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February 2018

Opportunities, Challenges Mark eCQM Debut
By Elizabeth S. Goar
For The Record
Vol. 30 No. 2 P. 14

CMS listened to stakeholder feedback in an attempt to make the process less onerous on health care organizations.

As hospitals scramble to comply with the second round of mandatory electronic clinical quality measures (eCQMs) reporting, they will benefit from adjustments made in the wake of feedback submitted during the 2016 calendar year (CY) reporting period. The most significant modifications include fewer eCQMs and reporting requirements.

According to the Centers for Medicare & Medicaid Services (CMS) inpatient quality reporting team, 94% of hospitals participated in the inaugural reporting period, which will impact 2018 payment determinations. Participation involved either submitting data by the extended March 13, 2017, deadline or securing an extraordinary circumstances exception. Successful submission netted participating facilities credit for both the eCQM portion of the hospital inpatient quality reporting (IQR) program and the CQM portion of the EHR incentive program.

"Leading up to the first year of mandatory eCQM reporting, we received feedback [via e-mail, webinar questions, help desk questions, and conference call discussions] from hospitals and health IT vendors about their challenges of implementing eCQM reporting," according to a representative for the team in response to an e-mail. "In response to these issues, we modified the eCQM reporting requirements for both the CY 2017 reporting period/fiscal year (FY) 2019 payment determination and the CY 2018 reporting period/FY 2020 payment determination by reducing the number of eCQMs and quarters of data required to be reported."

Feedback is summarized in the FY 2018 inpatient prospective payment system (IPPS) proposed and final rules. (The FY 2018 IPPS final rule can be found in the Federal Register at 82 FR 38355-38361).

A Program Primer
A subset of electronic clinical quality improvement, better known as eCQI, which was implemented by CMS and the Office of the National Coordinator for Health Information Technology to accelerate health care's transformation to a quality-based and patient-centric system, eCQMs leverage quality metrics to determine whether evidence-based standards of care are adhered to for each patient. The goal is to enable clinical decision support that leverages evidence-based medicine and the patient's personal history, preferences, and data to create patient-specific care recommendations and actions.

The initiative rewards hospitals that achieve improved outcomes and lower costs by implementing quality improvements and efficiencies to better address patient needs and preferences. It seeks to align measure components, tools, and standards and provide a foundation for the development, testing, certification, implementation, reporting, and continuous evaluation of both eCQMs and clinical decision support tools.

According to CMS, to receive credit for both the Hospital IQR and EHR incentive programs during the CY 2016 reporting period, hospitals needed to report quality data for four of 28 eCQMs for either third or fourth quarter 2016 discharges using certified EHRs. For EHR incentive program credit, hospitals could report aggregate level information rather than patient level by attesting to 16 of 29 eCQMs.

For the current reporting period, things have been scaled back a bit. The EHR incentive program can be met by electronically submitting four eCQMs for one self-selected quarter of 2017 discharges. Hospitals can meet the CQM requirements for both programs with the four eCQM submissions.

Those changes resulted from feedback from multiple stakeholders in the lead-up to the first eCQM reports. Among the concerns voiced were the potential impact of new EHR requirements and the consequences of a significant upgrade on a hospital's ability to report an increased number of measures in a timely manner. Stakeholders argue that such measures would necessitate at least one year between new EHR requirements, based on the six- to 24-month cycles needed for vendors to code new measures, test and institute measure updates, train hospital staff, and roll out other upgraded features.

Hospitals also reported struggling to identify applicable measures that reflect patient populations, given the reduction in the number of available eCQMs for CY 2017 reporting. Because hospitals must collect CY 2017 data while reporting CY 2016 data, data mapping to the required fields in a Quality Reporting Document Architecture format and to workflows was also problematic. Finally, challenges were identified with implementing annual updates and new editions of certified HIT because of significant impacts on workflows, staffing, and connected technology systems.

The challenges, however, are not limited to CMS requirements. Hospitals' first-round reporting efforts revealed internal issues. Data integrity was among the most significant, according to Zahid Butt, MD, CEO of the quality monitoring and reporting firm Medisolv.

"The significant requirements in eCQM … are that [data] need to reflect the actual practice and they need to be very accurate," he says, adding that many of the challenges "go back to the way the eCQMs were specified and the type of data needed to accurately produce results. Those data had to be primarily structured, codified, and captured consistently. The reality is that much of the data that are captured aren't captured like that, so people have had to change workflows or, worse, do workarounds."

The more successful facilities are those that adapt required workflows in a way that doesn't add to clinician burden while supporting the capture of needed data. For example, using computerized physician order entry with evidence-based order sets to help guide physicians' choices and document overrides "rather than trying to capture it later as a workaround outside the normal process," Butt says.

Stumbling Blocks
Butt points out that problems are expected with any new electronic reporting program. In the case of eCQM, hospitals that undertook voluntary electronic reporting in 2015 were tasked with working out the kinks on both the submission and receiving ends.

"Whoever is in the first group of submitters needs to be able to deal directly with the CMS technical staff to deal directly with the technical submitters, especially with CMS, to resolve the back and forth very quickly," he says.

Past AMIA Board Chair Thomas H. Payne, MD, agrees, noting that another key issue with eCQM is "that the measures require data, and that often requires extra effort on the part of the people who perform the documentation. That's a situation we want to avoid because the documentation is there to support the care of the patient. We don't want to introduce some other purpose that doesn't help that person during that encounter."

Payne continues, "If you ask for more data that aren't directly beneficial to the patient, there is a price to be paid. [Clinicians] will have less time to listen to the patients and address their concerns. We also have to reflect on the burden that documentation and EHRs have placed on practitioners of all disciplines, particularly physicians and nurses. They are already struggling to conform to documentation requirements. We don't [want] to make that worse as we move toward electronic quality measures."

Another risk is that the selected measures don't truly reflect what all stakeholders commonly consider an aspect of care quality. This becomes particularly problematic when the required data are not easily aggregated.

"There are [multiple] perspectives to consider, so that's another potential problem with early efforts to gather and report early quality measures," Payne says, pointing to a study in the March 2016 issue of Health Affairs that surveyed physician practices about experiences with quality measure reporting. Researchers found that physician practices spend more than $15.4 billion annually on reporting quality measures, with the average physician spending about 2.6 hours per week on the task, most of which went toward data entry.

Few of the practices surveyed felt the process was money and time well spent. Only 27% indicated that current measures are "moderately or very representative" of the quality of care patients receive, while 28% used the information to help with quality improvement activities.

To ensure the quality measures being reported are meaningful to all stakeholders, Payne suggests seeking input not only from providers and IT but also from clinical leadership "because their perspective on what is practical and what is not will help predict success.

"A harder group to involve but more important than any [other] is the public," Payne continues. "They often discover what's working well and what's not when they seek care. After all, if we're measuring quality, the group that benefits the most are the people who seek care. It is tricky for aspects of quality to be electronically measured today, but we should recognize what our objective is: 'What do you regard as quality care?' That should be considered along with the set of things that can be measured."

Learning by Doing
The good news is that the learning curve on both sides appears to be short. This can be seen in the experiences of a group of hospitals accredited by The Joint Commission that began voluntarily reporting quality measures in 2015. That year, 34 hospitals participated. By the following year, 470 hospitals were reporting electronically.

The Joint Commission conducted a "voice of the customer" survey after each round of reporting in which hospitals identified their most significant eCQM challenges, several of which mirrored the feedback submitted to CMS. Others included timeline for transmission, IT priorities, unplanned expenses, maintenance costs, and complying with discrete charting requirements without compromising bedside care.

The second survey subsequently revealed "an increase in confidence in the timeframe," says Tricia Elliott, MBA, CPHQ, director of quality measurement in The Joint Commission's division of health care quality evaluation. "We reached out to health care organizations specific to eCQM and their readiness [for it], trying to gauge where the field was in terms of readiness and how [the agency] could help. The difference between the two [surveys was] an increased confidence in their answers. They had the technology, the ability to generate the right type of files, and were confident in submission of the files."

The Joint Commission also addressed support needs by tapping into the experiences of hospitals with a successful track record of eCQM reporting to create Pioneers in Quality, a program designed to assist other health care organizations on their journey to eCQM. Part of that program is Proven Practices, under which leading hospitals shared their experiences and solutions to problems that arose along the way.

One standout, according to Elliott, was Virginia Commonwealth University Health System, which provided the following "10 Keys to eCQM Success":

• establish strong quality program leadership;

• develop vision/long-term strategy;

• dedicate resources;

• develop experts/expertise;

• employ standard nomenclature codes;

• create a quality IT partnership;

• establish/revise management processes;

• understand vendor role capabilities;

• understand drivers; and

• get involved nationally as advocates.

Proven Practices has helped hospitals keep up with eCQM requirements and allowed The Joint Commission to evolve its educational content as participants have gained more confidence in their reporting.

"At this point, we're starting to see a shift from the technical aspects—building and getting the file set up the right way, data accuracy vs quality improvement, [ensuring] data elements that are supposed to be in the file are and are in the right spot, and data integrity is good," Elliott says. "So now we are shifting to quality improvement. What are the data telling us? How can we positively impact the process of care that this measure is focused on? It's a shift from data accuracy to quality improvement."

Realizing the Benefits
As hospitals and CMS settle into a reporting rhythm, the benefits of electronic reporting will begin to be realized on both sides. Elliott points to the ability to quantify quality of care using EHR data as one benefit. It requires less manual intervention, freeing up resources to focus on process and quality rather than abstraction, and helps ensure the EHR is working as intended.

The CMS quality reporting team says the use of eCQMs enables the structured clinical data elements in EHRs—eg, lab results, functional assessments, medications, and symptoms—to assess care appropriateness and outcomes. It also facilitates access to real-time data for bedside quality improvement and clinical decision support—for example, by helping guide clinicians to evidence-based care and increasing patient safety.

As CMS continues aligning clinical quality measures across programs, "the reporting burden of multiple programs on hospitals will be reduced," according to the CMS team. "Our goal for the future is to continue to align those quality measurement requirements and to adopt a more streamlined set of clinical quality measures with electronic specifications aligned to standardized data elements so that electronic collection of performance information is a seamless component of care delivery."

— Elizabeth S. Goar is a Tampa, Florida-based freelance writer specializing in health care and HIT.


HealthIT.gov covers everything from general descriptions of the field to requirements and implementation information.

• The Centers for Medicare & Medicaid Services' (CMS) eCQI Resource Center (ecqi.healthit.gov) is a one-stop shop for the most current resources to support electronic clinical quality improvement, including an entire page dedicated to electronic clinical quality measures (eCQMs) (https://ecqi.healthit.gov/ecqms)

• The Joint Commission's Pioneers in Quality program can assist hospitals on their journey toward electronic clinical quality measure adoption (www.jointcommission.org/topics/pioneers_in_quality.aspx)

• Information and resources about the EHR incentive program are available on the CMS website: www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/
. Health care professionals can also contact the EHR Information Center at 1-888-734-6433.

• CMS's QualityNet.org provides information and resources about the hospital inpatient quality reporting program, including specific information about eCQM reporting requirements and resources (www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2F

• For questions concerning the QualityNet secure portal, the presubmission validation application tool, and file error messages, contact the QualityNet help desk at qnetsupport@hcqis.org.