This document discusses electronic clinical quality measures (eCQMs) and the transition to mandatory eCQM reporting. It notes that the 2016 IPPS rule will require hospitals to submit 4 eCQMs beginning in 2016. Additional programs like Joint Commission and Outpatient Quality Reporting are also moving to require eCQMs. The document reviews the eCQM reporting process and considerations for eCQM selection. It provides an example of eCQM reporting for the VTE-3 measure and submission in the QRDA format. Looking ahead, value-based programs and the transition to consolidated quality programs through MACRA are discussed.

3. Data Repository Experts Since 1998
In a Galaxy NOT So Far Far Away... eCQMs
Jodi Frei, PT, MSMIIT
Manager of Organizational Informatics
Northwestern Medical Center
Bill Presley
Vice President, Product Development
Acmeware

4. Objectives
Participants will understand the following concepts and their
relevance to healthcare settings:
2016 IPPS Final Rules for Inpatient Quality Reporting (IQR)
eCQM Definition and Background
Clinical Quality Measure Program Initiatives
Reporting Process – Selection to Submission
What’s On The Horizon?
Opportunities and Challenges

5. Why are eCQMs Important?
2016 IPPS Rule Finalized
From the Federal Register:
CMS is finalizing modifications of its proposals and will require hospitals to submit 4
of 28 available eCQMs of their choice beginning in CY 2016 for the FY 2018 payment
determination.
Hospitals will be required to submit one quarter (either Q3 or Q4) of electronic data
in CY 2016 by February 28, 2017.

6. Additional Programs Moving to eCQMs
In 2015 Joint Commission issued guidance that they were
transitioning from Core Measures to CMS eCQM Specifications
Outpatient Quality Reporting Program (OQR) has a proposed
2017 eCQM requirement
Comprehensive Primary Care Initiatives have embedded eCQM
submission into their reporting options.

7. CMS Demonstrates Commitment to eCQMs
Federal Register:
“We do not agree that electronic clinical quality measure
reporting should remain voluntary... We believe that
electronic clinical quality measures have matured since
their inception and we will address any specific eCQMs in
future rulemaking. “

8. Vision for Quality Reporting Programs
Unified and aligned set of clinical quality measures and
reporting requirements to synchronize and integrate CMS
quality programs which will reduce reporting burden and
improve on patient outcomes.

9. Quality Reporting Direction
The Future - One Specification
Core Measures
(Chart Abstraction)
•Manual Chart Abstracted
•Paper-based
specifications
•Translated to CMS
Specification Manual
Clinical Quality
Measure (eCQM)
•Electronically Captured
•Measure Concepts
•Electronic Codification
•Electronic Specification
•eCQM Library (One Spec)

10. Quality Reporting Specification Manual
Specifications Manual
 The Specifications Manual for National Hospital
Inpatient Quality Measures
 Uniform set of national hospital quality measures
 Paper tools for use in abstracting data for each
collection (discharge) period are provided with the
Specifications Manual
eCQM Library
 Electronically specified versions of traditionally
chart-abstracted Clinical Quality Measures
 Developed specifically so Certified Electronic Health
Record Technology (CEHRT) can capture, calculate,
export, and transmit the measure data
 For eReporting of eCQMs to demonstrate
meaningful use or for Quality Reporting Programs
Data Collection Period Specifications Manual
10/01/15 - 06/30/16 Version 5.0
01/01/15 - 09/30/15 Version 4.4a
01/01/14 - 12/31/14 Version 4.3b
Reporting Year eCQM Specifications
2016 May 2015 Update
2015 April 2014 Update
2014 April 2013 Update

11. Quality Measure Programs
Hospital
Quality
• EHR Incentive Program
• PPS-Exempt Cancer Hospitals
• Inpatient Psychiatric Facilities
• Inpatient Quality Reporting
• HAC payment reduction program
• Readmission reduction program
• Outpatient Quality Reporting
• Ambulatory Surgical Centers
• The Joint Commission (TJC)
Physician
Quality
• EHR Incentive Program
• Physician Quality Reporting System
(PQRS)
• eRX Quality Reporting
Payment
Model
• Medicare Shared Savings Program
• Hospital Value-Based Purchasing
• Accountable Care Organizations
(ACO)
• ESRD QIP

12. Program Requirements – MU EH
16 measures required across 3 NQS Domains

13. Program Requirements - IQR
4 measures submitted via eCQM
8 measures submitted via Chart Abstraction
6 measures via NHSN Submission
24 measures via Claims
4 measures via Web Entry
1 measure via Patient Survey

14. Program Requirements - ORYX

15. Clinical Quality Measure Alignment
VBP
25+ MeasuresORYX
23 Measures
MU EH
16 Measures
IQR
4
Measures
ACO
30+ Measures
MU EP
9
Measures
PQRS
9
Measures
IQR/MU EH
4 Measures
IQR/ORYX/
MU EH
6 Measures
PQRS/
MU EP
9
Measures
Note: green indicates non-eCQM measures

16. Hospital Quality Reporting Reductions
Year IQR EHR MU VBP HAC HRRP
2013 2.0% MBU N/A 1.0% DRG N/A 1.0% DRG
2014 2.0% MBU N/A 1.25% DRG N/A 2.00% DRG
2015 0.25% MBU 0.25% MBU 1.50% DRG 1.0% DRG+ 3.00% DRG
2016 0.25% MBU 0.25% MBU 1.75% DRG 1.0% DRG+ 3.00% DRG
2017 0.25% MBU 0.75% MBU 2.00% DRG 1.0% DRG+ 3.00% DRG
MBU = Market Basket Update
DRG = Diagnosis-related group

17. Hospital Quality Reporting Reductions
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
2013 2014 2015 2016 2017
IQR EHR VBP HAC HRRP

18. Physician Quality Reporting Reductions
Year PQRS EHR VBPM+ Sequestration Total
2013 0.5% N/A N/A -2.0% -1.5%
2014 0.5% N/A N/A -2.0% -1.5%
2015 -1.5% -1.0% -1.0% -2.0% -5.5%
2016 -2.0% -2.0% -2.0% -2.0% -8.0%
2017 -2.0% -3.0% -4.0% -2.0% -11.0%
Applied to all Medicare reimbursements
Schedule of payment adjustments depends on the size of the medical practice,
starting with 100+ EPs in 2015, followed by 10 to 99, then all. Table reports maximum penalty.

19. Physician Quality Reporting Reductions
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
2013 2014 2015 2016 2017
PQRS EHR VBPM+ Sequestration

20. Beginning the Reporting Process
Planning
Select your team
Choose your eCQM vendor
Choose a minimum of 4 eCQMs
Declare your intent to submit and submission
vendor

21. Building the Foundation
System Updates
Assure reporting system is upgraded with applicable
eCQM specifications
Update EMR nomenclature mapping with prior year’s
specifications

22. Assuring Accurate Data
Validation and Reconciliation
Validate data measure by measure
 Focus on patients who did not meet the measure
Reconcile electronic results with abstracted results
 Data sources will be different
 Checks and balances for nomenclature mapping

23. Testing the Waters
Practice Submissions
Your vendor will use program specific tools to submit test
files
 Pre-Submission Validation Application (PSVA) tool for IQR
 Submission Validation Engine Tool (SEVT) for PQRS
 Performance Measurement System Extranet Track (PET) for
ORYX
Intent is to work through submission errors

24. Wrapping It Up:
Final Submission
IQR: CY Q3 or 4 file submission deadline: Feb 28, 2017
PQRS submission deadline: Feb 28, 2017
ORYX submission deadline: March 15, 2017

25. NMC Approach to eCQM Selection
Many Factors to Consider
What are the 2016 reporting requirements for clinical
quality measures by program?
 IQR, MU EH, ORYX, VBP
 OQR, MU EP, PCMH, ACO
What measures are being tracked now?
What is the current reporting mechanism for each?
What CQMs are currently being electronically monitored?

26. Reconciliation: Meeting Requirements of Multiple Programs

27. Checks and Balances: Meeting Requirements?
IQR: Am I submitting a minimum of 4 eCQMs?
YES!
IQR: Am I abstracting my 8 required measures?
YES!
ORYX: Am I covering 6 sets?
YES!
MU: If I submit 4 eCQMs, do I fulfill my MU CQM
requirement?
YES!

28. Labor Comparison: Pre vs Post eCQM
0
10
20
30
40
50
60
70
80
90
100
Jan Feb March April May June
Pre eCQM Hrs (Abs Only) Post eCQM Hrs (eCQM & Abs)
- An NMC Study

29. Going Above the Regulatory Requirements!
eCQMs will not go away…
Beyond meeting the regulations, however, reporting
eCQMs:
 Creates efficiencies
 Requires hospitals to standardize their processes
 Creates dashboards which allow real time tracking
of performance, which leads to
 Real time improvements in clinical outcomes

30. Description:
This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral
(intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five
days of overlap therapy, they should be discharged on both medications or have a reason for discontinuation of overlap
therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater
than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or
have a reason for discontinuation of overlap therapy.
Data criteria (QDM Data Elements):
"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set
(2.16.840.1.113883.3.117.1.7.1.266)"
"Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific
RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
eMeasure Identifier: CMS-73
Reconcile and Validate eCQMs
VTE-3 Reporting Example

31. This shows a value set for a class of medications (Warfarin)
VTE-3 Reporting Example
Data criteria (QDM Data Elements):
"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“
Value Set Table:
eMeasure Identifier: CMS108

32. VTE-3 Reporting Example
Data criteria (QDM Data Elements):
"Medication, Administered: Warfarin" using "Warfarin RxNorm Value Set (2.16.840.1.113883.3.117.1.7.1.232)“
Value Set Table:
eMeasure Identifier: CMS108

33. Data criteria (QDM Data Elements):
"Medication, Administered: Warfarin" using "Warfarin RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.232)"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
"Medication, Discharge: Parenteral Anticoagulant" using "Parenteral Anticoagulant RXNORM Value Set
(2.16.840.1.113883.3.117.1.7.1.266)"
"Medication, Discharge: Parenteral anticoagulant ingredient specific" using "Parenteral anticoagulant ingredient specific
RXNORM Value Set (2.16.840.1.113762.1.4.1021.4)"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.473)"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set
(2.16.840.1.113883.3.117.1.7.1.93)"
VTE-3 Reporting Example
eMeasure Identifier: CMS108

34. VTE-3 Reporting Example

35. VTE-3 Reporting Example

36. VTE-3 Reporting Example

37. VTE-3 Submission File Example: QRDA

38. eCQM Reporting Submission
Meaningful
Use EP
Meaningful
Use EH
Electronic Clinical Quality Measures (eCQM)
PQRS IQR
Joint
Commission
QualityNet PQRS QualityNet IQR TJC
QRDA I or III

39. What’s On The Horizon?
Medicare Access & CHIP Reauthorization Act of 2015
◦ Consolidates reporting requirements
◦ Rewards providers of care for value versus volume
◦ Alternate Payment Models (APMs)
◦ Lump sum incentive payments for providers in ACOs, PCMHs, etc
◦ 5 percent of the prior year’s estimated aggregate expenditures under the fee
schedule through 2025
◦ Merit-Based Incentive Payment System (MIPS)
◦ Combines PQRS, MU, and Value Based Payment Modifier for EPs
◦ Focus on Quality, Resource Use, Clinical practice improvement, and Meaningful use
of certified EHR technology

41. Conclusion
CQM reporting is the focus of the present and future
◦ Electronic suubmission will become more pervasive
Opportunities and Challenges Exist
◦ Patient Population Tracking
◦ Concurrent Review for Nursing Quality
◦ Clinical Care Team Alerting
◦ Custom Report Development
Prepare your teams and systems now

42. References
http://www.jointcommission.org/assets/1/18/FAQ_2016_ORYX_PM_Reporting_Reqs_10-28-2015.pdf
http://www.jointcommission.org/performance_measurement.aspx
http://www.jointcommission.org/assets/1/18/2016_Measure_Set_Selection_Instx-Forms_10-28-2015.pdf
https://www.qualitynet.org/
Reference: Quality Net
https://www.federalregister.gov/articles/2015/08/17/2015-19049/medicare-program-hospital-inpatient-prospective-
payment-systems-for-acute-care-hospitals-and-the#p-811
https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM2014_GuideEH.pdf
https://innovation.cms.gov/Files/x/cpci-ecqm-manual.pdf
http://www.qualityreportingcenter.com/wp-content/uploads/2015/07/OQR_CY-2016-OQR-proposed-
rule_071515_FINAL.pdf
https://innovation.cms.gov/initiatives/Comprehensive-Primary-Care-Initiative/
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-
MIPS-and-APMs/Timeline.PDF
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-
MIPS-and-APMs/MACRA-MIPS-and-APMs.html

43. Discussion, Questions & Answers
International MUSE 2016
Tuesday Workshops
801 - The Alphabet Soup of Clinical Quality Measures Reporting Initiatives
1pm
Education Sessions
1032 - In a Galaxy NOT So Far, Far Away ... eCQMs
3:30pm
1094 - How to Successfully Submit eCQMs Electronically
11:15am