During the implementation and reporting of electronically specified clinical quality measures (eCQMs), I respond to many questions and concerns. Here are the top three questions I have received.
1. My quality department says our numbers don’t match. Is something wrong?
This is the biggest concern I hear from hospitals. They run their eCQM data by the quality department’s chart abstracted measures and teams are shocked to see the numbers don’t add up. CMS has stated on numerous occasions that they don’t line up, they were never intended to, and the never will.
It seems logical to want to check your Stroke 4 chart-abstracted measure against your eSTK4. However, they have different codes and elements that derive the end result. Trying to get them to match will most likely lead to frustration and lack of confidence in your data. To make sites feel more at ease, CMS has released the following statement regarding this:
At this time, there is not a direct crosswalk between the electronically specified Clinical Quality Measures (eCQMs) and the chart-abstracted measures, but there are tools available for you under the QualityNet eCQM tab that will give you more detail as far as the data elements needed to be able to report those measures. There is no penalty because that information is not compared currently. Chart-abstracted measures and electronically specified Clinical Quality Measures (eCQMs) have similar intents, but the specifications necessary to calculate the performance rate is different between the two. Hospitals should not expect the performance rates for chart-abstracted measures and eCQMs to be equal. The validation process for eCQM data has not yet been determined by CMS.
2. I’m running the certified reports our EHR vendor supplied. I am following the instructions exactly and our workflow isn’t THAT bad. Why do I still have zeros?
eCQMs require a lot of moving parts in order for them to work as designed. Make sure you know the version your certified technology uses. It’s also important to be aware of what changes and updates your vendor will (or will not) be implementing. The version ID can be found in the CMS version number of the eCQM.
Here is an example using a common emergency department measure.
Median time from ED arrival to ED departure for Admitted ED patients
NQF #: 0495
CQM ID: CMS55v3
The v# above represents the version of the CMS measure. In this case, version 3. Each year in April, a new version is released. These versions will have many differences from the previous version including value sets and patient populations. (In one extreme case I have seen OB patients excluded in the first three versions, only to be included in the latest release).
Once you verify the version, make sure the value sets used are accurate. You can check the value sets that relate to the different versions of the measures at http://www.nlm.nih.gov/research/umls/
The value sets dictate the codes (SNOMED, ICD, LOINC, etc) that are allowed to be processed into the measure logic. When you are chart abstracting, a human looks for aspirin at discharge. When your system is calculating, it reads everything in code (RxNorm codes in this case for apprpriate medication at discharge). If the value sets don’t add up, you are most likely going to encounter errors (or zeroes).
If the correct value sets being used and there are still zeroes, it would be smart to double-check the workflow. I’ve seen a number of facilities produce zeroes on VTE 3-5 due to VTE not being confirmed on the problem list in a SNOMED code format. They had VTE as a diagnosis code, but the measure logic was looking for “VTE confirmed” in order to place the patient into the denominator. Each measure is going to have nuances such as this. Diving in to the specs and finding these seemingly trivial data points can significantly change the results. If the spec looks Greek to you, check with your EHR vendor for a specialist that can help, or consult with an expert.
Keep in mind that CMS requires providers to report the eCQMs exactly as they are calculated in certified EHR technology. If your CEHRT says 0, then report a zero, and work with your vendor to possibly improve the next time around.
3. We are using this newly approved medicine for “insert name of diagnosis”, but it’s not in the “insert year” value sets. Should we change our best practices to make our numbers look better?
No. You should not. Medical best practice will most likely be years ahead of the specifications, at least for the foreseeable future . If your vendor certified in 2013, chances are they use 2013 value sets. I imagine new drugs and procedures have been approved since then. Reporting these measures should not keep anyone from taking the best care of patients. Remember the eCQMs don’t count against you for any payment program at this time, nor will the results be posted on Hospital Compare. We still have a long way to go with perfecting the eCQMS, but hopefully with wide-spread cooperation in the industry we will be there soon.
In addition to being the resident meaningful use expert, Sarah evangelizes and drives greater understanding of all things HIT through internal communications, newsletters, organized trainings, blogging, and social media.
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