To: CHIME Members From: CHIME Public Policy Staff Re: Hospital Inpatient Quality Reporting with Electronic Clinical Quality Measures

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College of Healthcare Information Management Executives, Public Policy Office 4300 Wilson Blvd., Suite 250 · Arlington, VA 22203

Phone: (734) 665-0000 · Fax: (734) 665-4922 · staff@cio-chime.org · www.cio-chime.org

To: CHIME Members

From: CHIME Public Policy Staff

Re: Hospital Inpatient Quality Reporting with Electronic Clinical Quality Measures

This brief outlines key provisions related to a voluntary reporting program that combines certain elements of the Hospital Inpatient Quality Reporting (IQR) program and the Medicare EHR Incentive Payments program, also known as Meaningful Use.

Background

In January 2013, the Centers for Medicare & Medicaid Services (CMS) published a request for information (RFI) to gather stakeholder feedback on the optimal timing and transition strategy for adopting electronic reporting of quality measures by hospitals participating in the IQR program

(see CHIME’s response to the RFI here). Subsequently, CMS issued a proposed rule in May 2013 that would give hospitals the option of electronically reporting a subset of quality measures shared by both the IQR program and Meaningful Use (see CHIME’s response to this proposed rule). CMS proposed that hospitals would be able to, on a voluntary basis, electronically report 16 clinical quality measures (CQMs) across four measure sets in CY 2014 for the FY 2016 Hospital IQR Program payment determination. These measures included stroke (STK), venous thromboembolism (VTE), emergency department (ED) and perinatal care (PC). CMS believed that providing this option to hospitals would enable them “to test systems and adjust workflow in CY 2014 in order to prepare for required electronic reporting,” in the future. Further, CMS sought to incentivize hospitals to choose this option by using the electronically reported IQR data to determine whether the hospital satisfied the Medicare EHR Incentive Program CQM reporting requirements. In order to receive credit in both the IQR and Meaningful Use programs, hospitals would be required to submit electronic data on all four measure sets, according to the proposed plan.

Final Rule

The final rule, released August 19, 2013, solidified many aspects of the voluntary electronic CQM reporting program, while modifying the proposed approach in a few important ways.1

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College of Healthcare Information Management Executives, Public Policy Office 4300 Wilson Blvd., Suite 250 · Arlington, VA 22203

Phone: (734) 665-0000 · Fax: (734) 665-4922 · staff@cio-chime.org · www.cio-chime.org  The final rule allows participants to pick any or all of the four measure sets proposed, rather

than require submission on all measure sets. The proposed rule would have required hospitals to submit data on all CQMs within the four proposed measure sets.

o This change allows flexibility for those hospitals who wish to participate, yet do not want to have all 16 of their Meaningful Use CQMs determined by the four IQR measures.2

 Participating hospitals must submit CQM data on a Calendar Year basis, keeping with IQR requirements, which will then be considered for EHR Incentive Program requirements.

o If the hospital chooses to report more than one measure set electronically, they must be all reported in the same calendar quarter.

o 4Q CY submissions will not be eligible for dual consideration, given that it occurs after the final EHR Incentive Program reporting period.3

 All other IQR chart-abstracted measures, including any measures in the four available measure sets not electronically reported, will need to be reported via chart-abstraction for all four calendar quarters.

o CMS note that the STK–1 measure cannot be electronically reported because electronic specifications have not been developed for that measure. Therefore, if a hospital chooses to report the STK measure set electronically, it would not need to report the STK–1 measure via chart-abstracted measure to satisfy the Hospital IQR Program reporting requirements.

 CMS encourages hospitals to continue submitting all measures via chart-abstraction if they choose, to “enable the most robust data set for the comparison,” and ultimate validation of electronic CQM data.

The final rule switched positions on the issue of public reporting on Hospital Compare. In the proposed rule, CMS stated that data results would not be publicly reported (due in part to CHIME and others telling CMS the current state of EHRs could convey misleading information about the quality of a hospital’s performance).

o According to the final rule, a majority of commenters opposed the CMS proposal, so the final rule indicates CMS will make the electronically reported data public on

Hospital Compare if they “deem that the data are accurate enough to be publicly

reported.”

o While this leaves open the possibility that IQR data will not be publicly posted, the onus falls on providers to argue the data is unfit for public comparison.

Government officials also finalized several important provisions of the voluntary program as proposed, including:

 Program measure sets include six CQMs for STK, seven for VTE, two for ED and one for PC;

2 For a diagram outlining potential options and combinations of IQR and MU eCQMs, see Table 2 in Appendix A 3

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College of Healthcare Information Management Executives, Public Policy Office 4300 Wilson Blvd., Suite 250 · Arlington, VA 22203

Phone: (734) 665-0000 · Fax: (734) 665-4922 · staff@cio-chime.org · www.cio-chime.org  Alignment of the case threshold exemption from the two programs, allowing hospitals to

declare a ‘‘case threshold exemption’’ of five or fewer discharges for either program;

 CMS will not validate electronic clinical quality measure data, as part of the regular Hospital IQR validation program, for the FY 2016 payment determination. They will, however, review the accuracy of the electronic CQM data assessing it for the electronic specification adherence before making it publicly available.

o CMS intends to develop and propose a validation strategy for electronically reported quality measure data in the FY 2015 IPPS/LTCH PPS proposed rule.

 CMS has decided to adopt the QRDA I reporting standard for the Hospital IQR Program because the QRDA I reporting standard aligns with the current Hospital IQR Program standard of collecting patient level data for chart-abstracted measures. CMS may consider the QRDA III standard in future rulemaking.

o This final rule, in section IX.E, also modified the Medicare EHR Incentive Program CQM reporting requirement for hospitals in 2014 to accept only the QRDA I (release 2) format for electronic reporting.

Implications

The IPPS Final Rule is important because it signals how CMS hopes to operationalize the long sought-after goal of CQM “harmonization.” The finalized approach does little to reduce complexity in either IQR or Meaningful Use; eCQMs must be submitted on a calendar basis, when all other MU data (including eCQMs reported for MU, but not IQR) must align with Fiscal Year quarters. But CMS did make positive changes to allow for more flexibility in this voluntary program:

“We understand that hospitals prefer to have the flexibility to choose from the list of 29 measures from Stage 2 of the Medicare EHR Incentive Program. CMS finalized a policy which permits hospitals, if they choose this voluntary option, to select one or more of the four measure sets (STK (except, as noted above, STK–1), ED, VTE, and PC) to electronically report in CY 2014, instead of requiring hospitals, if they choose this option, to use electronic reporting for all four measure sets. We believe that this modification allows enough flexibility for hospitals to begin electronically reporting, if, for example, a hospital’s vendor does not support all of the measures in the four measure sets originally proposed.” – (Federal Register, Volume 78, Number 160, page 50818)

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College of Healthcare Information Management Executives, Public Policy Office 4300 Wilson Blvd., Suite 250 · Arlington, VA 22203

Phone: (734) 665-0000 · Fax: (734) 665-4922 · staff@cio-chime.org · www.cio-chime.org

Appendix A

Table 1: Reporting Periods and Associated Submission Deadlines

FY 2016 Hospital IQR Program Electronic Reporting Periods and Submission Deadlines for EHs that are Beyond Their Fist Year of the Medicare EHR Incentive

Program**

Discharge reporting periods Submission deadlines

January 1, 2014 - March 31, 2014 November 30, 2014

April 1, 2014 - June 30, 2014 November 30, 2014

July 1, 2014 - September 30, 2014 November 30, 2014

October 1, 2014 - December 31, 2014 Not Applicable

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College of Healthcare Information Management Executives, Public Policy Office 4300 Wilson Blvd., Suite 250 · Arlington, VA 22203

Phone: (734) 665-0000 · Fax: (734) 665-4922 · staff@cio-chime.org · www.cio-chime.org Table 2: Diagram of potential voluntary program options (IQR eCQM submission counting for

MU requirements)

For more information, please contact: Jeffery Smith Director of Public Policy P: (703) 562-8876 E: jsmith@cio-chime.org

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