This document discusses how MEDITECH hospitals can meet new eCQM reporting requirements for 2017 using QRDA Category 1 files. It provides an overview of the 2017 eCQM reporting requirements, how to produce QRDA-1 files in MEDITECH, and the importance of testing and validating files before submission to ensure there are no errors. The presentation emphasizes that hospitals should not tackle eCQM reporting alone and should utilize available resources and expertise from companies like Iatric Systems.

1. How MEDITECH hospitals can meet the new
eCQM reporting requirements using QRDA
2017 Quality
Reporting with
eCQMs
Presented By:
Cindy Paul, RN, BSN
Sr. Consultant and Project Manager
Cindy.Paul@iatric.com

2. Agenda
• Is your Hospital ready for eCQM
reporting?
• Updates on reporting deadlines
• 2017 eCQM Reporting Requirements
using QRDA Category 1
• Producing QRDA-1 files in MEDITECH
• Are you prepared for eCQM testing &
validation?
• How to tackle the challenge and win!
• Is everyone on the same page?

3. Aligning Quality Reporting Programs
Inpatient Quality Reporting (IQR)
and EHR Incentive Meaningful Use
Programs have aligned through dual
submission of eCQMs to Quality Net
https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

4. Recent Updates for Reporting
CMS extended the reporting deadline for 2016
New deadline is March 13, 2017
Expect potential changes for CY 2017 reporting:
• Reduction in reporting period to 90 days
• Decrease the number of eCQMs
Address challenges many hospitals face:
• Transitioning to new EHR systems
• Upgrading EHR technology
• Changing workflows to meet eCQM
requirements

5. 2017 Alignment
IQR and EHR Incentive Program
CMS IPPS Final Rule released August 22, 2016
• Retained 15 eCQMs in the Hospital IQR
Program available for EHR Incentive Program
• Select a minimum of 8 of the 15 available
eCQMs
• Report 4 quarters of data on a quarterly, bi-
annual, or annual basis

6. 2017 Alignment
IQR and EHR Incentive Program
• IQR eCQM requirement aligns with CQM
reporting for the EHR Incentive Program
• Starting in 2018, hospitals and Critical
Access Hospitals participating in the EHR
Incentive Program will no longer have the
option for attestation
• eCQM reporting using CEHRT is required

7. 2017 Which CQM’s Are Retired?
AMI-2
AMI-7A
AMI-10
HTN
PN6
SCIP-Inf 1A
SCIP-Inf 2a
SCIP-Inf 9
STK-4
VTE-3
VTE-4
VTE-5
VTE-6

8. Selecting 2017 eCQMs

9. Scores
• Not reported to Hospital Compare
• Zero denominators “OK”
• CMS will use data as a baseline to establish
future threshold requirements
• Future ruling to be released

10. Producing a QRDA-1 file
• Follow MEDITECH Best Practices
• Documentation with updated value sets
• Ensure correct tables are turned on to Data Repository
• IMO updates
• All data sources must have accurate nomenclature
mapping
• ARRA Report Manager vs SQL reports
• Tools for populating a QRDA-1 for each measure
• Run reports to determine what’s missing
• Correct errors
• Map the missing data sources

11. Is it REALLY that Easy?
• Working through the ARRA Report
Manager requires dedicated staff
resources
• New documentation queries or
data capture will be required to
meet Best Practice
• New IMO mapping may be
required
• New value sets and OIDs
• Are there internal resources to
produce reports?

12. MEDITECH’s ARRA Tool
1. Install on the MEDITECH DR Server
2. Run most recent configuration for 2017
a. Use previous year specs
3. Upload new value sets
a. Requires UMLS license for VASC Value
Set Authority Center
4. Populate parameters specific to facility
5. Populate parameters specific to eMeasure
6. Run reports

13. ARRA Report Manager Errors
• 2015 Spec CQM reports running, but required
parameters in the
mtzcus_2015Spec_eCQMReportConfigurationTable
are not populated
• Generated report, but no data appears

14. QRDA-1 Files Created – What’s Next
Pre-Submission Validation Application
• QualityNet Secure Portal
• Register for a QualityNet account
• Have assigned EHR Data Upload Role
• Test QRDA-1 files & validate against 2017 CMS
requirements
• Produces reports to help identify errors
• Correct errors prior to submitting production files

15. Common PSVA Errors

16. Reality…..
• Tracking started January 1
• Involves new build & IMO mapping in
MEDITECH
• Requires updates for 2017 CMS specifications
and value set mapping
• Need to test & validate QRDA-1 files before
submission
• Potential to submit Q1 data in Q2

17. Don’t Go At it Alone!

18. How Can Iatric Systems Help?
ü We have clinical expertise in CQMs
ü We are experts in CMS Regulations and
eCQM requirements
ü We know MEDITECH
ü For years, customers have trusted Iatric
Systems with Meaningful Use Manager™ and
now Analytics on Demand™ for Quality
Reporting

19. Professional Services QRDA Assist™
• Assist with eCQM selection of 8 measures
• Gap Analysis of current data collection against CMS
Specifications and MEDITECH 2017 Best Practices
• Provide expert guidance for changes required
• Generate QRDA-1 files using MEDITECH’s ARRA tool
• Assist with validation and testing in QualityNet’s PSVA
tool
• Quickly generate QRDA-1 files from MEDITECH to your
quality vendor(s)
• Truven
• Quantros
• Press Ganey
• Acmeware/Medisolv

20. Don’t Delay…or You’ll Pay
• Could result in a one-fourth reduction of the
market basket update for IQR
• Requires numerous workflow changes
• New CMS value set mapping updates
• Strict deadlines

21. Making Quality Reporting Work
• Alignment of C-Suite, Quality, IT and Clinicians
in the front line
• Appropriate Training of Staff
• Implement Continuous Quality Improvement
• Quality Reporting specific to your Hospital
Culture

22. Resources
• eCQM and QRDA file specifications can be located on the
eCQM Library page of the CMS website at:
https://www.cms.gov/regulations-and-
guidance/legislation/ehrincentiveprograms/ecqm_library.html
• Resources for electronic clinical quality improvement
https://ecqi.healthit.gov/
• QualityNet eCQM Pages
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=
QnetPublic%2FPage%2FQnetTier2&cid=1228773849716

23. Questions
For assistance or follow up, please contact:
Cindy Paul, RN, BSN
Iatric Systems Professional Services
Sr. Consultant and Project Manager
Cindy.Paul@iatric.com
978-674-5927