This year your hospital must electronically submit four eCQMs to the Centers for Medicare and Medicaid Services (CMS) Inpatient Quality Reporting (IQR) program. In this week’s blog, we’ve compiled five recommendations for selecting eCQMs, Electronic Clinical Quality Measures, for submission to the IQR program.
Before you read this blog, make sure you are familiar with all of the requirements for submission to the CMS IQR program. You can read a quick blog about the requirements here.
Now that you are caught up, on to the good stuff; selecting the four mandatory eCQMs for submission. When you select your eCQMs you want to choose measures that are the best reflection of your hospital’s quality performance. We know this can be difficult, so here are the recommendations for evaluation and selection of your eCQMs for submission.
1. Confirm you are using the right specification version. In order for the file to be accepted it must be submitted in a QRDA file format based on the June 2015 version of the specifications.
2. Review your data. Look at your measure numbers from a previous quarter. Choose an historic quarter that reflects your results. This will help you determine which measures to focus on in Q3 or Q4 – which are the available reporting quarters for 2016.
3. Assess your Initial Patient Population. Successful submission is defined as submission of at least four eCQMs which can be reported as any combination of:
a. Accepted QRDA files with patients meeting the Initial Patient Population (IPP) of the applicable measures
b. Zero denominator declarations – if possible, select eCQMs that have Denominators in the reporting period
c. Case threshold exemptions - if possible, select eCQMs with more than five cases in the reporting period
4. Review the performance rates for your measures.
5. Choose four measures that you have a high degree of confidence that they are an accurate reflection of the quality of care at your hospital.
Remember that the data your hospital submits will not be posted on the Hospital Compare website, but it’s a good idea to start investing in quality reporting now before these results are publicly reported. Understanding and analyzing your eCQMs can take months and years of work in order to establish a high degree of confidence in your results. When you are ready to begin your eCQM journey, contact us to see how we can help you with eCQM implementation, validation and submission.