Electronic Clinical Quality Measures (ecqms) for Hospitals: What You Need to Know July 13, 2016
Agenda Opening Remarks Housekeeping Polling Question Presentations Q&A Closing Remarks 2
Introduction to the atom Alliance Multi-state alliance for powerful change composed of three nonprofit, healthcare QI consulting companies. 3
Objectives During this Webinar you will learn how to: Hospital reporting program alignment Basic understanding of ecqms and related language Steps to use for successful submissions of ecqms Changes that may be coming to ecqms in future years 4
Housekeeping Items: Chat To ensure maximum sound quality, participant lines have been muted; however we welcome ALL questions and comments via the chat board on the right hand side of your screen To submit questions or comments: Use WebEx chat send messages to the panelists or all participants using the chat feature drop down menu 5
Housekeeping Items: Polling During today s presentations you may be asked to participate in some polling questions. These questions will come up on the right side of your screen. When you do answer a polling question, be sure to hit the submit button so we can capture your answer. 6
Housekeeping Items: Q & A To ask panelists questions directly, and privately The panelist can then decide to answer the question privately (only the person that asked the question will see the response), or the panelist can answer publicly, and all participants will see the question and the answer. 7
Polling Question #1 What is your primary role in the hospital? Quality Improvement/Data Submission Health Information Management/Medical Records Nursing/Clinical Services Case Management/Discharge Planning Information Technology (IT) Mixed Audience Including IT Mixed Audience NOT including IT Other 8
Electronic Clinical Quality Measures (ecqms) for Hospitals: What You Need to Know Kristin Celesnik Hennette July 13, 2016
Objectives Provide an overview of alignment among hospital reporting programs Demonstrate a basic understanding of electronic clinical quality measures (ecqms) and related language Outline steps for successful submission of ecqms Recognize what changes may be coming to ecqms in future years 10
Hospital Quality Reporting (HQR) Alignment Alignment of measures across HQR programs will Simplify reporting for HQR programs through the collection and reporting of data through health information technology (HIT) Minimize the reporting burden imposed on hospitals Further align quality reporting programs across care settings in the future Initial focus is on aligning the Hospital Inpatient Quality Reporting (IQR) and the Medicare Electronic Health Record (EHR) Incentive programs for Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) 11
Submission Methods for the Medicare EHR Incentive Program Option 1: Electronic submission of data for four ecqms through the QualityNet Secure Portal Satisfies the CQM requirement of the Medicare EHR Incentive Program and aligns with IQR Program requirements Option 2: Aggregate reporting of 16 ecqms for a full year through the CMS Registration and Attestation System Available for facilities that do not participate in the Hospital IQR program Satisfies the CQM requirement of the Medicare EHR Incentive Program for 2016 12
Submission Methods for the Medicare EHR Incentive Program (cont.) Refer to the 2016 Program Requirements page at https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/2016Program Requirements.html for a complete program requirement listing. Hospitals who are also eligible to participate in the Medicaid Incentive Program will need to refer to their State Program requirements. 13
ecqm Reporting Requirement Specifications For the IQR Program for CY 2016 reporting, a hospital will be required to: Report a minimum of 4 of the 28 available ecqms Report for only one quarter (Q3 or Q4) of CY 2016 Submit October 2016 through February 2017 14
ecqm Reporting Requirement Specifications (cont.) Important Notes: Success with CY 2016 reporting will apply to FY 2018 payment determinations for Inpatient Prospective Payment System (IPPS) hospitals National Quality Strategy Domain distribution will not be required Meeting this requirement also satisfies the Clinical Quality Measure (CQM) electronic reporting option requirement of the Medicare EHR Incentive Program 15
What is an ecqm? An electronic clinical quality measure (ecqm) is: A clinical quality measure that is specified in a standard electronic format and is designed to use structured, encoded data present in the electronic health record. 16 Source: Joint Commission Pioneers in Quality
Chart Abstracted vs. ecqm Chart Abstracted Process ecqm Process Provide Care Interpret Care Calculate Rate Provide Care Calculate Rate 17 Source: Joint Commission Pioneers in Quality
Key Differences: Chart Abstracted vs. ecqm Chart Abstracted Allow data collection from any documentation format including free-text, structured fields, or scanned documents Multiple sources (H&P, orders, diagnosis, etc) may fulfill a single data element A trained abstractor determines which information is accurate when conflicting data exists Dependent on recorded time of observation or intervention Measures updated twice annually ecqm Only use structured or encoded information Data typically extracted from a single, structured field (the source of truth ) Rates are calculated based on data present. There is no human intervention to evaluate and correct conflicting data Dependent on EHR time stamps Measures updated annually 18 Source: Joint Commission Pioneers in Quality
ecqm Measure and Reporting Standards Health Level Seven (HL7) International standards organization Provides the framework for the way electronic health information is exchanged, integrated, shared, and retrieved ecqm Structure and Logic Health Quality Measure Format (HQMF), includes human readable and underlying XML document. Template to consistently organize the clinical information - Clinical Document Architecture (CDA) Format for reporting Category I, raw, single patient-level data - Quality Reporting Document Architecture (QRDA) 19
What is a value set? Lists of values to define clinical concepts (e.g. patients with diabetes, statin medications used for stroke treatment). Consists of numerical values (codes) and human-readable names (terms), drawn from standard vocabularies. For example: A list of SNOMED CT codes for stroke diagnosis A list of RxNorm codes for Statin medications https://vsac.nlm.nih.gov/ Source: Joint Commission Pioneers in Quality 20
Vocabularies Used In Value Sets Standard Vocabularies Lab tests and diagnostic studies Lab/ Diagnostic Test Names LOINC Lab/ Diagnostic Test Results SNOMED-CT Medications RxNorm Vaccines CVX Everything Else SNOMED-CT Source: Joint Commission Pioneers in Quality 21
Vocabularies Used In Value Sets (cont.) Transition Vocabularies Diagnoses ICD-9-CM, ICD-10-CM Encounter CPT, HCPCS, ICD-9-CM Procedures, ICD-10-PCS Diagnostic Study Names Interventions/ Procedures HCPCS CPT, HCPCS, ICD-9-CM Procedures, ICD-10-PCS Source: Joint Commission Pioneers in Quality 22
ecqm Reporting Standards for CY 2016 Reporting Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) that seek to report ecqms electronically must use: An EHR system certified to either the 2014 or 2015 Office of the National Coordinator for Health Information Technology (ONC) standards The June 2015 Update for ereporting for the 2016 Reporting Year version of the electronic specifications for the CQMs 23
ecqm Reporting Standards for CY 2016 Reporting (cont.) EHs and CAHs that seek to report ecqms electronically must use: The 2016 Centers for Medicare & Medicaid Services (CMS) Quality Reporting Data Architecture (QRDA) Implementation Guide for Hospital Quality Reporting ecqm and QRDA file specifications can be located on the ecqm Library page of the CMS website at: https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/ecqm_librar y.html 24
29 Available ecqms ED-1 STK-5 AMI-8a VTE-5 SCIP INF-2a ED-2 STK-6 AMI-10 VTE-6 SCIP INF-9 ED-3* STK-8 VTE-1 PC-01 EDHI-1a STK-2 STK-10 VTE-2 PC-05 HTN STK-3 AMI-2 VTE-3 CAC-3 PN-6 STK-4 AMI-7a VTE-4 SCIP INF-1a *ED-3 is an outpatient measure and not applicable for IQR. Required chart abstraction for IQR Program 25
Important Notes Regarding Clinical and HAI Measures ecqms do not eliminate the requirement to submit data for other chart-abstracted, web-based, and claims-based measures Chart-abstracted data will still need to be submitted for required measures Hospitals will be required to submit population and sample size data only for those measures submitted as chartabstracted under the Hospital IQR Program. 26
Required IQR Chart-Abstracted Measures for CY 2016 Reporting Measure ID Measure Name ED-1* Median Time from ED Arrival to ED Departure for Admitted ED Patients ED-2* Admit Decision Time to ED Departure Time for Admitted Patients IMM-2 Influenza Immunization SEP-1 Severe Sepsis and Septic Shock: Management Bundle (Composite Measure) * Also available as ecqm 27
Required IQR Chart-Abstracted Measures for CY 2016 Reporting (cont.) Measure ID STK-04* Thrombolytic Therapy Measure Name VTE-5* Venous Thromboembolism Discharge Instructions VTE-6* Incidence of Potentially Preventable Venous Thromboembolism PC-01* Elective Delivery (Collected in aggregate and submitted via Web-based tool) * Also available as ecqm 28
ecqm Submission: Hospitals In order for a hospital to submit data files to the CMS hospital ecqm receiving system through the QualityNet Secure Portal, they must: Register for a QualityNet account (new users only) Have the EHR Data Upload Role assigned to the QualityNet account 29
ecqm Submission: Vendors Hospitals may authorize their certified EHR vendor to submit data files on their behalf by Logging in to the QualityNet Secure Portal and authorizing the vendor by Measure set Data transmission start/end date Discharge quarter start/end date Vendors need to Register for a QualityNet account Request the EHR Data Upload role 30
Successful ecqm Submission Successful submission is defined as submission of at least four ecqms which can be reported as any combination of Accepted QRDA-I files with patients meeting the Initial Patient Population of the applicable measures Zero denominator declarations Case threshold exemptions 31
Zero Denominator Declaration A zero denominator can be used when both A hospital s EHR system is certified for an ecqm, and A hospital does not have patients that meet the denominator criteria of that CQM Submitting a zero denominator counts as a successful submission for that ecqm for both the Medicare EHR Incentive Program and the Hospital IQR program 32
Case Threshold Exemption The Case Threshold Exemption can be used when both A hospital s EHR system is certified to report data, and There are five or fewer discharges during the relevant EHR reporting quarter If an eligible hospital or CAH qualifies for an exemption for the ecqm, that ecqm counts toward meeting the program requirement Hospitals do NOT have to utilize the Case Threshold Exemption. They can submit applicable QRDA files if they choose 33
Extraordinary Circumstances Extensions or Exemptions for IQR Reporting There is a new exemption for Hospitals that demonstrate hardship in reporting ecqms effective with the FY 2018 payment determination. Hardships could include, but are not limited to: Infrastructure challenges No Internet access Vendor issues Issues outside the hospital s control, including a vendor product losing certification 34
Extraordinary Circumstances Extensions or Exemptions for IQR Reporting (cont.) Hardships could include, but are not limited to: The deadline would be within 30 days of the time that the event occurred. Note: A webinar entitled IQR-IPPS Measure Waivers and Extraordinary Circumstance Exemption was presented on January 19, 2016. A recording of this webinar can be located at http://www.qualityreportingcenter.com/inpatient/iqr/events/ 35
Public Reporting of ecqms For CY 2016/FY 2018 reporting, any data submitted as an ecqm will not be posted on the Hospital Compare website. Public Reporting of ecqm data will be addressed in the CY 2017/FY 2019 rule following the conclusion and assessment of the validation pilot. 36
Pre-Submission Validation Application (PSVA) The PSVA: Is a downloadable tool that operates on a User s system Allows submitters to catch and correct QRDA-I errors prior to data submission Provides validation feedback within the submitter s system Allows valid files to be separated and submitted while invalid files are identified for error correction Does not currently provide any measure calculations or measure data checks. 37
PSVA Technical Requirements To utilize the PSVA, organizations must: Create QRDA-I files based on the HL7 Base Standard for QRDA and the CMS QRDA Implementation Guide Download and install the PSVA to their system Requires a QualityNet Secure Portal (QSP) User Account Submit Files Requires a QSP User Account with an EHR Data Upload role Note: For assistance with user accounts or roles, please contact the QualityNet Help Desk at qnetsupport@hcqis.org or 866.288.8912 38
Hospital ecqm Receiving System: Test files Submission of test files to the hospital ecqm receiving system allows users to: Confirm that files are formatted correctly and will pass validation checks Have measure calculations completed View reports Fix any errors contained in the file(s) prior to production file submission. Available through the QualityNet Secure Portal Test file submissions do not count toward program requirements Submission period for production QRDA files begins October 2016 and runs through Feb. 28, 2017. 39
PSVA vs. Test Submissions If my file passes PSVA validation, does that mean it will pass CMS validation? Not necessarily. The CMS system will perform validations in addition to those performed by PSVA, such as CCN and ecqm verifications. Therefore, a file that passes PSVA validation may not be accepted by the CMS system. Do I need to use the PSVA, or can I just skip to the test portal? CMS recommends utilizing the Pre-Submission Validation Application (PSVA) to validate the format of the QRDA-I test file first, then submitting through the test portal once initial errors are corrected. 40
FY17 IPPS Proposed Rule: ecqm Removal Consideration of ecqms for removal in CY2017/FY2019 VTE-3 AMI-2a SCIP INF-1a VTE-4 AMI-7a SCIP INF-2 VTE-5 AMI-10 SCIP INF-9 VTE-6 CAC-3 PN-6 HTN 41
FY17 IPPS Proposed Rule: ecqm Reporting Adjustments Hospitals would be required to report on all 15 available ecqms (if proposal to remove 13 ecqms is finalized), beginning with CY 2017 reporting for the FY 2019 payment determination and subsequent years. QRDA-I files would need to be submitted on an annual basis for one full calendar year of data. The submission deadline would be end of two months following close of the reporting calendar year (e.g., CY 2017 ecqm submission deadline is Feb. 28, 2018). 42
FY17 IPPS Proposed Rule: ecqm Validation Modifications proposed for FY 2020 payment determination: ecqm validation would begin Spring 2018 for FY 2020 payment determinations Up to 200 hospitals would be selected for ecqm validation via random sample. 43
FY17 IPPS Proposed Rule: ecqm Validation (cont.) The following hospitals would be excluded: Any hospital selected for chart-abstracted measure validation Any hospital that has been granted a Hospital IQR Program Extraordinary Circumstances Exemption for the applicable ecqm reporting period 44
FY17 IPPS Proposed Rule: ecqm Validation, continued Require submission of timely and complete medical record information from the EHR for at least 75 percent of sampled records. Would not be scored on the basis of measure accuracy 32 cases (individual patient-level reports) would be randomly selected from the QRDA-I files submitted per hospital selected for validation CMS is proposing to require sufficient patient level information necessary to match the requested medical record to the original submitted ecqm measure data 45
Next Steps and Preparations Has your staff been discussing the CY 2016 Program Requirement to submit ecqms for IQR? Does your IT Staff have the 2014 version of the measures with 2015 updates if your facility is creating and submitting their own files? Does your staff know where to locate the tools to support ecqm data submission? ecqm Library, ecqi Resource Center, QualityNet? 46
Next Steps and Preparations (cont.) Is your IT staff/vendor aware the PSVA tool and test portal are available for testing QRDA files? Has your internal team coordinated who will ensure your ecqms will be reported by the Feb. 28, 2017 deadline? Are both you and your IT staff signed-up for the Hospital Reporting EHR ListServe (QualityNet) and participating in training opportunities? 47
Resources ecqm Library - https://www.cms.gov/regulations-andguidance/legislation/ehrincentiveprograms/ecqm_library.ht ml 48
Resources (cont.) ecqi Resource Center - https://ecqi.healthit.gov/ 49
Resources (cont.) QualityNet- http://www.qualitynet.org 50
Polling Question 2 What is the latest step your hospital has completed toward submission of ecqms? Selected at least four ecqms from the available 28 ecqms List. Began internal testing to confirm QRDA - I files are constructed according to proper specifications Submitted Test Files either via the PSVA tool or directly to the QNet Secure Portal (QSP). I m not sure, but I will find out! 51
52 Questions?
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