA Category I) and §170.205(k)(3) (QRDA Category III).

1. Overview

The Retinex CQM module lets a practice measure its clinical quality performance for MIPS / Promoting Interoperability reporting. The capability spans three certified criteria, which map to three things you do in the UI:

Certified measures

Retinex is certified to the following ophthalmology-focused eCQMs (eCQM annual update version 12):

2. Before You Begin

• You need a Retinex account with a role that grants CQM access (see Authorized Roles).
• Multi-factor authentication must be enrolled (see MFA documentation).
• To import, have your QRDA Category I XML file(s) or a patient CSV ready on your computer.
• To export / report, know which measure(s) and which reporting period (measurement period) you want to run.

3. Step 1 — Sign In and Open the MIPS Dashboard

1. Sign in to the Retinex application with your username, password, and MFA code.
2. From the left navigation, open MIPS (Quality Reporting) to land on the MIPS Dashboard.
3. The dashboard shows your current measure population counts and two primary actions: Import and Report Builder.

Self-service: Everything below is reachable from this dashboard. At no point is a support ticket, script, or developer action required to import data, calculate a measure, or export a QRDA file.

4. Step 2 — Import Patient Data (§170.315(c)(2))

From the MIPS Dashboard, click the Import button. The import panel accepts two file types:

Import flow

1. Click Import on the MIPS Dashboard.
2. Choose Upload QRDA (XML) or Upload Patients (CSV), then select one or more files from your computer. (You may select multiple QRDA files for a multi-patient import.)
3. Retinex parses and validates the file(s). A preview table shows the patients and codified entries detected — including exclusions and exceptions (patient reason, system reason, medical reason). Any rows that fail validation are flagged with the reason so you can correct and re-upload.
4. Review the parsed preview. When it looks correct, the Import (commit) button becomes enabled.
5. Click Import to write the data to the database. Retinex automatically de-duplicates against existing patients and records so the same patient/encounter is not counted twice.
6. A confirmation summary shows how many patients/records were imported, updated, de-duplicated, or skipped.

Parse → preview → import. Parsing happens first and is non-destructive; nothing reaches the database until you click the Import commit button. This lets you confirm the data before it counts toward a measure.

5. Step 3 — Run the Report Builder (§170.315(c)(1) & (c)(3))

Once data is imported, open Report Builder from the MIPS Dashboard. The Report Builder is where you both calculate measure results and export QRDA files.

1. Select measure(s). Choose one or more of the certified measures — CMS131v12, CMS143v12, CMS133v12. You may select several at once.
2. Select the reporting period. Pick the measurement period (start and end dates) over which the measure is evaluated — for example, the full calendar year for an annual MIPS submission, or a custom range.
3. Select the QRDA type to export. Choose QRDA Category I (per-patient files) or QRDA Category III (aggregate report).
   • QRDA Category I — one file per patient containing that patient's codified quality data for the selected measures and period. Use this for patient-level export or to hand data to another certified system. Single-patient and multi-patient (bulk) export are both supported.
   • QRDA Category III — a single aggregate file with the population results (IPP, Denominator, Denominator Exclusions, Numerator) per measure. Use this for CMS electronic submission.
4. Run / Calculate. Retinex calculates the aggregate population results for the selected measures and period and displays them on screen: Initial Patient Population (IPP), Denominator, Denominator Exclusions, and Numerator, plus the performance rate.
5. Export. Click Export to download the QRDA Category I file(s) or the QRDA Category III report in the format you selected.

Cypress validation. The exported QRDA Category I and Category III files are the same artifacts validated by the ONC CQM test tool (Cypress / the CMS test harness) during certification. Cypress calculates expected results from the supplied test deck and compares them against the values Retinex produces, confirming the population calculations are correct.

6. Understanding the Calculated Results

For every measure and reporting period, Retinex computes the standard CQM population components:

7. QRDA File Formats

QRDA Category I (patient-level)

• Container: HL7 CDA R2-based XML, UTF-8.
• Conforms to the standard adopted at §170.205(h)(2) — HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture — Category I (QRDA I), STU 5.x.
• One file per patient. File naming: QRDA-I_{MRN}_{MeasurementPeriod}.xml.
• Code systems used: LOINC, SNOMED CT, RxNorm, ICD-10-CM, CPT/HCPCS, CVX — as required by each measure's value sets (VSAC).

QRDA Category III (aggregate)

• Container: HL7 CDA R2-based XML, UTF-8.
• Conforms to the standard adopted at §170.205(k)(3) — HL7 CDA® R2 IG: QRDA — Category III (QRDA III), STU 2.x.
• One file covering all selected measures, with aggregate counts per measure population. File naming: QRDA-III_{Organization}_{MeasurementPeriod}.xml.
• Suitable for CMS electronic submission (QPP / MIPS).

8. Authorized User Roles (RBAC)

CQM import, calculation, and export are gated by Retinex's role-based access control. Default grants:

Customers may adjust these grants through the Access Admin UI. Every import and export is recorded in the audit log with the initiating user, organization, timestamp, measure(s), reporting period, and outcome.

9. No Developer Assistance Required

In compliance with §170.315(c)(1)–(c)(3), every capability on this page is available to an authorized end user on-demand, at any time the user chooses, and without subsequent developer assistance. Specifically:

• Import of QRDA Category I file(s) and patient CSV is performed entirely through the Import panel by the user.
• De-duplication and codified recording of data criteria (including patient reason, system reason, and medical reason exclusions/exceptions) is automatic.
• Calculation of aggregate population results (IPP, Denominator, Denominator Exclusions, Numerator) is performed by the system on the user's request.
• Export of QRDA Category I (single-patient and multi-patient/bulk) and QRDA Category III is initiated by the user from the Report Builder.
• No Retinex engineer runs a script, query, or background job on the user's behalf for any of these steps.

10. No-Charge Statement

Retinex does not charge a separate fee for the certified CQM import, calculation, or QRDA export/report capability described on this page. These functions are included in the standard EHR subscription. Access to this documentation is provided at no charge. Any optional value-added services beyond the certified scope (for example bespoke data migration or custom report development) would be offered separately under a written agreement and disclosed in the Costs and Certification Information page.

11. Implementation Guides & References

• eCQI Resource Center — QRDA
• HL7 CDA R2 IG: QRDA Category I (STU 5.x) — standard at §170.205(h)(2)
• HL7 CDA R2 IG: QRDA Category III (STU 2.x) — standard at §170.205(k)(3)
• eCQI — Eligible Professional / Eligible Clinician eCQMs (CMS131, CMS143, CMS133)
• VSAC — Value Set Authority Center (NLM)
• Cypress — ONC CQM Testing Tool
• CMS Quality Payment Program (MIPS)

12. Version History

Support

For help with a specific import, calculation, or QRDA export:

• Email: support@retinex.ai
• Compliance & certification: support@retinex.ai