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91������ supports QPP measure 243: "Cardiac Rehabilitation: Patient Referral from an Outpatient Setting" because it is clinically important to refer patients who are likely to benefit from rehabilitative services to outpatient therapy centers. While we support this measure, we advise developers to address the following concerns during the update process to improve the measure quality. First, the measure is nearly capped out. Developers cite a 97% performance rate based on data collected from the PINNACLE registry during the 2011 reporting year. However, this data may inaccurately represent national performance rates because it only represents clinicians who chose to participate in the cardiology registry. Second, implementation of this measure could unfairly penalize clinicians who practice in rural areas and who care for medically complex patient populations. Developers should consider revising the specifications to include a risk-adjustment model for patients with multiple co-morbidities, lower socioeconomic status, and limited access to rehabilitative services. Third, while this measure appropriately assesses performance of clinicians participating in the cardiology registry, it is an inappropriate accountability measure for general internists who do not report data in the PINNACLE registry. Lastly, while this measure is appropriately specified to assess the performance quality of clinicians practicing in metropolitan areas, it may not apply well to clinicians practicing in rural settings where patients have limited access to rehabilitative services. Specifications include exclusion criteria for “no rehabilitation program available within 60 minutes from patient home”, but 60 minutes is an unfair expectation. Patients who are faced with significant travel burdens are less likely to adhere to prescribed services.