Data Repository Experts Since 1998

In a Galaxy NOT So Far Far Away... eCQMs

Jodi Frei, PT, MSMIITManager of Organizational InformaticsNorthwestern Medical Center

Bill PresleyVice President, Product DevelopmentAcmeware

ObjectivesParticipants will understand the following concepts and their relevance to healthcare settings:

2016 IPPS Final Rules for Inpatient Quality Reporting (IQR)

eCQM Definition and Background

Clinical Quality Measure Program Initiatives

Reporting Process – Selection to Submission

What’s On The Horizon?

Opportunities and Challenges

Why are eCQMs Important?2016 IPPS Rule Finalized

From the Federal Register:

CMS is finalizing modifications of its proposals and will require hospitals to submit 4 of 28 available eCQMs of their choice beginning in CY 2016 for the FY 2018 payment determination.

Hospitals will be required to submit one quarter (either Q3 or Q4) of electronic data in CY 2016 by February 28, 2017.

Additional Programs Moving to eCQMsIn 2015 Joint Commission issued guidance that they were transitioning from Core Measures to CMS eCQM Specifications

Outpatient Quality Reporting Program (OQR) has a proposed 2017 eCQM requirement

Comprehensive Primary Care Initiatives have embedded eCQMsubmission into their reporting options.

CMS Demonstrates Commitment to eCQMsFederal Register:

“We do not agree that electronic clinical quality measure reporting should remain voluntary... We believe that electronic clinical quality measures have matured since their inception and we will address any specific eCQMs in future rulemaking. “

Vision for Quality Reporting Programs

Unified and aligned set of clinical quality measures and reporting requirements to synchronize and integrate CMS quality programs which will reduce reporting burden and improve on patient outcomes.

Quality Reporting DirectionThe Future - One Specification

Core Measures (Chart Abstraction)

• Manual Chart Abstracted

• Paper-based specifications

• Translated to CMS Specification Manual

Clinical Quality Measure (eCQM)

• Electronically Captured

• Measure Concepts

• Electronic Codification

• Electronic Specification

• eCQM Library (One Spec)

Quality Reporting Specification Manual

Specifications Manual

The Specifications Manual for National Hospital Inpatient Quality Measures

Uniform set of national hospital quality measures

Paper tools for use in abstracting data for each collection (discharge) period are provided with the Specifications Manual

eCQM Library

Electronically specified versions of traditionally chart-abstracted Clinical Quality Measures

Developed specifically so Certified Electronic Health Record Technology (CEHRT) can capture, calculate, export, and transmit the measure data

For eReporting of eCQMs to demonstrate meaningful use or for Quality Reporting Programs

Data Collection Period Specifications Manual

10/01/15 - 06/30/16 Version 5.0

01/01/15 - 09/30/15 Version 4.4a

01/01/14 - 12/31/14 Version 4.3b

Reporting Year eCQM Specifications

2016 May 2015 Update

2015 April 2014 Update

2014 April 2013 Update

Quality Measure Programs

Hospital Quality

• EHR Incentive Program

• PPS-Exempt Cancer Hospitals

• Inpatient Psychiatric Facilities

• Inpatient Quality Reporting

• HAC payment reduction program

• Readmission reduction program

• Outpatient Quality Reporting

• Ambulatory Surgical Centers

• The Joint Commission (TJC)

Physician Quality

• EHR Incentive Program

• Physician Quality Reporting System (PQRS)

• eRX Quality Reporting

Payment Model

• Medicare Shared Savings Program

• Hospital Value-Based Purchasing

• Accountable Care Organizations (ACO)

• ESRD QIP

Program Requirements – MU EH

16 measures required across 3 NQS Domains

Program Requirements - IQR4 measures submitted via eCQM

8 measures submitted via Chart Abstraction

6 measures via NHSN Submission

24 measures via Claims

4 measures via Web Entry

1 measure via Patient Survey

Program Requirements - ORYX

Clinical Quality Measure Alignment

VBP

25+ MeasuresORYX

23 Measures

MU EH

16 Measures

IQR

4

Measures

ACO

30+ Measures

MU EP

9

Measures

PQRS

9

Measures

IQR/MU EH

4 Measures

IQR/ORYX/

MU EH

6 Measures

PQRS/

MU EP

9

Measures

Note: green indicates non-eCQM measures

Hospital Quality Reporting Reductions

Year IQR EHR MU VBP HAC HRRP

2013 2.0% MBU N/A 1.0% DRG N/A 1.0% DRG

2014 2.0% MBU N/A 1.25% DRG N/A 2.00% DRG

2015 0.25% MBU 0.25% MBU 1.50% DRG 1.0% DRG+ 3.00% DRG

2016 0.25% MBU 0.25% MBU 1.75% DRG 1.0% DRG+ 3.00% DRG

2017 0.25% MBU 0.75% MBU 2.00% DRG 1.0% DRG+ 3.00% DRG

MBU = Market Basket UpdateDRG = Diagnosis-related group

Hospital Quality Reporting Reductions

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

2013 2014 2015 2016 2017

IQR EHR VBP HAC HRRP

Physician Quality Reporting Reductions

Year PQRS EHR VBPM+ Sequestration Total

2013 0.5% N/A N/A -2.0% -1.5%

2014 0.5% N/A N/A -2.0% -1.5%

2015 -1.5% -1.0% -1.0% -2.0% -5.5%

2016 -2.0% -2.0% -2.0% -2.0% -8.0%

2017 -2.0% -3.0% -4.0% -2.0% -11.0%

Applied to all Medicare reimbursements

Schedule of payment adjustments depends on the size of the medical practice, starting with 100+ EPs in 2015, followed by 10 to 99, then all. Table reports maximum penalty.

Physician Quality Reporting Reductions

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2013 2014 2015 2016 2017

PQRS EHR VBPM+ Sequestration

Beginning the Reporting Process

Planning

Select your team

Choose your eCQM vendor

Choose a minimum of 4 eCQMs

Declare your intent to submit and submission vendor

Building the Foundation

System Updates

Assure reporting system is upgraded with applicable eCQM specifications

Update EMR nomenclature mapping with prior year’s specifications

Assuring Accurate Data

Validation and Reconciliation

Validate data measure by measure Focus on patients who did not meet the measure

Reconcile electronic results with abstracted results Data sources will be different

Checks and balances for nomenclature mapping

Testing the WatersPractice Submissions

Your vendor will use program specific tools to submit test files Pre-Submission Validation Application (PSVA) tool for IQR

Submission Validation Engine Tool (SEVT) for PQRS

Performance Measurement System Extranet Track (PET) for ORYX

Intent is to work through submission errors

Wrapping It Up:Final Submission

IQR: CY Q3 or 4 file submission deadline: Feb 28, 2017

PQRS submission deadline: Feb 28, 2017

ORYX submission deadline: March 15, 2017

NMC Approach to eCQM SelectionMany Factors to Consider

What are the 2016 reporting requirements for clinical quality measures by program? IQR, MU EH, ORYX, VBP

OQR, MU EP, PCMH, ACO

What measures are being tracked now?

What is the current reporting mechanism for each?

What CQMs are currently being electronically monitored?

Reconciliation: Meeting Requirements of Multiple Programs

Checks and Balances: Meeting Requirements?

IQR: Am I submitting a minimum of 4 eCQMs?YES!

IQR: Am I abstracting my 8 required measures?YES!

ORYX: Am I covering 6 sets?YES!

MU: If I submit 4 eCQMs, do I fulfill my MU CQM requirement?YES!

Labor Comparison: Pre vs Post eCQM

0

10

20

30

40

50

60

70

80

90

100

Jan Feb March April May June

Pre eCQM Hrs (Abs Only) Post eCQM Hrs (eCQM & Abs)

- An NMC Study

Going Above the Regulatory Requirements!

eCQMs will not go away…

Beyond meeting the regulations, however, reporting eCQMs: Creates efficiencies

Requires hospitals to standardize their processes

Creates dashboards which allow real time tracking of performance, which leads to

Real time improvements in clinical outcomes

Description:This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a reason for discontinuation of overlap therapy.

Data criteria (QDM Data Elements):"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)""Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)""Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)""Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.266)""Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)""Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)""Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)"

eMeasure Identifier: CMS-73

Reconcile and Validate eCQMsVTE-3 Reporting Example

This shows a value set for a class of medications (Warfarin)

VTE-3 Reporting Example

Data criteria (QDM Data Elements):

"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“

Value Set Table:

eMeasure Identifier: CMS108

VTE-3 Reporting Example

Data criteria (QDM Data Elements):"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“

Value Set Table:

eMeasure Identifier: CMS108

Data criteria (QDM Data Elements):"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)""Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)""Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)""Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.266)""Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)""Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)""Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.93)"

VTE-3 Reporting ExampleeMeasure Identifier: CMS108

VTE-3 Reporting Example

VTE-3 Reporting Example

VTE-3 Reporting Example

VTE-3 Submission File Example: QRDA

eCQM Reporting Submission

Meaningful

Use EP

Meaningful

Use EH

Electronic Clinical Quality Measures (eCQM)

PQRS IQRJoint

Commission

QualityNet PQRS QualityNet IQR TJC

QRDA I or III

What’s On The Horizon? Medicare Access & CHIP Reauthorization Act of 2015◦ Consolidates reporting requirements

◦ Rewards providers of care for value versus volume

◦ Alternate Payment Models (APMs)◦ Lump sum incentive payments for providers in ACOs, PCMHs, etc

◦ 5 percent of the prior year’s estimated aggregate expenditures under the fee schedule through 2025

◦ Merit-Based Incentive Payment System (MIPS)◦ Combines PQRS, MU, and Value Based Payment Modifier for EPs

◦ Focus on Quality, Resource Use, Clinical practice improvement, and Meaningful use of certified EHR technology

ConclusionCQM reporting is the focus of the present and future

◦ Electronic suubmission will become more pervasive

Opportunities and Challenges Exist◦ Patient Population Tracking

◦ Concurrent Review for Nursing Quality

◦ Clinical Care Team Alerting

◦ Custom Report Development

Prepare your teams and systems now

Referenceshttp://www.jointcommission.org/assets/1/18/FAQ_2016_ORYX_PM_Reporting_Reqs_10-28-2015.pdf

http://www.jointcommission.org/performance_measurement.aspx

http://www.jointcommission.org/assets/1/18/2016_Measure_Set_Selection_Instx-Forms_10-28-2015.pdf

https://www.qualitynet.org/

Reference: Quality Net

https://www.federalregister.gov/articles/2015/08/17/2015-19049/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the#p-811

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideEH.pdf

https://innovation.cms.gov/Files/x/cpci-ecqm-manual.pdf

http://www.qualityreportingcenter.com/wp-content/uploads/2015/07/OQR_CY-2016-OQR-proposed-rule_071515_FINAL.pdf

https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Timeline.PDF

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html

Discussion, Questions & AnswersInternational MUSE 2016

Tuesday Workshops801 - The Alphabet Soup of Clinical Quality Measures Reporting Initiatives1pm

Education Sessions1032 - In a Galaxy NOT So Far, Far Away ... eCQMs3:30pm

1094 - How to Successfully Submit eCQMs Electronically11:15am