- The Healthcare Information and Management Systems Society (HIMSS) and Federation of American Hospitals (FHA) have issued comments critical of electronic clinical quality measures under the the Hospital Inpatient Prospective Payment Systems proposed rule. A concern shared between them is the number and kind of electronic clinical quality measures proposed for inclusion by the Centers for Medicare & Medicaid Services (CMS).
To recap, CMS has proposed that hospitals under the rule electronically report on a total of 15 eCQMs using their 2014 or 2015 Edition certified EHR technology using Quality Reporting Document Architecture (QRDA).
For HIMSS, its concerns relative to reporting CQMs electronically center on the lack of health IT infrastructure capable of support quality measurement.
"HIMSS asserts that the infrastructure and reporting functionality for eCQMs are not mature enough to facilitate mandatory electronic reporting for hospitals," the letter to CMS Acting Administrator Andy Slavitt states. "If the proposal is finalized, eligible hospitals must electronically report the remaining 15 measures using 2014 or 2015 CEHRT via QRDA1 in the manner prescribed by CMS or face the negative IQR payment adjustment."
The trouble as HIMSS sees it stems from the clinical quality measure certification process for certified EHR technology, which did not require EHR vendors to develop EHR technology certified for all 29 eCQMs in the CMS set. According to the organization, insufficient time remains to bring current EHR technology up to snuff:
Despite the seeming simplicity proposed in the reduction from 29 to 15 eCQMs proposed by CMS, the eight-month window between publication of the proposed rule and the January 1, 2017 start date of the performance period will not allow EHs, vendors and providers the appropriate implementation timelines necessary for systems to be updated, nor the appropriate care delivery workflows to be developed and incorporated for the purpose of accurate data capture for eCQMs that were not part of purchased CEHRT systems. Therefore, HIMSS asserts this requirement places an unfair burden on EHs and clinicians. Through no fault of their own, EHs and clinicians have targeted 2018 for mandatory electronic reporting of all measures; today, they do not have systems in which all 15 eCQMs certified.
For FHA, concerns over technical capabilities includes CMS as well as providers and EHR vendors. These technical limitations taken together, FHA argues, make the likelihood of hospitals to report on 15 clinical quality measures electronically slim to none.
"For 2016, hospitals must report four eCQMs and given the ongoing technical issues with vendor and CMS systems, we do not believe that it is feasible to require all participating hospitals to report 15 measures at this point," writes President & CEO Charles Kahn, III. "Problems with CMS’ technical ability to receive the measure data have led CMS to significantly delay reporting deadlines. We recommend that for 2017 hospitals be required to report at least six electronic measures, with the option of reporting all 15 measures. This will allow CMS and vendors more time to work out technical issues."
Testing and validation emerged as another major concern for both organizations. For HIMSS, a lack of faith in the approach proposed by CMS is the result of provider experiences in Stage 2 Meaningful Use:
The errors in the measure specifications for Meaningful Use Stage 2 were the result of specifications that had not been properly tested, field tested, nor determined to work correctly in CEHRT. As a result, the Meaningful Use Stage 2 eCQM measure set required anywhere from two to four updates in its specifications. Many of those eCQMs still do not accurately reflect the quality of care delivered, and are burdensome to collect and report as part of a normal care delivery workflow. As we move into MIPS and APM eCQM reporting, adding a post-implementation reporting burden to providers will not solve the issue of CQMs’ inability to produce an accurate reflection of care.
Meanwhile, FAH is critical of the eCQM Validation Pilot that CMS administered to prepare hospitals for electronically reporting clinical quality measures in the future:
The FAH appreciates that CMS released the eCQM Validation Pilot Summary on June 10, 2016, however, the summary does not contain quantifiable results of the pilot. The Validation Pilot did identify significant issues with data mapping and clinical workflow. Both of these are critical to having accurate data. Therefore, the FAH recommends that CMS conduct validation pilots and not publicly report or include any eCQM measures in pay for performance programs until such pilots are completed and the results made publicly available.
The organization also raised doubts about the merits of the 2015 pilot because of its use of a "remoting-in" process which is not a part of the validation summary CMS has proposed in the rule.
"The FAH recommends that the implementation of eCQM data validation be delayed and that CMS convene stakeholders to discuss issues arising from the pilot project, clarify operational validation procedures based on that input, and then implement a larger pilot test before proposing and finalizing a validation process," read its letter to CMS. "We believe taking the time to more carefully develop validation standards will result in a more suitable and equitable assessment of hospital eCQM submissions."
The summary of the pilot (via AHA News Now) identified several areas of electronic clinical quality measure reporting that CMS needed to address, namely increased outreach, education, and guidance. Technical limitations of EHR technology challenged many hospitals attempting to automate clinical quality reporting.