How MEDITECH hospitals can meet the new eCQM reporting requirements using QRDA

2017 Quality Reporting with eCQMs

Presented By:Cindy Paul, RN, BSN Sr. Consultant and Project ManagerCindy.Paul@iatric.com

Agenda• Is your Hospital ready for eCQM

reporting?• Updates on reporting deadlines• 2017 eCQM Reporting Requirements

using QRDA Category 1• Producing QRDA-1 files in MEDITECH• Are you prepared for eCQM testing &

validation?• How to tackle the challenge and win!• Is everyone on the same page?

Aligning Quality Reporting Programs

Inpatient Quality Reporting (IQR) and EHR Incentive Meaningful Use Programs have aligned through dual submission of eCQMs to Quality Net

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

Recent Updates for Reporting

CMS extended the reporting deadline for 2016 New deadline is March 13, 2017

Expect potential changes for CY 2017 reporting:• Reduction in reporting period to 90 days• Decrease the number of eCQMs

Address challenges many hospitals face:• Transitioning to new EHR systems• Upgrading EHR technology• Changing workflows to meet eCQM

requirements

2017 Alignment IQR and EHR Incentive Program

CMS IPPS Final Rule released August 22, 2016

• Retained 15 eCQMs in the Hospital IQR Program available for EHR Incentive Program

• Select a minimum of 8 of the 15 available eCQMs

• Report 4 quarters of data on a quarterly, bi-annual, or annual basis

2017 Alignment IQR and EHR Incentive Program

• IQR eCQM requirement aligns with CQM reporting for the EHR Incentive Program

• Starting in 2018, hospitals and Critical Access Hospitals participating in the EHR Incentive Program will no longer have the option for attestation

• eCQM reporting using CEHRT is required

2017 Which CQM’s Are Retired?

AMI-2AMI-7AAMI-10HTNPN6SCIP-Inf 1ASCIP-Inf 2aSCIP-Inf 9STK-4VTE-3VTE-4VTE-5VTE-6

Selecting 2017 eCQMs

Scores

• Not reported to Hospital Compare• Zero denominators “OK”• CMS will use data as a baseline to establish

future threshold requirements• Future ruling to be released

Producing a QRDA-1 file

• Follow MEDITECH Best Practices• Documentation with updated value sets• Ensure correct tables are turned on to Data Repository

• IMO updates• All data sources must have accurate nomenclature

mapping

• ARRA Report Manager vs SQL reports• Tools for populating a QRDA-1 for each measure• Run reports to determine what’s missing• Correct errors• Map the missing data sources

Is it REALLY that Easy?

• Working through the ARRA Report Manager requires dedicated staff resources

• New documentation queries or data capture will be required to meet Best Practice

• New IMO mapping may be required

• New value sets and OIDs • Are there internal resources to

produce reports?

MEDITECH’s ARRA Tool

1. Install on the MEDITECH DR Server2. Run most recent configuration for 2017

a. Use previous year specs3. Upload new value sets

a. Requires UMLS license for VASC Value Set Authority Center

4. Populate parameters specific to facility5. Populate parameters specific to eMeasure6. Run reports

ARRA Report Manager Errors

• 2015 Spec CQM reports running, but required parameters in the mtzcus_2015Spec_eCQMReportConfigurationTableare not populated

• Generated report, but no data appears

QRDA-1 Files Created – What’s Next

Pre-Submission Validation Application• QualityNet Secure Portal

• Register for a QualityNet account• Have assigned EHR Data Upload Role

• Test QRDA-1 files & validate against 2017 CMS requirements

• Produces reports to help identify errors• Correct errors prior to submitting production files

Common PSVA Errors

Reality…..

• Tracking started January 1• Involves new build & IMO mapping in

MEDITECH • Requires updates for 2017 CMS specifications

and value set mapping• Need to test & validate QRDA-1 files before

submission• Potential to submit Q1 data in Q2

Don’t Go At it Alone!

How Can Iatric Systems Help?

ü We have clinical expertise in CQMsü We are experts in CMS Regulations and

eCQM requirementsü We know MEDITECHü For years, customers have trusted Iatric

Systems with Meaningful Use Manager™ and now Analytics on Demand™ for Quality Reporting

Professional Services QRDA Assist™

• Assist with eCQM selection of 8 measures• Gap Analysis of current data collection against CMS

Specifications and MEDITECH 2017 Best Practices• Provide expert guidance for changes required• Generate QRDA-1 files using MEDITECH’s ARRA tool• Assist with validation and testing in QualityNet’s PSVA

tool• Quickly generate QRDA-1 files from MEDITECH to your

quality vendor(s)• Truven• Quantros• Press Ganey• Acmeware/Medisolv

Don’t Delay…or You’ll Pay

• Could result in a one-fourth reduction of the market basket update for IQR

• Requires numerous workflow changes• New CMS value set mapping updates• Strict deadlines

Making Quality Reporting Work

• Alignment of C-Suite, Quality, IT and Clinicians in the front line

• Appropriate Training of Staff• Implement Continuous Quality Improvement• Quality Reporting specific to your Hospital

Culture

Resources

• eCQM and QRDA file specifications can be located on the eCQM Library page of the CMS website at:

https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/ecqm_library.html

• Resources for electronic clinical quality improvementhttps://ecqi.healthit.gov/

• QualityNet eCQM Pageshttps://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228773849716

Questions

For assistance or follow up, please contact:

Cindy Paul, RN, BSN Iatric Systems Professional ServicesSr. Consultant and Project ManagerCindy.Paul@iatric.com978-674-5927