Merry Medisolving: How to Participate in Quality Measure Development

How to Participate in Quality Measure Development (And Why It’s Really Worth It!)

CMS’s new Severe Obstetric Complications eCQM (ePC-07) is one of two perinatal measures set to launch in 2023 before becoming required in 2024. 

(The other measure: ePC-02 Cesarean Births. You can learn how to get started with both measures here.)

But new eCQMs like ePC-07 aren’t created overnight. It starts with volunteer hospitals and healthcare systems—like BJC Healthcare in St. Louis—who are willing to lend their time, expertise, and data to the measure development and testing process.

This holiday season, we hosted a virtual fireside chat with two members of BJC Healthcare’s quality improvement team to learn more about their role in the development of ePC-07, why BJC makes it a priority to participate in measure testing, and what your team needs to know before entering the fascinating—and rewarding—world of measure development.

Meet BJC's Experts:

Liz O’Neil Greiner | Business Process Consultant
Mary Burton | Manager, Clinical Quality Reporting

ePC-07 was not your first rodeo with measure development, was it?

Mary: That’s right. Measure development has been a priority for BJC since 2017. We believe that the time to influence a measure is during the early stages of measure development. We have had some success in the past with submitting comments. But once a measure gets that far, it’s often too late.

Liz: Exactly! Our system leadership really supports early measure development participation so we can influence and advise measure specifications ahead of any final rules. It gives us a nice head start on the measure.

How do you identify which measures you want to volunteer for?

Liz: We share the opportunity up through our system to our clinicians and clinical quality partners in whatever area the measure is focused on. We want to know: is there the right level of interest internally and does it align with our system’s work? ePC-07 checked both those boxes.

Mary: With ePC-07, in particular, CMS provided a lot of data in its rationale to reassure us that this measure was evidence-based and to show that, across the country, we have a real issue with maternal mortality and morbidity. This is the first attempt to quantify at the hospital level some of those issues, so we all believed that this measure was an important one.

How do find out about measure development opportunities?

Mary: A few different ways. In 2017, it was a chance conversation about eCQMs at a conference between our chief medical information officer and a leader from Mathematica that resulted in our first foray in measure development. Our chief medical officer also sits on the National Quality Forum, which endorses many of the measures. So it helps to have leadership’s eyes and ears looking for opportunities.

Liz: In my role, I stay engaged with The Joint Commission [TJC] and CMS’s eCQM resources and development opportunities. ePC-07 was first developed by TJC, in partnership with Yale New Haven Health Services Corporation. In mid-2019, they sent out a list-serv request for participation on a Technical Expert Panel. We went through our usual vetting process with the appropriate clinicians and decided to submit an application to participate.

What is it like serving on a Technical Expert Panel?

Liz: We had our first onsite meeting in Boston right before COVID hit, and then we had two additional calls. The purpose of the meetings was to vet the measure’s specifications with the group. The group was great because it brought together expertise from all areas. There were maternal health experts, patients, quality team members, and technical experts. It was a great introduction to the measure—a great opportunity to bring our system to the work and to make our system ready for this work. We were happy that we got involved at such a nearly stage.

You then went one step further and volunteered to participate in feasibility testing for the measure. What was that like?

Liz: Actually, Medisolv brought that opportunity to us! We had just become a Medisolv client around this time, and Ken [McCormick, Medisolv’s executive vice president of client services] knew that measure development was important to us. So he brought the testing request to us, and of course we were interested.

What was the goal of the feasibility testing?

Mary: In general, feasibility testing is designed to get a measure to a place where it’s ready to be deployed. The measure developers want to make sure the logic of the measure is sound and the data elements required to track the measure are available in EHRs.

Liz: With ePC-07, in particular, the feasibility testing gave us a great head start on identifying issues with the EHR, local workflows, documentation gaps, and mapping issues. That was extremely helpful because there are some new data elements in this measure, like blood transfusions, that we haven’t had to track before. (Editor’s note: You can learn how the measure is set up here.)

Was there a lot of ramp-up required on your end to get the testing started?

Liz: Not too much! Medisolv handled quite a bit of the logistics, which was really nice. Understanding the logic in the data file requests, building everything out...their team handled all of that for us, which was great.

Mary: I would, however, tell other hospitals to be prepared for the legal process of reviewing the agreement and getting your legal team to sign off on participation. The key issue is making sure that patient health information (PHI) is protected during testing. For us, this step often requires some back and forth. In fact, the first time we were asked to participate in measure testing, the legal review took so long that we missed the window of opportunity to participate. The vetting is very serious.

What was the day-to-day work like for you once testing had begun?

Liz: Medisolv generated a patient log which was handed off to us for review by me and our lead clinical abstractor. The goal was to make sure that what the measure was calculating—the data that was being extracted and pushed through to our results—matched what we were seeing in the charts. We ended up focusing a lot on coding and present-on-arrival flags to make sure those were correctly identified.

How labor intensive was that review process?

Liz: It took quite a bit of time. We ended validating about 200 encounters in both the numerator and the denominator. Our lead clinical abstractor and I worked on it over the course of a month. But it was a valuable process because it really helps you understand what work you have to do in your EHR and in your workflows with your providers. It also shines a light on where additional mappings need to be done. As I mentioned, this measure did require us to map a few new data elements and determine how we would capture them, so it’s good to get that figured out now.

Mary: An organization needs to be committed to the process, because obviously it took Liz and our abstractor away from doing other things. This process becomes the priority. If you’re interested, it’s definitely worth it but you need to be aware of the time commitment and deadlines.

How did you submit your feedback to TJC and CMS?

Liz: Medisolv handled that for us as well. Kristen Beatson [Medisolv’s vice president of electronic measures] reported back to us that this process for ePC-07 went much smoother than with past measures, so clearly CMS, Medisolv, and hospital systems across the country are all learning and becoming more efficient as eCQMs are maturing. I think that’s a great sign.

How are you planning on implementing this measure now that you’ve been through it?

Liz: Now that we understand how the measure works, we can start shifting our focus to performance improvement. We’ve since enabled the measure at our large academic site for local testing and validation. Next, we’re going to build processes around the measure to better socialize it across our health system. That will introduce the next steps we need to take for performance improvement, so we can improve the care for our patients.

Mary: We are also focusing on clinician education. We share our perinatal measures with our physicians and advanced practice nurses so they understand what goes into performance. It helps them see the link between their documentation in an electronic health record and how it impacts an electronic measure.

Do you have plans to participate in future feasibility testing?

Mary: Yes, we recently completed the legal approval process to participate in maintenance testing for the Safe Use of Opioids eCQM. The test is being coordinated to assess future logic changes to the measure.

Liz: We’ve already asked Medisolv to help us with that test, too. Part of what makes our relationship withMedisolv so great is that their level of commitment to testing matches ours. We lean on each other. It’s a good partnership.

3 Ways You Can Get Started with Measure Development

• Visit CMS’s “Get Involved” page to see all the ways you can participate in the process
• Contact Medisolv to discuss how you can partner with us for upcoming measure testing
• Read our article, The Making of a Quality Measure, for a deep dive into the measure development process