Final HIT Incentive Rule Stage 1 Quality Measures Objective

Final HIT Incentive Rule Stage 1 Quality Measures Objective

(Link to full report)

Developed by Beth Dibbert and Louis Wenzlow

Summary

The Stage 1 meaningful use quality measure objective will pose significant challenges for rural community hospitals. In addition to current hospital efforts to submit core measure data (for AMI, HF, PN, Surgical Care, and others) to CMS, hospitals that seek to earn Stage 1 incentives will need to utilize certified EHR technology to report on 15 inpatient hospital measures within 3 measure sets (ED Throughput, VTE and STK). For hospitals with eligible professionals, there will also be the need to report on 6 Stage 1 ambulatory meaningful use measures.

This is the first in a series of reports intended to help rural community hospitals develop strategies to meet these new requirements and then to utilize the data to achieve process and quality improvement. Additionally, it’s our intention to engage rural hospitals in a dialogue to identify potential pitfalls in the Stage 1 requirements, as well as to determine what rurally relevant measures the rural hospital community believes would be appropriate to recommend to CMS for inclusion in Stage 2 of meaningful use.

While comment periods may come and go, and rules move from proposed to final, experience tells us that it’s never “over.” The quality and hospital community can and should expect for there to be edits, corrections, and revisions to various facets of this and future rules. While we may desire the regulations to be “final,” a fluid evolution is helpful to achieve an outcome of safe and efficient care for our patients. By committing an ear to the ground and a willingness to share ideas and information, we keep an active role and stake in the process.

I. Introduction

In order to qualify for Stage 1 HIT meaningful use incentive payments, eligible professionals (EPs), eligible hospitals and CAHs must meet 14 or 15 “core” meaningful use objectives, and 5 out of 10 “menu” objectives. One of the required/core objectives is for hospitals to use certified EHR technology to report clinical quality measures to CMS (or, for providers in the Medicaid incentive program, to the States.)

For an eligible provider to meet this quality reporting objective, the provider must, for 2011, use certified EHR technology to provide aggregate level data for the numerator, denominator, and exclusions through attestation as specified in section II.A.3 of the final rule; and for 2012, the provider must use certified EHR technology to electronically submit the measures as specified in section II.A.3.

This report includes a summary of the quality reporting requirements described in section II.A.3, as well as a description of each of the hospital quality measures.

A future follow-up report will contain (1) strategies for the electronic capture of the required data elements, (2) strategies for utilizing the data output toward process and quality improvement, and (3) recommendations for quality measures relevant to rural hospitals and to be considered for the Stage 2 meaningful use requirements.

II. Summary of Clinical Quality Measures in the Final Rule

For EPs, the final rule requires that EPs report on 6 measures: 3 core measures (or if the denominators for any of the core measures are 0, then the EP must report on up to 3 alternate core measures), and 3 from a list of 38 non core measures.

The core and alternative core measures for EPs are:

1. Core Measure: Hypertension: Blood Pressure Measurement (NQF# 0013)
2. Core Measure: Preventive Care and Screening Measure Pair: a. Tobacco Use Assessment b. Tobacco Cessation Intervention (NQF# 0028)
3. Core Measure: Adult Weight Screening and Follow-up (NQF# 0421; PQRI #128)
4. Alternate Core Measure: Weight Assessment and Counseling for Children and Adolescents (NQF #0024)
5. Alternate Core Measure: Preventive Care and Screening: Influenza Immunization for Patients _ 50 Years Old (NQF #0024; PQRI #110)
6. Alternate Core Measure: Childhood Immunization Status (NQF #0038)

The 38 non core measures (and more detail on the core measures), including links to electronic measure specification information, can be found in Table 6 on pages 86 through 97 of the final rule: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf

For hospitals, the final rule requires that “eligible hospitals and CAHs” report on 15 measures.

1. Emergency Department Throughput – admitted patients Median time from ED arrival to ED departure for admitted patients (NQF #0495)
2. Emergency Department Throughput – admitted patients Admission decision time to ED departure time for admitted patients (NQF #0497)
3. Ischemic stroke – Discharge on anti-thrombotics (NQF #0435)
4. Ischemic stroke – Anticoagulation for A-fib/flutter (NQF #0436)
5. Ischemic stroke – Thrombolytic therapy for patients arriving within 2 hours of symptom onset (NQF #0437)
6. Ischemic or hemorrhagic stroke – Antithrombotic therapy by day 2 (NQF #0438)
7. Ischemic stroke – Discharge on statins (NQF #0439)
8. Ischemic or hemorrhagic stroke – Stroke education (NQF #0440)
9. Ischemic or hemorrhagic stroke – Rehabilitation assessment (NQF #0441)
10. VTE prophylaxis within 24 hours of arrival (NQF #0371)
11. Intensive Care Unit VTE prophylaxis (NQF #0372)
12. Anticoagulation overlap therapy (NQF #0373)
13. Platelet monitoring on unfractionated heparin (NQF #0374)
14. VTE discharge instructions (NQF #0375)
15. Incidence of potentially preventable VTE (NQF #376)

More detail on the 15 hospital measures, including links to electronic measure specification information, can be found in Table 10 on pages 106 to 108 of the final rule: http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf. Our description of each of the hospital measures can be viewed in Section V. of this report, titled “Stage 1 Hospital Clinical Quality Measures.”

Note: CMS only requires hospitals to submit information that can be automatically calculated by their certified EHR technology. As long as a hospital collects and reports on the required data, even if numerators or denominators are displayed in certified EHR as 0, the hospital will meet the Stage 1 meaningful use clinical quality reporting objective.

III. Reporting Methods

Since CMS doesn’t expect to be capable of accepting electronic submission of quality summary data until 2012, the final rule has distinctive reporting methods for 2011 (attestation method) and for beginning with the 2012 Payment Year (electronic submission method):

For Payment Year 2011, the final rule requires that EPs, eligible hospitals and CAHs attest to the following information:

• The information submitted with respect to clinical quality measures was generated as output of an identified certified electronic health record.
• The information submitted is accurate to the best of the knowledge and belief of the EP or the official submitting on behalf of the “eligible hospital or CAH.”
• The information submitted includes information on all patients to whom the clinical quality measure applies for all patients included in the certified EHR technology.
• The identifying information for the “eligible hospital or CAH,” or the NPI and TIN of the EP submitting the information.
• The numerators, denominators, and exclusions for each clinical quality measure result reported, providing separate information for each clinical quality measure including the numerators, denominators, and exclusions for all applicable patients contained in the certified EHR technology irrespective of third party payer or lack thereof.
• The beginning and end dates for which the numerators, denominators, and exclusions apply (the Medicare EHR reporting period in payment year 1 is 90 days, and for payment year 2 is the beginning and end date of a 12 month EHR reporting period. For Medicaid providers whose first payment year is for adopting, implementing or upgrading certified EHR technology, their second payment year will have a 90-day EHR reporting period; and their third payment year will have a 12 months EHR reporting period.)

Starting in Payment Year 2012, the final rule requires that “EPs, eligible hospitals, and CAHs electronically submit clinical quality measures results (numerators, denominators, exclusions) as calculated by certified EHR technology.”

The primary method for submission will be through a CMS-designated portal. Providers will “be required to submit, through an upload process, data payload based on specified structures, such as Clinical Data Architecture (CDA), and accompanying templates produced as output from certified EHR technology.” Additionally, “electronic specifications will need to utilize standards that the certified EHR can support. ONC’s final (certification) rule limits this to PQRI Registry XML specifications.”

Alternatives to this primary method, “contingent on feasibility,” may include submission through Health Information Exchanges/Health Information Organizations and registries. However, for 2012, “submission through a portal is the only mechanism that is feasible and practical.”

Technical requirements for portal submission for Medicare EPs will be posted on or before July 1^st 2011, and for Medicare eligible hospitals and CAHs on or before April 1^st, 2011.

Providers eligible for the Medicare incentive program must submit the above information to CMS, and providers eligible for the Medicaid incentive program must submit the information to their State. States must propose in their State Medicaid HIT Plans how they will accept provider attestations in the first year of their Medicaid incentive program, and how they will accept electronic reporting in their second and subsequent years.

IV. Future Stage Quality Measures

The final rule indicates that the quality measures for which eligible providers will need to electronically submit information will rapidly expand in 2013 and beyond. A discussion of numerous potential future stage measures can be found on pages 110 through 118: http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf.

As indicated above, RWHC and WORH intend to work with rural hospitals and organizations to help develop a unified recommendation to CMS for Stage 2 metrics that are relevant to small-volume rural hospitals.

V. Stage 1 Hospital Clinical Quality Measures

Emergency Department Throughput Measure Set: Admitted Patients – the initial population for these measures will be determined by whether (1) the Patient Class is an inpatient encounter and (2) the Admission Source identifies the patient as an ED patient.

1. Measure ED-1: Emergency Department Throughput – Median time from ED arrival to ED departure for admitted patients (NQF #0495). This measure will be aggregated/stratified for three subpopulations:

• All ED patients admitted to the facility from the ED, excluding observation and mental health patients
• All ED Observation patients admitted to the facility from the ED
• All ED patients with a diagnosis of Psychiatric/Mental Health admitted to the facility from the ED

In addition to the data elements that need to be captured to identify the initial population (described above), the following data elements further define the sub-populations and calculation of this measure:

• Facility Location
• Arrival Date and Time
• ED Departure Date and Time
• Observation Services – whether the patient was admitted to the hospital as acute inpatient or observation status
• Principal Diagnosis Code
• Diagnosis Priority
• Problem Status

The final calculation for this measure will be expressed in terms of minutes (ED Arrival to ED Departure) for each of these sub-populations. The median value will ultimately be reported.

Challenges:

1. Data elements may or may not be discretely located within the electronic medical record (“Diagnosis Priority” and “Problem Status,” for instance). Additionally, some data elements are “derived,” in that the electronic medical record needs to calculate a value for use in a second calculation. Assuring the presence of the data and the accuracy of the derived data calculations will be a key to the process. Presumably certified EHR vendors will be required to incorporate the appropriate discrete fields and make the required calculations. However, there may be significant workflow issues involved in entering the required data.
2. If the medical record is “missing” data element dates or times, the record will be rejected and not able to be calculated successfully. If the record is “unable to determine” data element dates or times, the measure will not be calculable. Both of these scenarios will require a collaborative “drill-down” by the facility and the vendor to determine whether the missing or undeterminable data is a result of workflow, technical, or a combination of causes.
3. The updates to data definitions have historically been a source of constant vigilance for vendors and hospitals alike. Care will need to be taken that the vendor applies the updates appropriately and in a timely manner.
4. Without appropriate vendor tools/reports that optimize the use of the data for internal purposes, hospitals personnel will find it difficult to apply quality improvement strategies and interventions to improve ED arrival to departure time.

2. Measure ED-2: Emergency Department Throughput – Median time from admission decision time to ED departure for admitted patients (NQF #0497). This measure will be aggregated/stratified for three subpopulations:

• All ED patients admitted to the facility from the ED, excluding observation and mental health patients
• All ED Observation patients admitted to the facility from the ED
• All ED patients with a diagnosis of Psychiatric/Mental Health admitted to the facility from the ED

In addition to the data elements that need to be captured to identify the initial population (described above), these elements further define the sub-population and calculation of the measure:

• Arrival Date and Time
• Order to Admit Date/Time (Note: ED Admit Decision is based upon Admit Order Time)
• ED Departure Date and Time
• Observation Services – whether the patient was admitted to the hospital as acute inpatient or observation status
• Principal Diagnosis Code
• Diagnosis Priority
• Problem Status

The final calculation for this measure will be expressed in terms of minutes (Admission Decision Time to ED Departure Time) for each of these sub-populations. The median value will be ultimately reported.

Challenges:

1. The same challenges associated with ED-1 apply. Particular to this measure, hospitals will need to consider how they will electronically capture “order to admit” time.
2. There appears to be an inconsistency with this measure in that NQF 0497 describes ED-2 as “median time from admit decision time to time of departure from the emergency department of emergency department patients admitted to inpatient status” (Final Rule, p.303), but the stratification requires that observation patients (i.e. not inpatients) be included in the subpopulation. Presumably this discrepancy will be addressed in future CMS comments.

Ischemic Stroke Measure Set:

To be continued in future blog…

Readers are encouraged to provide input for potential inclusion in the final/complete version of this report.