cms ecqm strategy: the future of ecqms...cms ecqm strategy: the future of ecqms debbie krauss, nurse...
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Approved for Public Release; Distribution Unlimited. Case Number 18-0579. © 2018, The MITRE Corporation. All Rights Reserved.
CMS eCQM Strategy: The Future of eCQMs
Debbie Krauss, Nurse Consultant, CMS
Sam Sayer, Lead Software Systems Engineer, MITRE
March 2018
The MITRE Corporation operates the Centers for Medicare & Medicaid Services (CMS) Alliance to
Modernize Healthcare (CAMH), a federally funded research and development center (FFRDC)
dedicated to strengthening the nation’s health care system. MITRE operates CAMH in partnership
with CMS and the Department of Health and Human Services.
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Agenda
▪ Welcome and Introductions
▪ Electronic Clinical Quality Measures (eCQM) Strategy Project Background
▪ Stakeholder Feedback Received to Date
▪ Audience Feedback – Gallery Walk
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Learning Objectives
▪ Understand the Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC) eCQM Strategy project goals
▪ Learn the eCQM development and reporting pain points identified by industry stakeholders
▪ Provide feedback on eCQM lifecycle improvement opportunities
Approved for Public Release; Distribution Unlimited. Case Number 18-0579. © 2018, The MITRE Corporation. All Rights Reserved.
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eCQM Strategy Project:
Background
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Project Problem Statement
Providers participating in CMS quality and value-based purchasing programs
have shared challenges they experience related to the complexity and high
burden of electronic clinical quality measure (eCQM) implementation, data
capture, and reporting.
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Project Scope
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▪ eCQM Development
– Starts with developing the eCQM measure concept
– Ends with measure readiness to submit to Measures Under Consideration (MUC) list
▪ eCQM Reporting
– Will review processes and requirements for reporting eCQMs to CMS
– Will review processes related to eCQM clinical implementation and data capture
▪ Tools for Development and Reporting
– Measure Authoring Tool (MAT), https://www.emeasuretool.cms.gov/
– Bonnie (open source eCQM logic testing tool), https://bonnie.healthit.gov/
– Cypress (open source EHR certification testing tool), https://www.healthit.gov/cypress/
– CMS Measures Under Development Inventory (located in CMS Measures Inventory),
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/CMS-Measures-
Inventory.html
– Pre-submission validation tools
– Other tool(s) innovations
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Project Timeline and Activities
October 2017
Project Started
Environmental Scan Completed
November 2017
User-Centered Design Approach
December 2017 -
March 2018
Stakeholder Events
Site Visits
CMS Quality Conference
HIMSS 2018 Conference
April 2018
Final Recommendations Compiled
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eCQM Strategy Project:
Stakeholder Feedback Received to Date
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eCQM Stakeholder Event
▪ Ensure alignment and demonstrate eCQM value to ease burden
▪ Improve eCQM development processes
− Development and testing
▪ Improve eCQM reporting process
– Implementation – data collection and workflow
– Submission, attribution, and feedback mechanisms
▪ Clarify certification
▪ Focus on communications
Key Topic Themes:
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eCQM Strategy Project:
Audience Feedback – Gallery Walk
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Gallery Walk
▪ Stations:
Station # Station Name
1 Measure Development
2 Certification and Pre-submission Data Validation Tools
3 Data Element Reporting
4 Hospital Quality Data Submission
5 Communications
6 Patient Attribution for eCQMs
▪ Goal:
– Provide feedback on solutions to address stakeholder-identified eCQM pain points
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Journey Map
Journey Map: a tool to visualize the hospital eCQM processes and help identify gaps, moments of frustration/delight, etc., and thus lead to insights for improvement.
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Pain Point
ACTIVITY
Description
ACTOR 1ACTOR 2ACTOR 3ACTOR 4
PHASE 1 PHASE 2 PHASE 3 PHASE 4
Pain Point
Pain Point
Pain Point
Pain Point
Pain Point
Pain Point
Pain Point
ACTOR 1ACTOR 2ACTOR 3ACTOR 4
ACTOR 1ACTOR 2ACTOR 3ACTOR 4
ACTOR 1ACTOR 2ACTOR 3ACTOR 4
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
description of activity
independent
chronological
burden/pain
ACTORS
Journey Phase
ACTIVITY
Description
ACTIVITY
Description
ACTIVITY
Description
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Data Element Reporting
▪ A new approach to eCQM development and reporting informed by site visits
and listening sessions
▪ Concept still in development
▪ Focus on data requirements of eCQMs is to reduce provider and vendor
burden
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Data Element Reporting: Background
▪ eCQMs require capture of structured clinical data to enable accurate, repeatable calculation of quality measures
▪ Structured data capture has been cited as a source of provider burden
▪ Workflows vary widely by EHR, and also by configuration, which causes confusion for clinicians on how to capture some data elements
▪ Annual updates require analysis and redesign of workflows for capturing data based on measure logic changes
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Data Element Reporting: Principles
▪ Move eCQM calculation out of EHR vendors/systems
– Standardize calculation engines available to vendors and providers
▪ Required data should be:
– Available in current EHR systems
– Clinically valuable
– Widely used across programs
– Simple and efficient to record
▪ Align with existing data standardization efforts
– CMS Long Term Support Service (LTSS) Data Element Library
– ONC Common Clinical Data Set (CCDS)
– US Core Data Initiative (USCPI)
– CMS Common Clinical Data Elements (CCDE) Pilot
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Follow up
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To download a copy of this presentation, visit:
https://health.mitre.org/himss18
Data Interoperability to Reduce Clinician Burden
Follow us on social media: @MITREhealth
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Debbie [email protected]
&
Thank You!
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Gallery Walk
▪ Stations:
Station # Station Name
1 Measure Development
2 Certification and Pre-submission Data Validation Tools
3 Data Element Reporting
4 Hospital Quality Data Submission
5 Communications
6 Patient Attribution for eCQMs
▪ Instructions:
Please proceed to a station to provide feedback on one or more of the following solutions to reduce the burden of eCQMs.
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