Making Payment for Value Work: HIMSS Policy Recommendations

February 29th, 2016 Shelley DiGiacomo and Pauline Byom

HIMSS Quality, Cost, and Safety Committee

Conflict of Interest

Shelley DiGiacomo, RN, MSN, CPHIMS

Has no real or apparent conflicts of interest to report.

Conflict of Interest

Pauline Byom, MBA, FHIMSS, DSHS

Has no real or apparent conflicts of interest to report.

Agenda

• Background

• Primary Barriers to accurate and actionable quality measurement.

• Recommendations

• Questions

Learning Objectives

• Identify current barriers to eReporting for federal quality reporting

programs.

• Develop guiding principles for future feedback on CMS quality

measurement policy and the transition to an outcomes and value-driven

system of provider and hospital reimbursement.

• Identify opportunities to participate in the development of CMS policy

outside of regulatory public comments.

Background

• August 2011

• HIMSS, via the Quality, Cost, and Safety Committee, launched a review to identify ways to optimize the electronic clinical quality measurement timeline, development and implementation processes.

• As a result, HIMSS developed a set of recommendations to improve process steps in the following areas:

• Measure Specification Standards and Development

• CQM Endorsement Process

• EHR Software Development and Release

• EHR Certification and Testing

• Provider Implementation

The eCQM Policy World in 2012

• Meaningful Use Stage 1 program called for the rapid development of standards and processes to meet regulatory timelines.

• Cross-domain experts were assembled to develop, review and recommend guidelines used by measure developers to create detailed measure technical specifications known as “eCQMs” to be used for programming electronic health record systems.

• These first guidelines and processes contained features that introduced inadvertent inefficiencies and inaccuracies.

• The development timeline of the 2012 standards and procedures took several years from start-to-finish

eCQM Barriers 2012-Present

• eCQMs were introduced without robust testing for validity, accuracy and feasibility.

• Inaccurate measure specifications result in software remediation and implementation delays. 100 percent of Stage 2 eCQMs included errors.

• Electronic reporting standards (QRDA1) were not fully tested.

• eCQMs required data collection that took place outside of a normal EHR-enabled clinical workflow and didn’t always accurately reflect quality of care delivered.

• Inadequate timelines for measure development and implementation.

• Sub-regulatory guidance was vague and oftentimes difficult to find.

The CMS Response

• Kaizen Events designed to develop recommendations for eliminating barriers to successful eCQM reporting

– Work Groups

• Communications Plan

• Implementation

• Certification

• National Test Bed

• MU Stage 3 Standards

• Annual Update Timeline

• Value Sets

• Publication of a Quality Measure Development Plan

• Transition from Meaningful Use to MACRA/MIPS

• Rewarding Providers for Patient Outcomes

HIMSS Goals for Recommendations

• eCQM reporting accurately reflects the quality of care delivered

• eCQM reporting minimizes the implementation and data collection burden on providers by using discrete information already collected for care, reducing the introduction of new workflows.

• eCQMs and eCQM data to be useful, that is to be able to be used by providers to enhance care delivery and ultimately improve patient care outcomes. The eCQMs are relevant to the actual goal of quality improvement within a care delivery organization.

Recommendations for Testing and Feasibility of eCQMs

• CMS and ONC should implement an aggressive and thorough quality measures testing program to ensure that eCQM have been adequately specified and tested before inclusion in any CMS program

Recommendations for Funding a National Testing Collaborative

• The National Testing Collaborative (testing site) fully funded and endorsed by CMS

– Testing site includes sample data, testing examples and an implementation guide for vendors

– Call for measure feasibility testing partners to all providers and vendors to show feasibility within their current EMR and assure validity despite the great variation in provider systems and workflows

• Assist in the measure development process

• Allow providers/vendors to demonstrate feasibility and collaborate on future measure development

Recommended CMS eCQM “Check List”

• CMS should publish eCQM check list validating the measures meet the following criteria:

– eMeasures specifications are tested and piloted to confirm they are accurate, with the correct clinical category defined and mapped to the correct vocabulary standards (taxonomy) and codes, along with the correct attributes and state(s).

– eMeasures are validated by the measure steward and tested for validity and reliability against the measures intent.

– Required data elements are efficiently and accurately gathered in the care delivery workflow, if at all possible using data elements that are already collected as a byproduct of the care process and stored in the EHR and other certified business information systems.

– CQM reports based on eMeasures accurately reflect the care given by the applicable healthcare provider(s).

– This testing evaluates the output from translation of the measure to established standards in the electronic quality measure format (HQMF) and the successful transport using QRDA format to CMS.

State the Business Case for New eCQMs

CMS should publish a clear business and clinical case demonstrating:

• Selected CQMs should present a clear pathway to value and fit into analytics capability to provide a meaningful scorecard on performance.

• The eCQM clearly supports the goals of the Triple Aim

– Improving the patient experience of care (including quality, outcomes, and satisfaction);

– Improving the health of populations;

– Reducing the per capita cost of health care.

• The measure presents a clear value proposition for providers, including a cost to implement/collect versus benefit analysis of each measure.

Defining “Value” of eCQMs

• HIMSS defines value through The HIMSS STEPS™ value optimization framework.

• The STEPS framework provides an easily understood vocabulary for stakeholders to take advantage of when formulating their value strategies.

• The STEPS™ model is built around five categories. CMS should provide analysis on these five STEPS factors when determining value of an eCQM:

• Satisfaction

• Treatment/Clinical

• Electronic Secure Data

• Patient Engagement & Population Management

• Savings

Make Quality Reporting a “Value Driver”

• CQMs must be a meaningful measure that care providers can collect and utilize to evaluate their own quality improvement without being overly burdensome to collect and report.

• Current CQMs are not easily collected within the normal clinical workflow of many providers.

• EPs and EHs are collecting similar but not identical measures for accreditation, private payers, and state programs.

Recommendations to CMS for Building a True Value Proposition for Quality Reporting

• Develop a robust de-novo menu measure set of eCQMs redesigned specifically to capture quality data as part of an EHR-enabled clinical workflow

• If needed data for specific measures reside outside of the EHR, common workflows to access/import data are identified and tested as part of the approval process

• eCQMs selected for HHS programs should be actionable, meaning that reported clinical quality measures can be utilized to identify gaps in care, conduct root cause analysis, and trigger improvements

• MIPS and APM quality reporting requirements should be specifically designed and prioritized to drive improved clinical outcomes

• Collaborate with accreditation organizations like Joint Commission, private payers, and state governments to develop consensus supporting a core measure set that closely aligns to the CMS eCQM menu set

Timeline for eCQM development and implementation • Only non-substantive changes to eCQM measures/specifications

should be made annually through the Annual Update and PFS/IPPS rulemaking for the following reporting year.

• Example: changes not requiring corresponding changes in provider workflow or HIT systems

• Allow 18 months before data collection following the publication of the final rulemaking for substantive changes

• Example: New CQM or a change in a current CQM that requires a workflow/system change….a new CQM published in the 2016 Annual Update should not “go live” until the 2018 data collection period.

• Every effort should be made by CMS to publish annual updates and final rules well before the legislatively established deadlines.

Recommendations for Sub-Regulatory Guidance and Communications • When updates are posted to specifications, clarify changes made

from the previous version.

• Simplify ability to locate ALL federal quality reporting requirements (number of measures and domains, reporting periods, submission deadlines.)

• eCQM measure lists and identifiers should be standardize across CMS documents and websites, and encourage supporting organizations to follow (such as VSAC, JIRA etc.).

• This standardization should be consistent across all measure documents and references and contain both the CMS# and the NQF#. The measures should consistently be listed chronologically by either CMS#’s or NQF#’s and contain at least a reference name title.

Recommendations for JIRA-Communications with Vendors and End Users

• The JIRA problem-reporting tool doesn’t reliably produce a prompt response,

• No vehicle exists to escalate issues with an unsatisfactory response.

• CMS should adopt the following changes to JIRA:

• Launch tight change control processes and oversight to ensure the issues that are logged are managed within a reasonable time frame.

• Create a transparent recourse process for questions that stakeholders do not feel are being answered effectively.

• Responses should be publically available and easily searchable on the eCQM single source of truth website.

• JIRA tickets should be grouped according to measure number and reference name so all issues being addressed with a measure can be accessed for review and comment.

Questions

Shelley DiGiacomo, RN, MSN, CPHIMS

Executive Health Care Consultant

HIMSS Chair Quality, Cost and Safety Committee

• Email: sydigiacomo@gmail.com

Pauline Byom, MBA, FHIMSS, DSHS

Regional, Quality Administrator, Mayo Clinic

HIMSS Co-Chair Quality, Cost and Safety Committee

• Email: byom.pauline@mayo.edu