emeasures Transitions

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1 WHITE PAPER emeasures Transitions An Encore Point of View Barbara Doyle, emeasure Research & Review Board February 2014 EMEASURES TRANSITIONS Quality measures are transitioning from pure manual data abstraction to electronic data collection and calculation. Electronic measures (emeasures) are standardized performance measures in an electronic format; they help to ensure that measures are consistently defined and implemented, thereby promoting higher quality and more appropriate care delivery for safer, more affordable, and better coordinated care.¹ The onus of measure data collection and calculations is transitioning from dedicated Core Measures products -- where an end user enters data manually collected from a paper chart -- to now having data captured in certified electronic health record technology (CEHRT). The CEHRT then calculates the measure based on data contained discretely within the CEHRT itself Encore Health Resources

2 Electronic Measures are standardized performance emeasures TRANSITIONS (cont d) The new emeasures, or electronic clinical quality measures (ecqms), are often labeled with the same names as the manually abstracted measures and with the same intent to track improvement for specific disease groups. However, they have inherent differences in data definitions, calculations, inclusions, and exclusions. Consequently, results for what is apparently the same measure will change, and remediation to reconcile and manage the differences will be necessary measures in an electronic format. By name, emeasures often The transition to emeasures will take years, and, during that transition period, the quality abstractor role will be a hybrid. Abstraction will still be required for measures not yet defined as an emeasure, but quality teams will have growing 1 appear to be the same 0 responsibility to proactively intervene with clinical teams for inpatients that measure as manually qualify for emeasures reporting. This will ensure that all expected care has been delivered and appropriately documented in the CEHRT. Interdisciplinary abstracted measures; teams will have to work together to ensure that quality measures documentation is embedded in the workflow of CEHRT documentation. however, there can be inherent differences in data definitions, calculations, inclusions and exclusions. Alignment of Measures In 2001, the Centers for Medicare and Medicaid Services (CMS) worked with The Joint Commission () to align measure specifications for measures common to both organizations in their 7th Scope of Work.² By 2003, CMS and began working to completely align common measures so they would be identical, which led to the National Hospital Inpatient Quality Measures (NHIQM) used by both organizations.³ As the need for continued measures alignment and standardization grew beyond just NHIQM, the National Quality Forum (NQF) contracted with the Department of Health and Human Services (HHS) in 2010 to provide a consensus-based entity to prioritize, endorse, and maintain valid quality performance measures. The project was intended to more closely align performance-measure development and endorsement as well as to serve as a bridge to measure applications to meet the goals of the National Quality Strategy, including NHIQM measures. The presence of a single governing body to endorse all measures continued to drive alignment across different measurement organizations.⁴ In 2011, to support implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the HHS again reached out to the NQF to retool 113 quality measures for eligible providers from a paper-based (i.e., abstracted) format to an emeasure⁵ format. Retooled measures allow clinical data to be captured routinely during patient-care documentation, emeasures Transitions : WHITE PAPER 2

3 The HITECH Act prompted the retooling of quality reducing ambiguity within measures and enabling the implementation of clinical decision support to improve care. In July 2010, 44 of these 113 measures were published in the CMS Electronic Health Record (EHR) Incentive Program Final Rule. Many of these measures have been updated or revised in anticipation of Meaningful Use Stage 2 (MU2).⁶ measures; retooled from a paper-based and manually abstracted format to an emeasure format. With the Affordable Care Act (ACA) in 2010, the focus of healthcare reimbursement has shifted away from fee-for-service to fee-for-value, where reimbursement is shifting from the volume of services performed to demonstrating improvements and value in patient care provided. Performance in quality measures is increasingly used to identify improvements through the CMS value-based-purchasing program, where payment is tied directly to value proven by quality measures performance.⁷ The ACA enacted reform to payment models with a focus on shifting healthcare reimbursement from fee-for-service to fee-for-value. The schematic below shows the progression of healthcare changes starting with the Medicare Modernization Action (MMA) in 2003 that expanded prescription drug coverage for seniors; the establishment of the Office of the National Coordinator (ONC) in 2004 to coordinate national efforts related to healthcare technology; and the Deficit Reduction Act (DRA) in 2005, allowing states to pursue innovative ideas in healthcare. It illustrates the progression to current state and beyond as well as the interplay of national healthcare programs and the growing use of emeasures, with overlap to manually abstracted measures. Encore Health Resources Figure 1. You can t improve what you don t measure. You can t measure what you don t understand. You can t understand what you don t collect. emeasures Transitions : WHITE PAPER 3

4 When comparing the data collection and calculations Stage 2 Meaningful Use: Sweet Sixteen Clinical Quality Measures Eligible Hospitals must submit sixteen clinical quality measures via an electronic format as one of the requirements to achieve Meaningful Use in 2014 and beyond. Encore has dubbed these measures the Sweet Sixteen, as they can be used to meet requirements for both Meaningful Use and Inpatient Quality Reporting (IQR), if hospitals opt to submit their IQR data electronically. The sixteen measures are selected from a list of 29 measures from across different quality measurement programs, and if used for both programs must meet case threshold requirements and be selected from across four measure sets: Six measures from Stroke (STK), seven for Venous Thromboembolism (VTE), two for Emergency Department (ED), and one for Perinatal Care (PC).⁸ For Meaningful Use, of the sixteen measures, one measure must be selected from 3 of the 6 Health and Human Services (HHS) National Quality Strategy domains, which hospitals will meet if they select IQR measures, as they represent four domains, noted below with an (*): between manually abstracted quality measures and ecqms, a number of thematic differences emerged whereby the spirit of the measure is maintained but the exact data sources and calcula tions are different. 1. Patient & Family Engagement* 2. Patient Safety* 3. Care Coordination* 4. Efficient Use of Healthcare Resources 5. Population and Public Health 6. Clinical Processes and Effectiveness* See appendix for a full list of the menu of the 29 Stage 2 Meaningful Use emeasures and details related to case threshold requirements. emeasures To analyze and report ecqms from a certified electronic health record technology, electronic specifications must be developed in such a way that the data elements, logic, and definitions for that measure are in a format that can be captured and stored in the EHR. This allows the data to be analyzed and shared electronically with other entities in a structured, standardized format. Thematic differences: Manually abstracted measures and ecqms When comparing the data collection and calculations between manually abstracted quality measures and ecqms, a number of thematic differences emerged whereby the spirit of the measure is maintained but the exact data sources and calculations are different. emeasures Transitions : WHITE PAPER 4

5 Manual measures rely on human intervention, where chart as emeasures rely solely on ecqm Similar to Group X Case will be Conditions that exclude available data, in order to automate calculations. If the information is not Theme Data Source Exclusions ecqm Exceptions Calculations Manually Abstracted Quality Measures Manual data collection from different areas of documentation in patient rejected Similar to Group B not in measure population Algorithm calculated in Core Measures product documented within the Data Capture Historical from discharged patients Real Time 001 CEHRT, it cannot be included Population Sampling takes place No sampling Reporting Publicly reported on Hospital Compare Timing unknown if / when in the emeasure calculations. ( these measures will go to ecqm Data captured from documentation in EHR patient from all calculations Conditions that will remove a patient from the denominator only if the numerator criteria are not met Algorithm calculated in CEHRT Hospital Compare Comfort Measures Only Data Element Comparison Manual measures rely on human intervention, whereas emeasures rely solely on available data, in order to automate calculations. If the information is not documented within the CEHRT, it cannot be included in the emeasure calculations. For example, excluding patients with orders of comfort measures only is a multi-step process if being captured via manual data collection, but for emeasures requires the presence of either a documented order or intervention. emeasures Transitions : WHITE PAPER 5

6 Excluding patients with orders of comfort measures only is a Business Exclude patients from measure Exclude patients from measure Rule population with comfort measures population with multi-step process if being only documented An order or intervention for captured via manual data collection, but for emeasures, requires the presence of either Data Element: Comfort Measures Only Manually Abstracted a documented order or inter- vention inpatient visit Allowable 1 - Day 0 or 1 (exclude) Palliative Care Order or Values 2 - Day 2 or after (exclude) Intervention: Timing unclear (exclude) Hospice care (SNOMED CT 4 - Not Documented/UTD ) ecqm palliative care on patients admitted directly to inpatient setting For patients admitted via ED, Inpatient encounter must start <= 1 hour after end of ED visit And order or intervention must occur after the start of the ED visit or during the Palliative care (SNOMEDCT ) Notes for Abstraction Suggested Data Sources Physician/APN/PA documentation of comfort measures only (hospice, palliative care, etc.) mentioned in the following contexts suffices: Comfort measures only recommendation Order for consultation or evaluation by a hospice / palliative care service Patient or family request for comfort measures only Plan for comfort measures only Referral to hospice/palliative care service Progress Notes Discharge summary DNR/MOLST/POLST forms Physician Orders Physician Progress Notes None None (ecqm specifications do not include recommendations for location of documentation in the CEHRT) Continued > emeasures Transitions : WHITE PAPER 6

7 Results over a 3-month time-span were compared Inclusion Brain dead None Guidelines Brain death for three facilities partici for Comfort care pating in voluntary data abstraction for ED, Stroke, and VTE measures against emeasure results for ecqms collected as part of Terminal care 001 Meaningful Use Stage Exclusion DNR-CCA None Guidelines DNR-Comfort Care Arrest (Note: Exclusions and exceptions for DNRCC-A are at numerator and All measures dependent Abstraction DNRCC-Arrest denominator levels, not at data Data Element: Comfort Measures Only Abstraction Manually Abstracted Comfort measures Comfort only DNR-CC End of life care Comfort measures only (CMO) Hospice Hospice care Organ harvest Palliative care Palliative measures DNRCCA ecqm element levels) upon clinical documentation either worsened or stayed the same. Results Comparison: Manually Abstracted versus ecqm Results over a 3-month time-span were compared for three facilities participating in voluntary data abstraction for ED, Stroke, and VTE measures against emeasure results for ecqms collected as part of Meaningful Use Stage 1, using Healthcare Information Technology Standards (HITSP) definitions. The only improvement noted were in ED measures that rely only on date/time data recorded in the system, and no clinical documentation. All measures dependent upon clinical documentation either worsened or stayed the same. Difference in Results Between ecqm Calculation & Manually Abstracted Measure Results Metric Facility 1 Facility 2 Facility 3 ED 1 - ED Arrival to Departure (Inpt) -9 min N/A -42 min ED 2 - Decision to Admit to Departure (Inpt) -2 min N/A -16 min STK 2 - D/C Antithrombotics -23.1% -5.6% -11.4% STK 3 - Anticoagulation -41.7% 0.0% -50.0% STK 4 - Thrombolytic Therapy % % 0.0% STK 5 - Antithrombotic by Day % -96.3% -75.9% Continued > emeasures Transitions : WHITE PAPER 7

8 Facilities should create an interdisciplinary team to STK 6 - D/C on Statins -28.3% -18.8% -5.4% plan and develop required documentation. As facilities migrate from manual abstraction to emeasures, measure results VTE 4 - Unfractionated Heparin % % % 001 will change. There are VTE 5 - D/C Instructions -27.8% -56.2% -75.0% VTE 6 - Potentially Preventable VTE 8.3% 40.0% 100.0% inherent differences between how the measure algorithms are defined and calculated, and sampling is no longer required. Therefore results will be different and performance improvement baselines may have to be recalculated. Metric STK 8 - Education STK 10 - Rehab Assessment VTE 1 - Prophylaxis VTE 2 - ICU Prophylaxis VTE 3 - Anticoagulant Overlap Difference in Results Between ecqm Calculation & Manually Abstracted Measure Results Facility % -12.1% -32.5% -21.6% -90.5% Facility % -20.0% -24.4% -14.7% % Facility % -3.5% -21.9% -11.0% -96.4% The ecqm definitions have since been updated and the new specifications have been endorsed by the NQF as part of the 2014 Meaningful Use programs. Because the definitions are different, the measure results will be different than what was captured with the HITSP definitions. However, since both definitions have dependencies on information documented in the CEHRT, the impact against manually collected measures will likely be similar. A study conducted by the American Hospital Association (AHA) evaluated four hospitals, each with significant experience with EHRs, and their experiences with implementation of the Medicare Electronic Health Record Incentive Program s Meaningful Use Stage 1 ecqms. Although committed to the implementation of ecqms as part of their overall quality improvement goals, they found that ecqm results were often underreported and inaccurate. ¹⁰ Considerations when implementing emeasures The transition to emeasures will ultimately allow members of Quality Departments to move away from dedicated chart abstraction and enable them to proactively intervene with clinicians, ensuring that all proper care is delivered and documented during inpatient stays to help improve patient outcomes. But the transition must be well planned across the organization. Interdisciplinary teams While designing ecqm data capture, facilities will have to design clinical documentation especially physician documentation so that all ecqm data emeasures Transitions : WHITE PAPER 8

9 emeasures will continue to grow, and they will likely replace manually collected quality measures. The transition to emeasures will take years, and, during that transition 001 period, the quality abstractors will be in a hybrid role requiring participation on an interdisciplinary team to ensure that quality measures documentation is embedded in the workflow is captured. This must be accomplished hand-in-hand with physician champions. It is estimated that facilities will contribute about 80% of the effort to update clinical workflows against 20% effort from the CEHRT vendors to support ecqm data capture.¹¹ An easy workflow solution may seem to be to make the documentation required, or create an alert, or make it so the clinical provider can t do any more in the chart until x is documented. The reality will be different: implementing required fields and hard stops during CEHRT workflow will impair usability for the clinical providers and their satisfaction. Many facilities are feeling that pain now with alert fatigue. Facilities should create an interdisciplinary team that includes the Quality Team, physicians, nursing, and the Informatics Team responsible for EHR implementation to plan and develop required documentation. Sometimes an alert or required field will be the right solution, while at other times it may be education or a check-and-balance workflow. For example, the CEHRT may be set up to send alerts to the Quality Team when certain items are not documented, and the Quality Team can then intervene with the Clinical Team to ensure that everything has been done for the patient during his/her stay to meet measure requirements. Measure results will change Lastly, as facilities migrate from manual abstraction to emeasures, measure results will change. There are inherent differences between how the measure algorithms are defined and calculated, and sampling is no longer required. Therefore results will be different. Stakeholders within facilities will have to be aware that results could improve, but they must also recognize that results could drop if all information is not documented within the system. If facilities use Core Measures results to track improvements or drive incentive programs, then their baselines will have to be recalculated as they transition to emeasures. of CEHRT documentation. Open issues still to be determined Public reporting: CMS has stated they will make electronically reported data public on Hospital Compare if we deem that the data are accurate enough to be publically reported. Hospitals should be prepared that emeasures will be publicly reported at some point in the future, but that it likely will not be before FY Period to calculate new baselines? Because measure results will change, it is likely that new baselines will need to be calculated from which to measure improvements. It is unclear at this time what that process will be. emeasures will continue to grow, and they will likely replace manually collected quality measures as they promote standardization and consistency of measurement. This transition will take years to complete, allowing Quality Departments to adequately prepare and transition their roles and processes to better support pro-active patient intervention and improved patient care. emeasures Transitions : WHITE PAPER 9

10 REFERENCES 1. emeasures Fact Sheet (December 2011). National Quality Forum. 2. The Joint Commission Website/Core Measure Sets: 3. The Joint Commission Website/Core Measure Sets: 4. Measure Development & Endorsement Agenda Project. (January 2011) National Quality Forum. 5. National Quality Forum website/electronic Quality Measures (emeasures): 6. National Quality Forum website/electronic Quality Measures (emeasures): 7. CMS.gov website/hospital Quality Initiative/Hospital Value-based Purchasing program: Patient-Assessment-Instruments/HospitalQualityInits/index.html? redirect=/hospitalqualityinits/30_hospitalhcahps.asp 8. CMS Federal Register/Vol. 78, No. 160/Monday, August 19, 2013/Rules and Regulations, pages CMS EHR Incentive Program Stage 2 Final Rule Eligible Hospital and Critical Access Hospital Clinical Quality Measures and Reporting Topical Review. (2012) HIMSS 10. Eisenberg, F et al. (2013). A Study of the Impact of Meaningful Use Clinical Quality Measures. American Hospital Association and iparsimony, LLC Eisenberg, F et al. (2013). A Study of the Impact of Meaningful Use Clinical Quality Measures. American Hospital Association and iparsimony, LLC. emeasures Transitions : WHITE PAPER 10

11 APPENDIX A REFERENCES 12. CMS EHR Incentive Program Stage 2 Final Rule Eligible Hospital and Critical Access Hospital Clinical Quality Measures and Reporting Topical Review. (2012) HIMSS 13. The Joint Commission 14. Center for Medicare and Medicaid Services Inpatient Quality Reporting Program 15. HVBP Hospital Value-based Purchasing Program 16. CMQCC: California Maternal Quality Care Collaborative 17. OFMQ: Oklahoma Foundation for Medical Quality, Inc. 18. CMS Federal Register/Vol. 78, No. 160/Monday, August 19, 2013/Rules and Regulations, pages Interim Final Rule. Health Information Technology: Revisions to the 2014 Edition Electronic Health Record Certification Criteria; and Medicare and Medicaid Programs; Revisions to the Electronic Health Record Incentive Program. RIN 0991-AB89, RIN 0938-AR7a ABOUT ENCORE Encore Health Resources is one of the most successful consulting firms in the health information technology (HIT) industry. Founded in 2009 and led by Encore CEO Dana Sellers and President Tom Niehaus, the company provides consulting services and solutions that assist its expanding client base with a wide range of HIT strategy, advisory, implementation, process-redesign, and optimization initiatives. Encore focuses on capturing the right data at the right time, establishing analytical capabilities that meet the evolving information and reporting needs of healthcare providers to document and improve clinical and operational performance. For more information about Encore, please visit emeasures Transitions : WHITE PAPER 11

12 APPENDIX A: MEANINGFUL USE STAGE 2 EH/CAH MEASURE MENU¹² Meaningful Use Stage 2 EH/CAH Measure Menu NQF Measure # CMS/ Measure Description QM Programs Using Measure Care Coordination NQF 0441 STK 10 Ischemic or hemorrhagic stroke % of ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. ¹³ ¹⁴ NQF 0496 ED Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department. Clinical Process and Effectiveness NQF 0435 STK 2 Ischemic Stroke Discharged on Antithrombotic therapy. NQF 0436 STK 3 Ischemic Stroke Anticoagulation therapy for Atrial Fibrillation/Flutter % prescribed at discharge. NQF 0437 STK 4 Ischemic Stroke Thrombolytic Therapy Acute ischemic stroke patients who arrive at this hospital within 120 minutes of time last known well and for whom IV t-pa was initiated within 180 minutes of time last known well. NQF 0438 STK 5 Ischemic stroke % of stroke patients administered antithrombotic therapy by end of hospital day 2. NQF 0439 STK 6 Ischemic stroke % of stroke patients with LDL > 100mg/dL discharged on statin medication. NQF 0373 VTE 3 VTE Patients with Overlap of Anticoagulation Therapy: number of patients diagnosed with confirmed VTE who received an overlap of parenteral IV or subcutaneous anticoagulation and warfarin therapy. NQF 0374 VTE 4 VTE Patients Unfractionated Heparin (UFH) Dosages / Platelet Count Monitoring by Protocol (or Nomogram) Receiving Unfractionated Heparin (UFH) with Dosages / Platelet Count Monitored by Protocol (or Nomogram). NQF 0142 AMI % of acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge. NQF 0469 PC 01 % of babies electively delivered prior to 39 completed weeks gestation. NQF 0164 AMI % of acute myocardial infarction (AMI) patients receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less. HVBP¹⁵ Continued > emeasures Transitions : WHITE PAPER 12

13 NQF Measure # CMS/ Measure Description QM Programs Using Measure NQF 0163 AMI % of acute myocardial infarction (AMI) patients receiving percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less. HVBP NQF 0639 AMI % of acute myocardial infarction (AMI) patients 18 + who are prescribed a statin medication at hospital discharge. NQF 0480 OB Exclusive Breastfeeding at Hospital Discharge Rate. CMQCC¹⁶ State Use NQF 1354 OB The proportion of births that have been screened for hearing loss before hospital discharge. CDC State Use Efficient Use of Healthcare Resources NQF 0147 PN % of pneumonia patients 18+ selected for initial receipts of antibiotics for community-acquired pneumonia. HVBP NQF 0528 SCIP # of surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). HVBP Patient and Family Engagement NQF 0495 ED 1 Emergency Department Throughput Median time from ED arrival to ED departure for admitted ED patients. OFMQ17 NQF 0497 ED 2 Emergency Department Throughput Admit decision time to ED departure time for admitted patients. OFMQ NQF 0440 STK 8 Ischemic or hemorrhagic stroke % of patients or caregivers given stroke education materials addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. NQF 0375 VTE 5 VTE discharge instructions: the number of patients diagnosed with confirmed VTE that are discharged on warfarin with written discharge instructions that address all four criteria: compliance, dietary advice, follow-up monitoring, and adverse drug reactions / interactions. NQF 0338 Plan of Care Documentation exists that the Home Management Plan of Care as a separate document, specific to the patient, was given to the patient/caregiver, prior to or upon discharge. State Use Patient Safety NQF 0371 VTE 1 Venous Thromboembolism (VTE): the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after admission. Continued > emeasures Transitions : WHITE PAPER 13

14 NQF Measure # CMS/ Measure Description QM Programs Using Measure NQF 0372 VTE 2 Intensive Care Unit (ICU) VTE Prophylaxis: the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the ICU or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer). NQF 0376 VTE 6 VTE-6 Incidence of potentially preventable VTE: the number of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between admission and the day before the testing order date. NQF 0527 SCIP # of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. HVBP NQF 0453 SCIP Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero. NQF 0716 OB % of term singleton livebirths (excluding those with diagnoses originating in the fetal period) who DO NOT have significant complications during birth or the nursery care. CMQCC State Use NQF 0527 SCIP # of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. HVBP Measure for electronic reporting via CEHRT in the Hospital IQR Program (voluntary participation in CY 2014)¹⁸ CQM Case Threshold Exemptions¹⁹ Beginning in FY 2014, in order to be exempted from reporting fewer than 16 CQMs the hospital would need to qualify for the case threshold exemption for more than 13 of the 29 CQMs. Eligible hospitals with 20 or fewer discharges during the year reporting period (or 5 or fewer if attesting to a 90-day reporting period) as defined by the CQMs denominator population would be exempted from reporting on that CQM. If the hospital does not meet the case threshold for 13 or fewer CQMs, the hospital would be able to report at least 16 CQMs. Likewise, if the CQMs for which the hospital can meet the case threshold of discharges do not cover at least 3 domains, the hospital would be exempt from the requirement to cover the remaining domains. For example, if the hospital does not meet the case threshold of discharges for 13 CQMs, and thus could report 16 CQMs, but the 16 CQMs cover only 2 of the 3 domains, then the hospital would be exempt from covering the third domain. emeasures Transitions : WHITE PAPER 14