Alteon Health, a physician-owned and physician-led acute care medical group based in Germantown, MD, recently became a Qualified Clinical Data Registry (QCDR), a Centers for Medicare & Medicaid Services (CMS)-approved vendor that is in the business of improving healthcare quality. QCDRs may include specialty societies, regional health collaboratives, large health systems, or software vendors working in collaboration with one of these medical entities.1

“One of the ways QCDRs can help to improve the quality of care patients receive is by collecting clinical data from clinicians and reporting this data to CMS on their behalf for purposes of MIPS [Merit-based Incentive Payment System]. QCDR submission differs from qualified registry submission in that QCDRs can submit non-MIPS measures, called QCDR measures, as well as MIPS quality measures,” CMS says.1

The QCDR status allows the medical group to develop unique performance measures with more granularity and more significance to the profession than traditional MIPS measures, says Marvin Gallo, Sr., program manager of value-based programs with Alteon Health, which specializes in emergency medicine. The practice was assisted by Healthmonix in Malvern, PA, which provides value-based care analytics and other services.

The project began in 2018, with the practice looking for quality metrics that would be more useful for improving care.

“One of the things that stood out for me was the fact that quality metrics that are specific to emergency are really topped out and may not be as relevant anymore. They have not been updated in a long time,” Gallo says. “If we really wanted to succeed, there were only a couple things we could do. The one we decided on in early 2020 was to become our own Qualified Clinical Data Registry.”

To qualify as a QCDR, the applicant must have substantial experience with managing data and creating reports, as well as specialty-specific expertise.

“CMS likes to only give QCDR status to organizations that demonstrate they truly have the expertise, so we involved a group from within Alteon. We have over 1,700 providers, and we selected 20 providers who truly stood out for the quality work they’ve done with our hospital partners,” Gallo says. “The effort involved everyone from our chief medical officer, our chief performance officer, all the way down to our providers who are working on the front lines.”

The project took 90 days, which Gallo says is relatively fast, but Alteon already had in place much of the quality improvement structure and data-gathering resources.

“We were already working in the quality space, so really all we needed to do was a deeper selection and create a framework to be more specific for the QCDR requirements,” he says.

A challenge was helping individuals understand what the QCDR application process involved and how it affects the organization.

“A lot of providers are not really privy to the nuances concerning the quality payment program. They might be more focused on their patient care and really taking care of the patient, rather than understanding how documentation practices or prescription habits may affect their bottom line,” Gallo says. “That was the biggest lift for us. We kicked off a training campaign for all of our providers. Thankfully, our leaders are well-versed in value-based care and the quality payment program.”

Hospitals could follow the same path to acquiring QCDR status, Gallo says, which would allow them to create quality metrics that might be more specific to the type of care they provide.

“I would encourage other organizations to look at those specific measures rather than focusing totally on the CMS MIPS measures,” he says. “It would allow them to fill the gaps more easily.”


  1. Centers for Medicare & Medicaid Services. A brief overview of Qualified Clinical Data Registries (QCDRs).