Prepping for 2019 Hospital Quality Reporting

Rear-View Mirror

• On the Quality Net site, we
  experienced issues with generating reports and site speed.  Apparently, others had the same issues.  Fortunately, CMS extended the 2018 deadline
  from February 28 to April 14.
• To compound the frustration,
  Quality Net lacks an open forum for support tickets.  MIPS, Cypress, CDA 2.0 and C-CDA and FHIR all
  have open Jira or Google Groups for support, allowing developers, implementers, and users to comment and ask questions using a transparent process. CMS does
  not.
• The support process is tedious and
  time-consuming.  Undisclosed reporting
  tool issues created “false alarms” for our calculations and turnaround on
  support tickets moved slowly.   Nonetheless,
  we worked with the CMS help desk and technical support to ensure that our CQMsolution
  calculations matched Quality Net.
• In spite of these obstacles, our
  new ‘Submit to DHIT’ button made testing and submitting a much smoother process.   All
  clients submitted successfully prior to the deadline.

Challenges

• 2015 Certified EHR Technology
  (CEHRT) must be in place during the entire reporting period, although it is
  permissible for the certification to happen later, as long as it is posted on
  the ONC CHPL prior to the end of the reporting period. 
• In case you still have
  doubts, 2014 Certified software is not acceptable for 2019 reporting.
• 2019 Promoting
  Interoperability (formerly Meaningful Use) now has a MIPS-like scoring system,
  although unlike MIPS, Quality Measures are not part of the scoring.
• The big challenge for EHR
  vendors and other suppliers of eCQM software is the transition to Clinical
  Quality Language (CQL) but, if done correctly, this transition
  should be transparent to software users.
• Keep in mind that your CQM results
  are digested and posted to the Medicare Hospital
  Compare website.

Opportunities for Success

• By submitting eCQMs to the IQR
  program, you will meet PI (MU) requirements for EHR submission.
• Start running CQM reports early to
  identify problem areas and home in on CQMs that are best suited to your
  hospital.
• In spite of CMS’ new “Meaningful
  Measures” initiative, the actual eCQMs and reporting period requirements are not changing
  for 2019:  You still choose a minimum of
  4 eCQMs for one self-selected calendar quarter.
• The overall list of hospital CMS
  eCQM measures in 2019 will stay the same, except for one adjustment:
• CMS 55 is discontinued in the IQR
  program, but will remain in TJC (see below).
•  For 2020, CMS is proposing to
  remove the 7 eCQMs (highlighted in blue, below) so you may want to take this
  into consideration when choosing your 2019 eCQMs:

• For 2021, CMS is proposing to
  adopt two new opioid-related eCQMs: 
• Safe Use of Opioids – Concurrent
  Prescribing eCQM, and
• Hospital Harm – Opioid-Related
  Adverse Events eCQM. 

TJC Submission

• The big news is that next year
  Joint Commission ORYX vendors will assist hospitals using their Direct Data
  Submission Platform (DDSP).  Additional
  communication regarding the transition is supposed to be released this Spring.
• 2019 Measure selection was due on
  12/31/2018. Hospitals that still need to select can do so by contacting hcooryx@jointcommission.org
  .
• 2019 Measures: (no changes from
  2018), hospitals choose a minimum of 4 measures for 1 quarter.
• We submitted to ORYX for a number
  of clients and found that the calculations from our CQMsolution software were
  consistent with TJC across the board.