Hidden ecqm Dangers and How to Avoid Them

Catherine Gorman Klug RN, MSN Director, Quality Service Line Nuance Communications ecqm Lessons Learned and how to Prepare for 2017 Submissions and How to Avoid Them 2017 Nuance Communications, Inc. All rights reserved. Hidden ecqm Dangers and How to Avoid Them ecqm Background New 2017 TJC and CMS regulatory mandates Hidden dangers How to reduce risk Questions to ask your IT department 2017 Nuance Communications, Inc. All rights reserved. 2 1

ecqm Background FY16 Centers for Medicare and Medicaid Services (CMS) mandate 4 of 28 a available measures must be submitted electronically using data collected in the 3 rd of 4 th quarter by February 28, 2017 (Submission deadline extended to March 13, 2017) QRDA Category 1 file format required Meaningful Use requires all EHRs to support ecqms 2017 Nuance Communications, Inc. All rights reserved. 3 New 2017 TJC and CMS Regulatory Mandates 2017 Nuance Communications, Inc. All rights reserved. 4 2

CMS Proposed Rule Released on 4-14-17 CMS has proposed to reduce both the number of measures required as well as the number of quarters of data required for hospitals to submit Calendar Year (CY) 2017: Reporting Period: two self-selected quarters of ecqm data in CY 2017 ecqms: report on at least six (self-selected) of the available ecqms Calendar Year (CY) 2018: Reporting Period: the first 3 quarters of CY 2018 ecqms: report on at least 6 (self-selected) of the available CQMs 2017 Nuance Communications, Inc. All rights reserved. 5 TJC Changes Moving away from traditional measure sets to individual measures Introduced ecqm requirement Moving to a new vendor less reporting option 2017 Nuance Communications, Inc. All rights reserved. 6 3

TJC Changes 2017 Acute Care hospitals will be required to submit 5 chart abstracted measures: 1. ED-1 2. ED-2 3. IMM-2 4. VTE-6 5. PC-01 (required on any hospital providing OB Services These 5 measures are already required by CMS as chart abstracted 2017 Nuance Communications, Inc. All rights reserved. 7 TJC Changes If a hospital has more than 300 births per year they will also be required to submit to: PC-02 PC-03 PC-04 PC-5 2017 Nuance Communications, Inc. All rights reserved. 8 4

TJC Changes If a hospital does NOT provide Obstetrical Services then they will only submit 4 chart abstracted measures to the Joint Commission: ED-1 ED-2 IMM-2 VTE-6 2017 Nuance Communications, Inc. All rights reserved. 9 TJC/CMS ecqms Hospitals will also be required to submit 6 ecqm measures to the Joint Commission eed-1 eed-2 evte-1 evte-2 estk-2 estk-3 estk-5 estk-6 epc-01 epc-05 eehdi-1a ecac-3 eami-8a 2017 Nuance Communications, Inc. All rights reserved. 10 5

CMS Requirements Hospitals must report 8 of the available 15 ecqms 13 previously approved ecqms have been removed Data must be reported for the entire year Continues to require chart abstracted measures 2017 Nuance Communications, Inc. All rights reserved. 11 CMS is expecting One file, per patient, per quarter That the file will include all the episodes for care and the measures associated with the patient Files uploaded to WSFTP by Zip file (.zip) If you submit to CMS: Maximum individual file size of 5MB Maximum submission of 15,000 files 2017 Nuance Communications, Inc. All rights reserved. 12 6

Hidden Dangers 2017 Nuance Communications, Inc. All rights reserved. 13 Danger: lack of experience ecqm vendors may support a broad number of ecqms, but lack adequate depth of coverage Adequate time for vendors to respond to CMS and TJC changes prior to submission 2017 Nuance Communications, Inc. All rights reserved. 14 7

Danger: inaccurate data Inaccurate file submission may result from formatting the files or data elements within the QRDA 1 files No way to validate before submission 2017 Nuance Communications, Inc. All rights reserved. 15 Danger: multiple EHRs Multiple QRDA I data files generated from more than one system must be tested Challenge to aggregate results across a system 2017 Nuance Communications, Inc. All rights reserved. 16 8

Consequences Annual Payment Update Reduction one-fourth reduction of the applicable percentage increase in their APU for the applicable fiscal year APU are cumulative and compound exponentially year over year Failure to receive Electronic Health Record (EHR) incentive payment Poor quality scores Hospital Compare TJC accreditation 2017 Nuance Communications, Inc. All rights reserved. 17 Reducing Risk All hospitals: Ask you core measures vendor to validate the QRDA 1 file prior to submitting to CMS Review QRDA 1 file error reports from your core measures vendor Correct the file before submitting Multi-EHR systems: Review aggregated QRDA 1 file error reports for results 2017 Nuance Communications, Inc. All rights reserved. 18 9

Questions for your IT department How are we validating the QRDA 1 files prior to submission to ensure accuracy? Can you provide me with a QRDA 1 file error report? If we are not validating the QRDA 1 files prior to submission and errors exist, what is our remediation strategy? What reports can help us better understand the data? Outcomes IPP, Denominator, Denominator Exclusion/Exception, Numerator, Missing Data - Diagnosis codes, procedure codes, encounter information Errors Admission date/time after D/C date/time Exit Codes IPP only, measure population, pass, fail excluded 2017 Nuance Communications, Inc. All rights reserved. 19 How Can I Help? 2017 Nuance Communications, Inc. All rights reserved. 20 10

Coding Accurately is Essential 2017 Nuance Communications, Inc. All rights reserved. 23 Helping The Team Develop/deepen relationships with the Quality Department Understand the basic implications of the Inpatient Quality Reporting Program Study the ecqms being submitted by your organization Learn the coding associations for each measure 2017 Nuance Communications, Inc. All rights reserved. 24 12