CMS’ Hybrid Measure: What Your IT Team Needs to Know

New hybrid performance measures in 2020 may test the ability of your quality and IT departments to seamlessly work together. Do you know what it takes to be prepared? Gain valuable insight from our Director of Electronic Measures.

If you’ve ever attended the HIMSS Global Health Conference and Exhibition, you know that the thousands of attendees and vendors eat, drink and sleep health IT all day, every day.

Amid all the shiny new things, don’t miss Medisolv’s own registered nurse and clinical quality measure guru roaming the halls of the Orange County Convention Center in Orlando, Fla., in March.

Kristen Beatson, Medisolv’s Director of Electronic Measures, will deliver her presentation, “Hybrid Measures: What the Heck Are They? How Do They Work?” on Thursday, March 12. We caught up with her before she flew to Orlando to get a preview of her hour-long talk.  

Why are you speaking at HIMSS?

Kristen Beatson: Anytime you’re talking about electronic clinical quality measures, you’re involving IT. Your IT staff works behind the scenes to make things happen from an administrative perspective. They’re the ones doing things like data extraction and mapping to make sure that your quality data gets transmitted to where it needs to go.

If you walked into the health IT department at a hospital today and asked for a show of hands of who knows about CMS’ new hybrid measures, how many hands would go up?

Kristen: My guess would be not many, but there may be some who are starting to hear about it. That’s why education is so important and why Medisolv is at HIMSS. Health IT professionals need to get up to speed on hybrid measures, understand what they’re all about, how they work and, most importantly, how they affect patient care.

If someone at your session asks you why they should care about hybrid measures, what will you say?

Kristen: Fear is a great motivator, right? I think there are three things that will scare them into paying attention. The first is that hybrid measures are required. You don’t have a choice of whether to submit the data or not. Second, CMS will post your hybrid measures on the Hospital Compare website for all the world to see. You don’t want them to be missing or wrong, and you want to look your best compared with your peers. Third, CMS calculates your hybrid measures by combining the claims data it already has with the clinical data that you’re submitting from your EHR. You want to make sure CMS gets it right by submitting the most accurate clinical data possible and linking that data to the right claims. You’re not going to see those results until CMS publishes them. That’s pretty scary.

How are hybrid measures different from other eCQMs that hospitals submit to CMS?

Kristen: From a health IT standpoint, the biggest difference is that it’s all EHR data. eCQMs are their own data sets, and you’re sending them in separately. With hybrid measures, you’re culling the required core clinical data elements from your EHR and submitting them to CMS. To the lay person, that doesn’t sound any different, but for an IT person at a hospital, that’s very different.

How many CCDEs do hospitals have to pull from their EHR systems and send to CMS?

Kristen: There are 13 CCDEs for the hybrid readmission measure. Seven are lab values from diagnostic tests like blood work. Six are vital signs like the patient’s weight, blood pressure and temperature.

That almost sounds too easy. What’s the catch?

Kristen: There are two. The lab values and vital signs have to be the first taken of the patient. That means within 24 hours before an inpatient visit starts or within two hours after an inpatient visit starts. CMS wants to know what shape the patient was in when you went to the hospital. Any values or vitals captured outside that window won’t count. Second, the values and vitals you need may be in other information systems used in other parts of the hospital—in a specific department, in a specific office, on a specific floor, or in a specific format like pounds or kilograms. If those information systems don’t automatically standardize and funnel that data into your primary EHR system, you’ll need to figure out how to capture it, or it won’t count.

That sounds challenging from a technical perspective. Is it?

Kristen: It sounds challenging because it is challenging. The good news is, CMS has given everyone a grace period. The voluntary submission period for the hybrid readmission measure begins on July 1, 2021, and submission isn’t mandatory until July 1, 2023. That gives health IT departments working with their quality departments time to find out where all of that data is and make sure it gets into their EHR systems in the right format to transmit to CMS.

You mentioned mapping earlier. Can you explain that a little more?

Kristen: Absolutely. Each CCDE has to be assigned, or mapped, to a value set code. Your electronic data capture system reads the code to know what CCDE to pick up and send to CMS. During this grace period from CMS, your health IT department will need to map the codes to each of the 13 CCDEs for the hybrid readmission measure and then test the mapping to see if it’s working properly. That will take some time. If the code is wrong, if there’s a typo in the code, if it’s an old code, or if you’re missing a code, then the data doesn’t get picked up at all. It’s as if it didn’t exist.

If I work in the health IT department, how will this affect my workflow?

Kristen: It will take some time to get your clinical data house in order and do the mapping and testing. After it’s all set up and working, it shouldn’t take a lot of time on a daily basis. At that point, you’re just monitoring and updating.

What am I monitoring and what am I updating?

Kristen: There are a few things you should be looking for after you’re up and running. You should have a reporting tool that tells you you’re capturing the right CCDEs (like Medisolv!). If you see that blood pressure readings are suddenly missing, you can go in and fix that. I’d check the data every week, because mapping can be overwritten or a data field could change. After you or a vendor like Medisolv submits your data to CMS you have to confirm that it wasn’t rejected for some reason. The last check would be the big one, and that’s when CMS publishes your readmission rate on Hospital Compare. Does your information look right? How do you compare with similar hospitals? If something seems incorrect, then you need to go back and find out why.

What’s the big message you want your attendees to remember from your presentation?

Kristen: First, to do this right, it really is a team effort. Your quality department and your IT department need to work hand in hand to make this happen. Readmissions are only the start, and there will be other hybrid measures coming from CMS in the future. Second: Start now. Work out the bugs. Get proficient at it. Don’t wait until a week before the mandatory deadline to set it up. And finally, this isn’t just about submitting data to CMS to check off a box. This is about learning how to use data to improve patient care and patient outcomes. They’re called quality measures for a reason.

We hope to see you in Orlando at HIMSS. Our booth number is #2979. Come find us! If you miss Kristen’s presentation, you can download her slides here after the conference.