Clinical Quality Measures for Hospitals

posted by Kevin Heubusch

Feb 17, 2010 01:26 pm

AHIMA Meaningful Use White Paper Series
Paper no. 6b

Papers 5a and 5b in this series reviewed the functionality measures for providers and hospitals described in the notice of proposed rulemaking on meaningful use, published by the Centers for Medicare and Medicaid Services on January 13, 2010. This paper offers an overview of the requirements for reporting clinical quality measures for eligible hospitals. A companion paper (6a) provides an overview of the requirements for providers.

When Congress developed the meaningful use EHR incentive program, one of its goals was to improve the quality and efficiency of care for the Medicare and Medicaid populations. Accordingly, hospitals and providers that participate in the program will be required to capture and report clinical quality measures using certified EHR technology, in addition to the functionality measures they must report to prove they are using EHR technology in a meaningful way.

For purposes of the incentive program, CMS defines clinical quality measures as the “processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care” (p. 1871).

Electronic Reporting to Begin in 2012

CMS acknowledges that it cannot require program participants to submit measures electronically until it has the capacity to receive them. CMS does not anticipate it will have that capacity for the 2011 payment year (FY2011). There will be a pilot test of electronic reporting, but it is unlikely that by 2011 there will be adequate testing and demonstration on a widespread basis.

In addition, electronic reporting requires that the Department of Health and Human Services promulgate technical specifications for the transmission of measurement data from hospitals to CMS. Once EHR vendors have these specifications, they will need time to develop and adapt software.
CMS anticipates that electronic reporting will begin in FY2012. Any eligible hospital reporting in that year will be required to report accordingly, whether or not the hospital is in its first or second year of participation in the program.

If CMS is not ready to receive electronic reports in 2012, the attestation program it is proposing for 2011, described below, will continue. CMS will post notifications of its status and the required method for reporting in the Federal Register.

Proof through Attestation in 2011

In 2011 eligible hospitals will meet the reporting requirements through attestation. As described in the NPRM, the process utilizes the same system as that it used for meaningful use attestation (p. 1871 and 1901).

CMS proposes that in 2011 eligible hospitals attest to the following (p. 1901):

  • The information submitted was generated as output from an identified certified EHR.
  • The information is accurate and complete to the knowledge and belief of the official submitting on behalf of the eligible hospital.
  • The information submitted includes information on all patients to whom the measure applies.
  • The identifying information for the eligible hospital.
  • For eligible hospitals that do not report one or more measures an attestation that the clinical quality measures not reported do not apply to any patients treated by the eligible hospital during the reporting period.
  • The numerators, denominators, and exclusions for each clinical quality measure result reported, providing separate information for each clinical quality measure including the numerators, denominators, and exclusions for all patients irrespective third party payer or lack thereof; for Medicare FFS patients; for Medicare Advantage patients; and for Medicaid patients.
  • The beginning and end dates for which the numerators, denominators, and exclusions apply.

CMS notes that it believes it has the authority to require clinical quality measures reporting on all patients regardless of payer type.

Duplication of Reporting Requirements

Within the NPRM CMS acknowledges concern that hospitals could be required to submit a different set of clinical quality measures to states for the Medicaid program. It recommends that the measures adopted for the Medicare incentive program also apply to hospitals in the Medicaid programs (p. 1871).

Alternative Medicaid-specific measures have been developed for eligible hospitals whose population might warrant their use.

Proposed Clinical Quality Measures

CMS recognizes that “considerable work needs to be done by measure owners and developers” on the clinical quality measures it has proposed. Such work includes completing electronic specifications for measures, implementing those specifications into EHR technology to capture and calculate the results, and implementing the systems.

CMS believes there is sufficient time to complete all of these tasks. However, it writes that it will delay finalizing any measures where this work has not been completed.

The proposed measures for hospitals appear on table 20; the alternative Medicaid measures appear in table 21 (linked here in a single file-table 21 begins on page 1899).

The tables identify the measure title, number, owner or developer, and contact information as well as a link to existing electronic specifications where applicable. As noted, these measures are to apply to all patients, not just those covered in the Medicaid or Medicare programs.

HITECH requires that the Health and Human Services secretary provide preference to those measures that have been endorsed by an entity contracted with the secretary as provided under the Medicare Improvements for Patients and Providers Act of 2008 or measures that have been selected for the Reporting Hospital Quality Data for Annual Payment Update program under Medicare.

CMS notes that not all of the measures it proposes are from these programs and that it has the authority to add additional measures that need only its own approval or that of “professional societies or other stakeholders” to be included in the incentive program.

The proposed list of measures will likely undergo revision before a final rule is issued. CMS requests comments on the proposed measures, and it has stated publically that it expects to retract some measures as a result of the comment process.

The requirements will take effect 60 days after the final rule is published, and no changes will be made except through further rulemaking (p. 1872). However, CMS “may make administrative and/or technical modification or refinements such as revisions to the clinical quality measures titles and code additions, corrections, or revisions to the detailed specifications for the 2011 and 2012 payment year measures.”

CMS will post the final measures in a group on its Web site, even if the measures are already used in another Medicare incentive program. On or before April 1, 2010, CMS intends to finalize and publish the detailed eligible hospital specification documents for all 2011 payment year Medicare EHR incentive program clinical quality measures.

It should be noted that CMS solicits comment on whether it is appropriate to defer some or all clinical quality reporting until 2012, and it asks for rationale on what measures should or should not be deferred (p. 1895).

CMS writes that the measures it selected (pp. 1872–73):

  • Facilitate alignment with, or allow determination of satisfactory reporting in other Medicare programs, including RHQDAPU, Medicaid, and Children’s Health Insurance Program (CHIP) program priorities
  • Are widely applicable to eligible hospitals based on the services provided for the population of patients seen
  • Promote CMS and [Health and Human Services] policy priorities related to improved quality and efficiency of care for the Medicare and Medicaid populations that will allow the tracking of improvement in care over time
  • Have been recommended to CMS for inclusion in the EHR incentive by federal advisory committees including the Health IT Policy Committee

Eligible hospitals will be required to report summary data to CMS in FY2011 and electronically in FY2012 (p.1895). It is unclear if this summary report will be in addition to the attestation previously described.

2013 Payment Year

CMS expects the number of clinical quality measures that can be reported will grow rapidly in 2013 and beyond (p. 1900).  It notes the source of such growth and requests comments. CMS lists some of the new clinical areas for reporting as well.

Alternatives to Electronic Reporting

Finally, CMS discusses alternatives for electronic reporting using certified EHR technology, including the use of portals and structures such as the Clinical  Document Architecture (p.1902). An alternative to portals might be the use of health information exchange though health information organizations. Again, CMS seeks comments on these alternatives.

The next paper in this series will finalize coverage of the NPRM and will discuss the processes for demonstrating meaningful use.

AHIMA. "Clinical Quality Measures for Hospitals." (AHIMA report, February 17, 2010).