How to Take the Leap into eCQMs for ACOs

If CMS’s announcement that it was sunsetting the CMS Web Interface was a battle cry towards the digital transformation of quality improvement for ACOs, then Physician Organization of Michigan (POM) ACO is the tip of the spear.

Since 2023, POM ACO—which includes 6 provider organizations, 77 TINs, more than 1,100 practices and 6,000 eligible clinicians serving 55,000+ beneficiaries—has worked relentlessly to prepare for 2024 eCQM reporting, blazing a trail that other ACOs can learn from.

We sat down with two of the leaders who guided POM ACO’s eCQM transformation to get a better look at what their process looked like, where they stand today in their quest toward 2024 eCQM reporting, and what bumps in the battlefield they’ve encountered along the way.

Meet POM ACO’s Experts

Name: Tate Rugenstein
Title: Senior Manager of Business Planning
Organization: Physician Organization of Michigan ACO

Name: Mary Margaret Dunneback
Title: Supervisor of Operations
Organization: University of Michigan Health - Sparrow Care Network

The Interview

When did POM ACO decide to go full steam ahead on eCQMs?

Tate: POM’s work toward reporting eCQMs actually started after CMS’s first announcement about the Web Interface transition in 2021. POM had gone as far as establishing a workgroup, onboarding a vendor, and testing QRDA III data uploads across EHRs, but chose to pause the work in 2022 when CMS announced that it was changing the required file type for eCQMs from QRDA III to QRDA I. It wasn’t until 2023, when POM felt that CMS’s expectations had stabilized, that we decided to resume the work.

Did that pause cause any immediate setbacks?

Tate: If anything, it proved to be beneficial because it allowed POM ACO to build up the capacity for the work—that “capacity” being me [chuckles]. We also found that when we resumed the process, our practices were primed and expected the work. We had a foundation of organizational buy-in that we could build on. So, we were able to hit the ground running last summer [2023] with the goal of reporting eCQMs for the 2024 performance year. The 2024 target was important to us, because we would still have Web Interface reporting as a safety net.

You mentioned that POM ACO started by establishing an eCQM workgroup. What does that group look like?

Tate: It’s a group of Quality and IT leads from each of our six provider organizations [POs]. It was imperative, given the depth and complexity of our ACO, that we had active engagement from all our POs, so we included the likes of Directors of IT, EHR analysts, and a project leader from each PO. The entire workgroup is led by a physician chair and a project manager from the ACO.

The group formulated a charter which outlined our objectives and scope of work, as well as our chain of command. We report to ACO leadership and the Board of Managers, and if the group has any critical decisions to make, the project manager is responsible for bringing forward evidence-based recommendations before putting the decision to a majority-rules vote.

Mary Margaret: As the project lead for my PO, I believe the workgroup was critical in establishing the POs as the conduits between the ACO and the practices. It ensured that there was a two-way dialogue between the practices and the ACO. It also helped that the POs could hold the practices accountable for all the tasks and requirements that emerged throughout this process.

Where did the group decide to start in terms of tackling the project?

Tate: First things first, we wanted to have a clear and up-to-date understanding of CMS’s APP reporting requirements around eCQMs. It’s the same process you go through with any CMS updates: hours of digging into the QPP and eCQI resources and trying to consolidate all the requirements into one cohesive picture.

We also tasked our PO project leads, like Mary Margaret, to help conduct an EHR capability analysis. We needed to identify what EHRs our practices were using and develop a detailed picture of what our current EHR landscape looked like. We knew that with 77 TINs in our organization, this would take a lot of time and effort.

What kind of intel were you gathering in your EHR capability analysis?

Mary Margaret: We surveyed each practice to find out what EHR was being utilized, if it was CEHRT-compliant, and if it was able to generate a QRDA I file. We also asked the practices if they had any plans to update or switch their EHR in the next 12 months.

Our team completed this assessment with each practice, and we kept a detailed spreadsheet of the capabilities for each one. We received a pretty good response from most of our TINs, but my PO [University of Michigan - Sparrow Care Network] is a bit unique in that we have some employed physicians and some independent physicians.

How did having independent physicians impact your EHR capability analysis?

Mary Margaret: It was a little difficult to get some of our independent physicians to respond to our questions. That’s where we leaned on our population health liaison team quite heavily. Our population health liaison team meets quarterly with their practices to go over quality and performance data. We were able to give the liaisons the required questions, and then they were able to dig that information up for us. We threw it into a lovely spreadsheet, tied it up with a nice bow, and sent it back over to Tate.

Tate: Yes, I kept a master spreadsheet of all our EHRs—47 in total. It was absolutely crucial to this process. I highly recommend not just creating a spreadsheet, but also keeping it up to date after the initial audit is over to track EHR changes and upgrades and ensure you have ongoing compliance.

Once you had your 47 EHRs mapped out into your spreadsheet, what next?

Mary Margaret: Well, as you can imagine, the results were all over the place. Not all EHRs have the same capabilities. There were a lot of challenges that we had to overcome and still need to overcome on our way to full eCQM implementation across every practice. The first challenge being that not all of our EHRs could generate QRDA I files.

This required our team to go through various troubleshooting exercises with each practice and their specific EHR to develop a plan to move forward. Sometimes that required us to say, “Hey, if you update your EHR to this version, you’ll be able to pull those QRDA I files. There might be a cost associated with that. Are you comfortable with the increased costs?” Sometimes the answer was yes. Sometimes the answer was no.

What happened if a practice said no?

Mary Margaret: If the answer was no, then, quite honestly, it became a larger conversation about how the practice wouldn’t be able to continue with the ACO moving forward based on our reporting requirements.

Tate: Yes, an unplanned byproduct of this process was that we ended up modifying our requirements for participating in the ACO to reflect the new eCQM technical requirements. Any practice that was unable to meet these requirements was removed from the ACO, and future practices that can’t meet the requirements are ineligible to join. It protects our ability to report eCQMs and it ingrains our expectations around quality reporting into the culture of our organization.

What other gaps did you need to account for in your EHR landscape?

Mary Margaret: Some EHRs couldn’t meet the reporting timelines that our eCQM workgroup had established. We were able to overcome this challenge with some EHRs by asking them to pull QRDA I data for previous years, just to prove that they have the ability to do so in a test file while also preserving their capability to pull for the current performance year.

That’s just one challenge, but there were so many! And they were usually highly technical. So, you have to attack this as a coordinated effort with your EHR vendors’ technical teams. We had very robust email threads going with some of our EHR technical teams [laughs].

Tate: It's important to remember that this whole eCQM process is new for a lot of the EHR vendor teams as well. Many of the smaller EHRs we worked with had never produced a QRDA I file. There were definitely multiple rounds of rejections, identifying errors, going back to the EHR so they could correct and regenerate a file. The good thing is that once you go through that process with an EHR, it’s correct moving forward. It is short-term pain for long-term gain.

So, you should prepare for an “it takes a village” approach to the QRDA I creation phase?

Tate: Yes, and I should mention that Medisolv was a crucial partner in this process as well. As we were wrapping up our initial EHR landscape audit, we were also locking down Medisolv as our vendor. We evaluated several vendors—and even briefly considered doing this by ourselves—but we ultimately chose to collaborate with Medisolv based on their ability to meet each of our practices where they were at in their EHR capabilities.

Our PO participation ranges from academic medical centers to rural health centers and FQHCs to independent specialists. We knew Medisolv was willing to do the work with each of them—and with all our EHR vendors as well—to minimize the downstream impact of our transition to eCQMs as much as possible.

We are glad to be on this journey with you! So, after all your EHR troubleshooting, did you feel like the pieces were in place to start tracking eCQMs?

Tate: I would say we had the pieces in place to begin testing the process, specifically the QRDA I file production and upload process from all of our EHRs with Medisolv. POM uses quality performance for shared savings distribution, so it was important for us to be able to assess performance in a year-over-year manner. As such, we chose to upload 2023 performance year data into Medisolv’s platform to complete this proof-of-concept process, even though we did not intend on submitting that data.

We completed this test in April 2024, and by early summer started working through our first quarterly upload of 2024 performance data. We’re still deep into the process right now, working through data uploads, troubleshooting with EHRs as necessary, all to ensure we have a successful submission of performance year 2024 data to CMS in March of 2025.

Are there any big issues you’ve run into with the testing and implementation phase?

Mary Margaret: One prevailing issue has been rooting out unstructured data. We had to understand where there was a lack of standardization and implement new processes to ensure the gaps for each measure were being closed.

For example, there were some discrepancies with our depression screening protocols across various practices. Making sure that those protocols were shored up to meet all of the CMS specs and standardizing how we would need to pull the data for Medisolv was crucial.

Tate: I think it’s eye-opening to see how going from Web Interface reporting to all-payer eCQM reporting explodes the amount of data that you need to evaluate. So far, we’ve produced more than 400 QRDA I files covering 3 million patients and 13 million encounters.

Of the three eCQMs that CMS is requiring this performance year, that’s translated into about 150,000 patients qualifying for the diabetes A1C measure, 200,000 patients for the controlling high blood pressure measure, and 500,000 patients in our depression screening population. These are our numbers so far. We only had about 65% of TIN participation in 2024 at the time these numbers were snapshot. The populations of these eCQMs are significantly larger than anything we’ve dealt with before, and it’s something to keep in mind as you work through how eCQMs will impact your organization.

What do the next 12 months look like for POM ACO’s eCQM journey?

Tate: We plan on reporting both eCQMs and CMS Web Interface for 2024. And as we continue to work on the 2024 performance year data collection, we’re keeping a close eye on the proposed rule and any changes to reporting requirements for 2025.

If the changes to the APP eCQM measure set are finalized, we will begin work immediately for implementing the two new measures, colorectal cancer screening and breast cancer screening, for ‘25. When CMS announced those two in the proposed rule, I tasked the eCQM work group with conducting an unofficial gap analysis to identify any EHRs within our participating TINs who are not prepared to report them, and to also identify what steps may be needed to get them ready to do so. We want to make sure that we're able to continue to hit the ground running if and when CMS finalizes those quality reporting requirements for next year.

We are also just starting to understand the quality improvement implications of CMS Web Interface versus eCQMs. While the transition to eCQMs has mostly been embraced in our organization, we still have work to do on normalizing the effects of that transition as it relates to performance scores and expectations. We plan to partner closely with our Medisolv Clinical Quality Advisor and our eCQM workgroup to understand these differences in performance and make action plans for future improvement.

I think Medisolv’s centralized dashboard will be critical to this effort, because we're able to see our quality performance at all levels of our ACO throughout the year for the first time ever. It allows us to further entrench continuous quality improvement into our culture.

Your hard work has really put you ahead of the curve on eCQM reporting. Do you have any advice for ACOs that are just starting the process?

Tate: For me, the most important thing you can do is commit to climbing the mountain. I cannot emphasize it enough. Commit to the climb, rip that Band-Aid off, bite the bullet, face the music, eat the frog. Whatever metaphor makes you happy, the message is the same: start now and fully embrace the undertaking.

Another thing we haven’t touched on is how important it was for us to engage all levels of leadership in this work. We made sure they understood the “why,” even if the technical details were a little muddy to them. Getting leadership buy-in ensures you have the people, resources, and funds you need to accomplish this work. It’s a major investment and you need leadership to support it 100%.

Mary Margaret: One thing that I’m glad we did was we took the time to make sure that our PO staff and practice staff were adequately educated on the upcoming changes. This was crucial not just from a buy-in perspective, but also because it allowed other members of our staff, when they’re talking to practices, to field questions on our behalf. You better believe your practices are going to have a lot of questions! Sharing information allowed us to spread out some of that work.

Ultimately, I would echo and expand on what Tate said: it’s crucial to have all of your participants buy into this process. The success of your team really hinges on that. Making sure that leadership and practices are all moving in the same direction; rowing the boat together will really get you to your goal much faster.

Get the right tools and team for your eCQM journey

Medisolv is here to walk you through every step. Check out our all-in-one APP Reporting Package for ACOs or any of these free resources:

• Watch: Preparing Your ACO for APP Reporting
• Watch: eCQMs 101 for ACOs
• Download: CERHT Compliance Checklist for ACOs
• Schedule: Request a Free Demo Today