The document summarizes an after-action meeting to discuss issues with the 2014 eCQM certification and submission process. It notes that common errors in submitted data included missing payer data, incorrect dates, and invalid performance rates. Feedback on submissions was often late, lacked detail on errors, and discrepancies between certification and submission tools made the process difficult. Meeting participants discussed how to streamline certification testing, improve documentation and samples, and address issues to prevent errors for 2015-2016 submissions. The next eCQM subgroup meeting was scheduled.

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eCQM Certification Subgroup
After-Action Kaizen Meetings
August 25th, 2015

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Today’s Topics
■ August 20th Vendor Summit Recap
– Submission Issues
– Testing/Certification Improvements
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August 20th EHR Vendor Summit
■ Hosted, MITRE Baltimore
– 100+ Attendees, from 42 organizations
■ Focused on understanding the issues with the submission
processes leading to errors
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4. © 2013 The MITRE Corporation. All rights Reserved.
2014 Submission Stats
■ Analysis of 2014 Submission via the
Physician Quality Reporting System
– QRDA I Issues
■ Missing payer data (24%)
■ Incorrect reporting parameter ends dates
(1%)
– QRDA III Issues
■ Invalid performance rates (83%)
■ Reported data errors (54%)
■ Performance rate calculation (7%)
■ Incorrect reporting parameter dates (3%)
■ Hospital eCQM Data Submission
Statistics
■ QRDA Document Format
■ CMS Certification Number
■ Service Event and Performer
■ Terminology
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PQRS HQR
QRDA
Cat I
QRDA
Cat III
QRDA
Cat I
Total Files 902,695 55,159 237,097
Unique
TIN/NPI
3,201 78,672
Error % 25% 93% 77%
Successful
Submitters
2,095 9,806 14

5. © 2013 The MITRE Corporation. All rights Reserved.
Focus Questions – What are the issues
with certification and submission?
■ What are five factors that may have contributed to the data
errors outlined?
■ What are barriers to successful data submission?
■ What new considerations or challenges were added with the
introduction of the 2014 PQRS GPRO option?
■ Discussion your experience using CMS testing and
validation tools – how can these tools be streamlined or
improved?
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6. © 2013 The MITRE Corporation. All rights Reserved.
Focus Questions – What can be done to
fix these issues?
■ What changes to submission systems or procedures would
help to streamline or improve the submission process?
■ What can be done to prevent data issues in 2015? 2016?
■ How could certification testing be improved?
– How could certification play a role in preventing submission
issues in the future?
■ What types of testing tools would be helpful to meet
submission requirements?
■ What types of education would be of most benefit?
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7. © 2013 The MITRE Corporation. All rights Reserved.
Top issues
■ Timing, format of feedback
■ Limited documentation and samples
■ Discrepancies between tools
■ Submission process is very manual
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Feedback
■ Timing, format of feedback
– Late to need, ~2-3 days after submission
– Feedback sent to submitters, not vendors
– No errors indicated, but still failed
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Documentation + Samples
■ Inadequate samples
– Need for non-happy path situations
■ Need better documentation of standards
– Especially with regards to edge cases
■ Intent of measures do not match eCQM logic
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Tool Discrepancies
■ Certification and submission tools are non-congruent
– Submission programs have unique requirements
■ Difficulty getting access to testing tools
■ Little insight into the availability and timeline of tools
– Need to post submission schedules for tools, standards,
Implementation Guides, deadlines
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OPEN DISCUSSION
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12. © 2013 The MITRE Corporation. All rights Reserved.
Next eCQM Certification Subgroup Meeting
■ Tuesday September 28th at 2pm EST
■ Completed Webinars will be posted on the Cypress Website
on the Timeline Tab.
– http://projectcypress.org/timeline.html
■ Send questions and feedback to the Cypress Talk List as
talk@projectcypress.org
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