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In 2016, the Center for Medicare and Medicaid Services (CMS) officially began requiring hospitals to report Electronic Clinical Quality Measures (eCQMs). eCQMs are quality measures that are based on electronic specifications. The specifications include the data elements, measure logic, value sets and definitions for each measure. eCQMs must be calculated using Certified Electronic Health Record Technology (CEHRT).

The goal of clinical quality measures is to provide a measure of the quality of care provided. As reimbursement for healthcare organizations and providers shifts from volume of services provided to the value of services provided, quality measures become increasingly important. Abstracted clinical quality measures are very resource intensive. eCQMs utilize data that should be collected as a byproduct of documentation in CEHRT. Although abstracted CQMs will not disappear anytime soon, the move has begun to eCQMs with the requirements in the IPPS 2016 Final Rule. The recently released IPPS 2017 proposed rule increases the number of required eCQMs to be reported from 4 to 15.

Most healthcare organizations and providers have paid little attention to their eCQMs measure performance to date. For CMS’s Electronic Health Record (EHR) Incentive Payment Program or Meaningful Use, the requirement was to calculate the measure using CEHRT and attest. There was no electronic submission and no thresholds. Most organizations were focused on what was formerly known as Core and Menu measures that did have threshold requirements. Organizations will need to focus on eCQM measure performance in preparation for an increasing number of required eCQMs, future public reporting of eCQM measure performance, and measure thresholds. 

Although there are different methodologies for calculating abstracted CQMs and eCQMs, measure performance should be similar. The same clinical care is provided to the patient, but the method for measurement is different. It is important to understand the differences in methods.  Abstracted CQMs are calculated on a sample of patients whereas eCQMs utilize the entire population. Abstractors use data found anywhere in the patient’s medical record.  That data can be found in structured data (such as orders or drop down fields), unstructured data (such as physician or nursing notes) and even in scanned documentation. For eCQMs, the data must be in structured fields to be included in the calculation. eCQM reports can be configured to pull data requirements from a single location in the EHR or multiple locations. In addition, certain eCQM data elements must use specific values from defined value sets. Although the methodologies differ for calculating abstracted CQMs and eCQMs, measure performance should be similar. However, most organizations find that their CQM and eCQM measure performance can differ dramatically. Certain CQMs are reported publicly. Currently, abstracted CQMs are reported publically on the Hospital Compare website for the Inpatient Quality Reporting (IQR) Program. Many organizations that have reported high performing abstracted CQMs will not want to report eCQMs reflecting lower performance.

No time to waste

In 2016, hospitals must submit data for four of the 28 Hospital Inpatient Quality Reporting (IQR) program eCQMs that align with the EHR Meaningful Use (MU) Incentive program. Hospitals will choose four measures from a list of 28 eCQMS, which they will report electronically for Q3 or Q4 2016. Inr 2017, the IPPS 2017 proposed rule removes 13 of the 28 eCQMs and requires the remaining 15 eCQMs to be reported for a full calendar year.

Hospitals that do not know how their eCQM measure performance stacks up to their abstracted CQMs should get started.  eCQMs are now tied to Medicare reimbursement (a quarter of a percent of a hospital’s Medicare Market Basket adjustment is at risk for 2016 reporting year). With the proposed increase in the number of eCQMs required in 2017 and the lack of choice (all 15 measures are required), the stakes are increasing. Although the IPPS 2017 proposed rule does not require public reporting or thresholds, it is anticipated that it will be coming. Hospitals need to assess the current state of their measure performance and review if they have built all the eCQMs that are proposed to be required in 2017. The first step in this process is to evaluate eCQM measure performance compared to abstracted CQMs. For measures where there are differences, root causes must be identified and action plans developed. Common reasons why eCQM measure performance differs from abstracted CQMs include;

  • Data requirements are not captured as discreet data
  • Data is captured as discreet data but the eCQM reports are not configured to capture the data in that location
  • Workflows exist to capture the data but workflows are not followed due to lack of training, education or reinforcement
  • Workflows to capture data are disruptive to clinician workflow and are not followed
  • Workflows do not exist to discretely capture the data
  • Data is not in the correct format (value sets)

eCQMs are complicated. Assessing the current state of your eCQMs, determining root causes of measure performance and developing action plans for remediation is not a small task. It can feel overwhelming for hospitals who are already overburdened and understaffed. In many cases, these facilities overcome these obstacles by working with outside experts and consultants who can guide these initiatives, help them develop and implement action plans, and ensure they get the right data management tools and processes in place to accurately report the quality of their care through these eCQMs.

Getting ahead of this trend will be difficult, but the sooner hospitals make this transition, the easier it will be for them to meet ongoing reporting requirements, and ensure that they focus their time and resources on quality improvement efforts that will deliver the highest quality of care to their patients while complying with quality reporting requirements and protecting their bottom line.