5 Ways to Optimize eCQM Workflows
Building inpatient eCQMs to submit to Medicare can be a cumbersome process, but if you follow these five tips, you can make your workflows more efficient and improve the accuracy and timeliness of your measures.
To the layman, it seems pretty simple: Pick at least four of nine electronic clinical quality measures and send them electronically to CMS in order to get paid. To hospital quality directors and quality departments, though, what seems simple is anything but. Often, the biggest hurdle is the efficiency of the workflows required to build the measures, capture the data, and submit the results to CMS.
Why is your eCQM workflow efficiency important? It’s important because the more efficient you are, the more accurate and timelier your eCQMs are, and the more accurate and timelier your eCQMs are, the more you can use them not only for reimbursement purposes but for quality-improvement goals.
Let’s review the nine eCQMs for calendar year 2021. Your hospital can submit any combination of these to CMS this year to earn an upward adjustment to your Medicare rates for inpatient care in fiscal 2023. You are required to submit four measures with two quarters of data, but you can submit more than four—and many hospitals do so, because they have the workflows in place.
The nine eCQMs are:
- Admit decision time to emergency department time for admitted patients
- Anticoagulation therapy for atrial fibrillation/flutter
- Antithrombotic therapy by the end of hospital day two
- Discharged on antithrombotic therapy
- Discharged on statin medication
- Exclusive breast milk feeding
- Intensive care unit venous thromboembolism prophylaxis
- Safe use of opioids—current prescribing
- Venous thromboembolism prophylaxis
Submission is actually a very small part of the entire process and probably the least complex. It’s what happens before you hit “upload files” that makes all the difference. And what happens before you hit “upload files” generally follows four steps.
1. Logic. The first step is identifying the different data elements that you need to build a measure. Logic refers to the language that identifies each of those data elements.
2. Mapping. The second step is data capture. Here we’re talking about how you capture the data elements that you need for each measure. The data elements are captured directly from your clinical documentation in the Electronic Health Record. Each data element has associated codes (specified in a value set) which you map to your electronic documentation. During the reporting and submission process, the mapped codes link the required element to your documentation.
3. Validation. The third step is data validation. This means reviewing results to confirm your data capture and mapping is correct. To see if they, in fact, generate complete populations and results, and whether they accurately reflect your performance on each particular measure.
4. Maintenance. The fourth step is maintenance. This involves continually monitoring your measures and watching for trends over an established time frame, or sudden or unexpected upward or downward movements in measure performance and populations.
Each of the four steps comes with unique workflow challenges that threaten to make the entire process inefficient, resulting in inaccurate, incomplete and potentially useless measures. But regardless of the specific workflow challenge, the solution comes down to one of three things, or a combination of those three things: people, processes and technology.
Here’s a checklist of five things that you and your quality department can do to optimize your internal workflows for any eCQMs.
1. Educate staff on why a measure is important
It’s critical that you educate the stakeholders at each of those four steps on why a particular measure is important from a patient care perspective. You’re explaining the benefit of a measure versus the burden of a measure. As we say at Medisolv, you’re not just doing this to check a box and get paid. You’re doing this to improve the clinical outcomes and the health of your patients.
For example, clinicians prescribe blood thinners to patients diagnosed with atrial fibrillation to help prevent them from having a stroke in the future. That may be obvious to patients’ doctors, but it might not be so obvious to non-clinical stakeholders who have a hand in that measure. If you know the reason behind a measure, you’re more likely to be more efficient in building, implementing and supporting it. In this case, you don’t want to delay life-saving medication.
2. Get the right stakeholders for each measure
Before you start your eCQM journey for any measure identify who needs to be involved with that particular measure—and it’s not just IT, the quality team, doctors or nurses. This list can include administrative staff, clinical department heads and licensed clinical support staff.
All too often, a hospital neglects to include a stakeholder who is critical to a particular measure. When that happens, you create a gap in the process even before that process starts, thereby building in inefficiencies. Trying to bring that missing stakeholder into the process later will go about as well as you can imagine.
3. Understand the logic behind each measure
Quality directors and other quality team members know the language of quality improvement. They don’t necessarily know the language of computers, or the logic required to identify the data elements for each eCQM. It’s a world they typically don’t live in and aren’t familiar with. As a result, quality can understandably be overwhelmed with eCQM implementations. One common mistake is to add more documentation than is needed to capture the eCQM data elements. You've heard the phrase "covering your bases?" Well, think of this as covering your bases, outfield, pitcher and catcher. In an effort to make sure nothing is missed during data capture, many hospitals add unnecessary documentation and we all know that more "clicks" causes more problems!
When you’re documenting and capturing more data elements that you need for an eCQM, you’re building inefficiencies into the first step of the four-step process that we described above. You’re creating more work that really doesn’t need to be done. Here is where you may need help and feedback from other clinical stakeholders or your IT department. Ask the questions:
1) Are we already documenting this data element electronically in a structured field? If so, how is compliance? Work on compliance and improving current workflow before considering adding new or duplicative documentation.
2) Can we capture this data element in one assessment (for example), or do we really need to document it on two different assessments and an order? Consider stepping up education and/or adding a rule to require documentation, as opposed to adding multiple instances of documentation.
4. Map the shortest route for each measure
Like understanding the logic of each eCQM to minimize additional documentation and workflow changes, you should also understand how to map documentation in your EHR. Documentation must be mapped to the required data elements using the correct codes. Don’t assume one instance of documentation equals one map for one data element using one code. Occasionally, believe it or not, there are shorts cuts in the implementation process.
In fact, some data elements that are documented in your EHR are actually amalgams of other individual data elements. For example, VTE 1 requires documentation of two unique data elements: VTE Risk Assessment, and a result of Low Risk for VTE. To effectively capture this data, you need to map the code for the assessment and the code for low risk. In this case, you can map both codes to one instance of documentation of Low Risk for VTE (assuming documentation of low risk indicates the assessment was completed). Again, you are minimizing the clicks and changes to workflow. Talk to your IT department or EHR contact, they can assist you in identifying opportunities to use technology in order to improve efficiencies.
5. Validate to spot gaps in data capture, workflow and mapping
This fifth and final tip is to determine how well you followed the first four tips, through validation. You’re reviewing your eCQM reports regularly to see if they generate accurate results. Validation is important so that you have confidence that you are submitting complete, error-free data and you can use that data effectively to support your internal quality-improvement efforts. During validation, you’re looking for gaps in your data capture process, workflow or mapping that leave out or don't meet requirements for the essential data elements you need for a specific measure.
The workflow efficiency secret is what you do after you spot those gaps. You should trace them to their source and correct them through staff education, improved clinical documentation, mapping corrections and other permanent fixes. And you’ll need to monitor those fixes to make sure they work. Try to avoid band-aid fixes and other temporary workarounds, eCQMs aren't going anywhere and those quick fixes always break again. Lastly, the common theme in all of these recommendations, include the clinical stakeholders in the decision-making process plus provide feedback on improvement successes.
When you consider these five recommendations collectively, you’re trying to minimize the impact on internal workflow and data capture, plus minimize the number of steps from eCQM implementation to eCQM submission. Everyone you work with is counting the clicks, so keeping that number to a minimum will improve compliance and submission success, but most importantly will improve the quality of care you're providing to patients.
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Kristen Beatson is the Vice President of Electronic Measures at Medisolv, Inc.