Prepping for 2019 Hospital Quality Reporting

Now that the 2018 reporting year has
been wrapped up and submitted, this is a good opportunity to examine what
worked and what areas need improvement to ensure a successful 2019 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
  • 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.


  • 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

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
  • 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
  • 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.

We hope this helps with your 2019
reporting process and, as always, welcome your feedback.