Quality Measure Submission: A Brief Review, A Look Ahead

For most, the 2017 submission period for eCQMs is over. Not only did we survive, we thrived. Dynamic Health IT worked with clients submitting measures to CMS for the Hospital Quality Reporting (HQR) program and Quality Payment Program (QPP) to improve timelines for submission as compared to 2016.

On the Ambulatory side, this was everyone’s first trip through MIPS submission and, in light of that fact alone, the process was a great success. DHIT worked with clients to submit both individual and group data, rolling out some new validation and user experience enhancements to ensure continuity between the submission program and the output.

We assisted clients in file validation using a series of newly-developed APIs, received files securely for validation via a cloud-based submission server and assisted our clients in both data troubleshooting and making an informed decision regarding submission type by comparing measure outcomes.

Achieving successful submission doesn’t mean we haven’t learned something along the way – quite to the contrary – so we wanted to share a few lessons learned in this space. CQMs have become a perpetual development and submission cycle, which means we can’t pause long before looking ahead.

Lessons from 2017 submission
The 2017 submission cycle was highly educational, particularly on the Ambulatory side (QPP/MIPS submission).  Here are a few lessons to carry into 2018:
  1. Make sure to choose your most clinically-relevant

    Reaching consensus in your organization about measure selection prior to
    data review will eliminate inconvenient reversals later in the process.
    Running an initial report with all available measures for the previous
    and/or current years can aid in this process (CQMsolution excludes all
    non-MIPS EP measures from QRDA-III output specific to MIPS). 
  2. Review data early and often: The most time-consuming aspect of eCQM reporting is making sure data is complete, accurate and does not trigger submission errors. To ease the burden, we have upgraded our specs, error handling and validation options to get data client into shape. In our CQM specs, we want you to know exactly what has changed from the previous submission period so you can move quickly from stored procedure changes to measure performance review. A quarterly submission option is available on the Inpatient side to facilitate incremental quality checks.
  3. Weigh your options: With CQMsolution, you can run reports using a variety of reporting periods, measures and outputs to compare ahead of time choose your best performance. The MIPS program enables providers to submit with their group and/or as an individual, taking the best performance. The key here, as always, is giving yourself the time for this step.
  4. Know your core data elements: We have ramped up validation options to catch warnings and errors as soon as a report is complete, but you can also get a lead on these errors by checking a few important values and identifiers:
    • General (across programs): Check to make sure you have mapped essential rows for identifying patients, clinicians and encounters
    • HQR: Make sure you know your hospital’s TIN, CCN, CMS EHR Certification Number and, if available, the Medicare Beneficiary Identifier (MBI) for your patient.
    • QPP Group: Make sure your practice is providing a TIN (CQMsolution will take it in your data or you can provide on the UI) and sending all data for the entire group practice of clinicians under that TIN (whether virtual or not)
    • QPP Individual: Make sure you provide a TIN and a single NPI and make sure your data is filtered by a unique identifier (most commonly, NPI)
    • General (across programs): Check to make sure you have mapped essential rows for identifying patients, clinicians and encounters
  5. Ensure quick turn around on pre-submission validation: When your files are ready for pre-submission
    validation, we will work with you on an option that makes the most sense,
    including available APIs to DHIT to provide Data Submission Vendor services and
    direct submission and feedback from the MIPS program.
  6. Be prepared for Value Set and Measure changes: The change to Inpatient value sets for Q4 was highly disruptive and while CMS is working to avoid similar, there’s no guarantee there won’t be mid-stream changes afoot in 2018.

Next Steps
It’s a relief to get submission in on time, but quality measure submission now allows for less down time than ever. In addition to getting ready for HQR and QPP 2018, here are a few things to consider:

  • Hardship exemption deadlines: Some providers affected by disasters in 2017 have deadlines extended (and now looming)
  • Joint Commission: If you are submitting Inpatient eCQMs for the ORYX program, the deadline was extended until June 29, 2018. DHIT is an approved vendor for the program.
  • Medicaid Submission: Do you have any clients submitting to states? CQMsolution offers support for Medicaid Submission for all States
  • MIPS feedback: MIPS Preliminary Feedback is now available. If you submitted data through the Quality Payment Program website, you are now able to review your preliminary performance feedback data. 
  • Hybrid Measures: If you’re a hospital submitting HQR, you can submit this optional measure to QualityNet to assist in risk-adjustment
  • Get in touch with your DSV or Registry early: Along with our CQMsolution full-service quality measure application, server as a Data Submission Vendor (DSV) and MIPS Registry.

We’d love to talk to you about data submission that fits yourschedule and show you our expanded roster of measures, new error validation processes and submission management/archiving.