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eCQM Data Validation: Practices From Our Most Successful Hospitals

What do the words “eCQM data validation” mean to you? Let’s suppose that you’ve gone through the process of implementing eCQMs. Now what? And yes, we should start with a big “congratulations” if you have made it that far. Implementing eCQMs is a big project by itself. But now, what’s your plan? Do you have a team that’s ready to jump in and analyze your eCQM results and address any gaps in performance? Or was your plan to just submit your eCQMs to the required regulatory programs and be done with it?

Well, you know where we are going with this. In today’s world of ever-changing regulations tied to Medicare reimbursements, it’s better that you begin the process of validating your eCQM data now. That way, when CMS sets eCQM thresholds and then publishes those results on Hospital Compare, your hospital will be ready with accurate eCQM data.

This week, we reveal the tools that our most successful hospitals use to validate their eCQM data.

IT & Quality Partnership

We start this discussion with one of the most important aspects of validating your data. And from our experience, often one of the most understated tools for success. The Medisolv hospitals that have the "best" eCQM data tend to have teams with a tight Quality and IT relationship.

When Meaningful Use first started, it was often the IT department that took eCQM ownership. Since eCQMs are now required for CMS and The Joint Commission reporting programs, it makes sense that IT teams begin to work closely with their Quality departments.

We suggest getting Quality heavily involved if they aren’t already. Make sure to educate your Quality department around eCQMs. Help them to understand how they differ from chart-abstracted measures, what regulatory programs require eCQMs and why it’s important to care about the eCQM data results.

[Upcoming Webinar] A Quality and IT "Love Story" At Beaufort Memorial Hospital 
(In partnership with the American Hospital Association.)

Do Your Homework

Once you turn your eCQMs on, it’s likely the first thing you’ll want to do is dive right in and assess your rates. But if you don’t have a good understanding of how the measures work, then you’ll struggle to understand what to address gaps in performance.

Study the measure

Understanding eCQM basics still seems to be a struggle for hospitals. What is a quality measure? What does it do?Make sure that both Quality and IT have a solid understanding of each of the populations that make up an eCQM and how those factor into your final performance rate.

Also see: What makes up an eCQM?

Understand the requirements

Keeping up with eCQM requirements can be very overwhelming. And we aren’t just talking about what CMS or The Joint Commission are requiring you to report. Every year, CMS updates the eCQM specifications with new requirements. You should have a process in place to keep up with those changes. Either have a staff member responsible for monitoring those changes or work with a reporting vendor (like Medisolv) that shares those changes with you on a regular basis. The Medisolv hospitals that have success with their eCQMs have a team in place that they meet with regularly. They have a process in place to keep up with the changes and a methodology to quickly adapt their environment to those changes.

Also see: Hospital IQR Program Reporting Requirements for 2017

Also see: eCQM Requirements for The Joint Commission ORYX® Initiative for Quality Improvement

Select your measures of focus

Before you begin the process of validating your data, you must know your starting point. Review each measure that you have implemented. Look at the requirements for each of the populations mentioned above within each measure. Then have a conversation with your team to understand where you are today. How is your hospital currently doing your documentation for that measure?What data elements does the measure need and how would this affect your clinical workflows? Find out what documentation and practices you already have in place and the effort it might take to improve that measure.

Once you’ve decided on which measures your organization will focus upon, it’s time to start the validation process.

Validation Starts with Quality

Now even as I write the title about validation starting with Quality, it really depends on where your organization currently stands. After we’ve implemented a hospital’s eCQMs and turned them on for review, we still primarily work with the IT department to sort out the initial errors. Issues like nomenclature, mapping, issues with the application, EHR or database all get resolved at the start.

Once you’ve moved past the initial validation, then it’s time to really begin the process of ongoing data validation. The hospitals that we find to be the most successful with their eCQMs are those hospitals that have Quality taking the lead in validation. Quality reviews the measures and then works with the appropriate department to fix the problem.

Repetition is key

This won't surprise any of you, but our most successful clients tend to be those hospitals that have been doing eCQM data validation the longest. It takes time and effort to get good at eCQM data validation. It can be a frustrating process, especially if you don't know where to begin looking. Over time, their experiences help them to understand what they should be on the lookout for. 

At Medisolv, we've worked with hundreds of hospitals, so we've noticed some patterns as well. Let’s review three of the most common eCQM errors we see in our Medisolv hospitals.

Mapping Errors

One of the most common problems we find is with mapping. This makes sense because mapping is the area where the most things can go wrong. Common mapping errors include:

  • Unstructured documentation
  • Codes not mapped or the wrong codes were mapped
  • Updated documentation not reflected on eCQMs
  • CMS updates the value sets for eCQMs
  • Physicians use new medication not in the eCQM value set list

Compliance Errors

Compliance is the second most common problem that we see. Inevitably, somewhere along the road, someone didn’t complete necessary documentation. Perhaps it was dictated or done in a free text note and so it was not properly captured. The top issues with compliance that we have seen are:

  • Issues with the problem list
  • Contraindication documentation compliance
  • Compliance with electronic medications ordered at discharge

Timing Errors

One of the biggest headaches we at Medisolv experience is timing, which is critical for eCQM capture. Just about every data element requires timing documentation. For example, the eCQM STK-8 (Stroke Education) requires the documentation to occur while the patient is in the inpatient encounter. So, if the documentation occurs after discharge, the patient’s going to fail the measure.

As Quality identifies these issues, they can determine what is needed to fix the problem. Perhaps they need to reinforce the compliance with education. Or maybe they need to work with the clinicians to determine if Quality and IT need to change their workflow.

Tips for Successful eCQM Data Validation

  • Form a tight IT & Quality Partnership.
  • Identify clinical representatives and keep them involved in the eCQM process to get input on clinical workflows.
  • Set recurring meetings with invested parties. At a minimum, set up quarterly meetings with Quality and IT to talk about how things are going.
  • Quality should be looking at your eCQM data weekly at the very least. You don’t want to wait until right before submission to look at your data. At that point, it will be hard to fix anything.
  • Create an annual process for monitoring and mapping changes.
  • Consider education requirements for staff. What type of education reinforcement does your hospital need to put in place? Think about staff turn-over. How will you handle training of new staff?
  • Stay up to date with the changes to eCQM requirements from CMS and The Joint Commission.
  • Partner with a vendor like Medisolv to help you with the process. We work with you not just during implementation, but also during the entire data validation process. We provide guidance and keep your team up to date with the latest eCQM changes that are critical for success. When it comes time to reporting your eCQMs, Medisolv submits them on your behalf with very little effort on your side. Request a demo today.



Data Driven Patient Care: Using ECQM Validation For Performance Improvement
An ECQM Process For Your Hospital

If you’ve already implemented eCQMs, but you aren’t sure what to do next, this webinar is for you. Meet your regulatory reporting requirements and drive performance improvement activities at your hospital.

In this video you will learn about:

  • Common challenges facing hospitals during eCQM data validation.
  • Constructing a plan to improve your eCQM results.
  • Identifying common errors when performing eCQM data validation and recognize how to locate and address gaps.
  • Identifying the requirements for regulatory programs requiring eCQM submission.

data driven patient care

Kristen Beatson, RN

Kristen Beatson is the Director of Electronic Measures of Medisolv, Inc.

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