Best Practices for CQM Submissions

General CQM Overview

2016 Submission Requirements

2017 Submission Requirements

Selecting the Right Platform

CQM Partner Functionality Considerations

Agenda

October 11, 2016

2 October 12, 2016

HITECH’s Impact on EHR Adoption

• < 10% of hospitals had a basic EHR

• > 20% in only 2 states

2008

• Meaningful Use reporting began

• Basic EHR adoption increased to almost 30%, with 75% being certified systems

2011

• 3 out of 4 hospitals have basic EHR

• 97% of those have certified EHR

2014

3 October 12, 2016

CQM Reporting Timeline

4 October 12, 2016

2010 2012 2014 2015 2016 2017

CQMs developed as quality component of Meaningful

Use Stage 1 – Reporting via attestation

Stage 2 Meaningful Use Final Rule published;

CQMs reporting continues to be required by

MU, but requirements moved to HIQR program

– Electronic reporting becomes an option

Stage 3 Meaningful Use and 2015-

2017 MU Reporting Options rules

published – Reporting via attestation

or electronic submission

HIQR ruling establishes electronic reporting

requirement for 2016 – Reporting via

attestation or electronic submission

Electronic reporting of 4 self-selected

CQMs required for 1 calendar quarter –

Only hospitals who do not participate

in HIQR continue to attest

Electronic reporting of 8 self-selected

CQMs required for full CY – Only

hospitals who do not participate in

HIQR continue to attest

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What are

CQMs & Why

are They

Important

CQMs are tools that measure and track the quality of healthcare services provided by hospitals and providers.

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CQMs Support

Achievement of

Health Care

Goals

Better Health

Lower Cost

Better Health Care

Hospitals who participate in HIQR must • Electronically submit 4 CQMs ‒ Self-selected from available 28

inpatient CQMs

• Report one calendar quarter of data (either Q3 or Q4 2016)

• Deadline: February 28, 2017

2016 CQM Reporting Requirements CMS

Consequences of failing to report • Hospitals who fail to meet the

above will lose Medicare Annual Payment Update

6 October 12, 2016

2016 CQMs for CMS

eAMI-1 eAMI-7a eAMI-8a eAMI-10 eSCIP-INF-1

eSCIP-INF-2

eSCIP-INF-9

eCAC-3 eVTE-1 eVTE-2 eVTE-3 eVTE-4 eVTE-5 eVTE-6

eSTK-2 eSTK-3 eSTK-4 eSTK-5 eSTK-6 eSTK-8 eSTK-10

eED-1 eED-2 ePN-6 ePC-01 ePC-05 eEHDI-

1a eHTN

7 October 12, 2016

2016 Reporting Options TJC

Option 1 – Chart

abstracted

reporting only

•Select & report on 6

chart-abstracted

measure sets

•Perinatal care required

for hospitals with >=

300 live births/year

Option 2 – eCQM

reporting only

• Select & report on 8

CQM sets

‒ Data must be reported on at

least ONE eCQM from each

set selected

• Perinatal care required

for hospitals with >= 300

live births/year

Option 3 – Combination of chart-

abstracted and eCQM reporting

• Select and report on 6 measure sets

‒ For eCQM sets, data must be reported on at least

ONE eCQM

• Perinatal care required for hospitals with >=

300 live births/year

•Hospitals encouraged to submit same

chart-abstracted and eCQM sets

‒ Reduces abstraction burden

‒ Report on only 3 sets, credit given for 6

8 October 12, 2016

Chart-abstracted Measure Sets

• ED (-1a, -2a)

• PC (-01, -02, -03, -04, -05)

• STK (-4)

• VTE (-5, -6)

• IMM (-2)

• HBIPS (-1, -2, -3, -5)

• SUB (-1, -2, -3)

• TOB (-1, -2, -3)

• OP (-1, -2, -3, -4, -5, -18, -20, -21, -23)

2016 TJC Measure Options

eCQM Measure Sets

• eAMI (-7a, -8a)

• eCAC (-3)

• eED (-1a, -2a)

• ePC (-01, -05/-05a)

• eSTK (-2, -3, -4, -5, -6, -8, -10)

• eSCIP-INF (-1, -9)

• eVTE (-1, -2, -3, -4, -5, -6)

• eEHDI (-1a)

9 October 12, 2016

Hospitals who participate in HIQR must: • Electronically submit 8 CQMs

‒ Self-selected from available 15 inpatient CQMs

• Report full calendar year

‒ May report quarterly, bi-annually, or annually

• Deadline: February 28, 2018

• 200 hospitals will be selected for validation

‒ Scoring based on ability to submit COMPLETE charts NOT data element matches

‒ Feedback on data element matches will be provided

‒ If selected for chart-abstracted validation exempt from CQM validation

• No public reporting

2017 CQM Reporting Requirements for CMS

Consequences of failing to report OR failing validation • Hospitals who fail to

meet above will lose Medicare Annual Payment Update

10 October 12, 2016

2017 CQMs for CMS

eAMI-1 eAMI-7a eAMI-8a eAMI-10 eSCIP-INF-1

eSCIP-INF-2

eSCIP-INF-9

eCAC-3 eVTE-1 eVTE-2 eVTE-3 eVTE-4 eVTE-5 eVTE-6

eSTK-2 eSTK-3 eSTK-4 eSTK-5 eSTK-6 eSTK-8 eSTK-10

eED-1 eED-2 ePN-6 ePC-01 ePC-05 eEHDI-

1a eHTN

11 October 12, 2016

Chart-abstracted measures • Report on 5 chart-abstracted

MEASURES

• All PC measures required for hospitals with >= 300 live births/year

2017 Reporting Requirements TJC

eCQM measures • Report on 6 eCQMs

• Hospitals encouraged to report on additional eCQMs

12 October 12, 2016

Chart-abstracted Measure Sets

• ED (-1a, -2a)

• PC (-01*)

• VTE (-6)

• IMM (-2)

• PC (-02, -03, -04, -05)

2017 TJC Measure Options

eCQM Measure Sets

• eAMI (-8a)

• eCAC (-3)

• eED (-1a, -2a)

• ePC (-01, -05)

• eSTK (-2, -3, -5, -6)

• eVTE (-1, -2)

• eEHDI (-1a)

13 October 12, 2016

• Identify CQM vendor

• Identify data needs ‒ Strategy for 2016 & 2017 may be to

determine measures for submission and prepare for only those measures

‒ Must keep in mind that CMS will increase measure requirements

Preparing for CQM Submissions

• Map internal client codes to industry standard codes (LOINC, SNOMED, RXNORM)

• Validate CQM results

• Submit ‒ register, review, finalize

14 October 12, 2016

EHR certification edition • Must be 2014 Edition CEHRT for 2016

& 2017

• Must be 2015 Edition CEHRT by January 1, 2018

Ability to submit to The Joint Commission • Must be contracted and meet TJC

requirements

Supports all available CQMs

What to Look for in a CQM Partner

Flexible options for data integration and services to manage data extraction • HL7 interface

• Flat file transmissions

• QRDA (not recommended)

Services to help hospital achieve internal quality objectives • Ensure measure results reflect patient care

• Use data to identify areas of improvement and create transformation strategies

15 October 12, 2016

• Interface system allows data from all systems to be utilized for CQM calculation, ensuring completeness of data

‒ Integrate data from separate systems like ED, OB, Surgery, and other specialties that may not be integrated with certified EHR

‒ Ability to include unstructured data

• Services to assist with data extraction, mapping, submission

‒ Report writing

‒ Mapping experts

Advantages of an Interface System

16 October 12, 2016

COMPLETE DATA =

CQMs BETTER REFLECT PATIENT CARE

Ability to:

• Update client-to-industry code mappings via batch file or on code-by-code basis

• Generate a list of all patients qualifying for any CQM by location

• Summarize CQM results

• View CQM results at patient level

• Analyze data used in calculation

• Manage QRDA file header information

• Choose measures for submission and evaluate readiness

CQM Functionality Considerations

17 October 12, 2016

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CQM

Mapping

Editor

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CQM

Census

Report

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CQM

Scoring

Report

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CQM

Measure

Category

Report

22

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CQM

Analysis

Report

23

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CQM

Maintenance

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CQM

Submission

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Data Extraction Services

Data Integration

• Supports All Measures

• Census Report

• Scoring Report

• Measure Category Report

• Analysis Report

Holistic CQM Reporting

Quality Improvement Services

Things to

consider when

selecting a CQM

partner…

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Today in Summary

Questions? Carla McCorkle, Product Manager, Midas+ Live and CPMS

Linda Justice, RN Nurse Executive

For more information contact us at hcprovider@xerox.com

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