HIT Policy Update: Summary of Proposed Hospital Quality Reporting Changes

The following update is a special feature provided by emids + encore subject matter experts in the wake of HIT policy changes important to our customers and partners. 

On April 24, 2018, the Centers for Medicare and Medicaid Services (CMS) filed its fiscal year (FY) 2019 Inpatient Prospective Payment System (IPPS) proposed rule.  In this rule, CMS is proposing changes and policy updates to the five hospital and long-term care value-based quality reporting programs included under IPPS.  CMS is promoting the revisions as being patient-centered, reducing burden to providers, and encouraging interoperability.  In this rule, CMS is proposing to implement policy driven by the Meaningful Measures Initiative, with a goal to reduce costs associated with payment policy, quality measures, documentation requirements, conditions of participation, and health information technology; and to utilize measures that are outcome-based where possible.  Some of the proposed changes hold true to the priority of reducing burden, such as the proposals to eliminate 25 measures among the five programs.

For this rule, the eMRB team provides a summary and analysis of two programs.  The Hospital Inpatient Quality Reporting (IQR) Program and the EHR Incentive Program, which has been renamed as the Medicare and Medicaid Promoting Interoperability (PI) Programs.  Proposed changes to these two programs have implications for providers reporting electronic clinical quality measures (eCQMs) and the Meaningful Use (MU) objectives and measures.  Some of these changes may not reduce provider burden, especially in the near term as CMS is not just updating reporting requirements, but they are also proposing changes to the programs.  For example, CMS is proposing a new performance-based scoring methodology for the Promoting Interoperability Programs.  The proposed policy is more in line with how CMS scores the clinician-based quality payment program (QPP); it is also more complex than the current approach of meeting measure thresholds.

Some key highlights of the proposed rule are:

  • CMS is changing the focus of the previously named EHR Incentive Program from adoption of electronic health records (EHRs) to interoperability, flexibility, burden relief and quality measures that require electronic exchange of health information between providers and patients.
  • Thus, the renaming of the EHR Incentive Program to the Medicare and Medicaid Promoting Interoperability Programs.  The rename is not proposed; it is effective immediately and it applies to eligible hospitals as well as clinicians under the QPP merit-based incentive payment system (MIPS) Advancing Care Information performance category.
  • CMS did not propose a change to requiring 2015 edition of CEHRT in the calendar year (CY) 2019 reporting year.  This is a driver for major EHR upgrades by the end of the year.  It will also require workflow changes.
  • CMS is proposing a reduction to eCQM requirements for eligible hospitals with better alignment to the IQR and value-based purchasing (VBP) quality measures programs (administrative burden reduction).
  • There are also new proposed measures focused on query of PDMPs (prescription drug monitoring programs) and Opioid treatment agreement.

Please see below for more details of the proposed changes to the programs and measures.

Key Observations

  • Most impactful – Changes to the EHR Incentive Programs, now referred to as Promoting Interoperability (PI) Programs, would require implementing functionality and reporting on a reduced set of measures.
  • Most welcome – The proposed reduction in EHR reporting period in CY 2019 and CY 2020 to any continuous 90-day period for the Promoting Interoperability (PI) Program.
  • Most surprising – CMS continues to reduce the number of eCQMs to choose from, proposing to remove 7 from the IQR program and 8 from the PI program leaving only eight (8) eCQMs beginning with the CY 2020 reporting year.
  • Most consequential – Requirement to be on the 2015 Edition of certified EHR technology (CEHRT) as well as implementation of the Clinical Quality Language (CQL) eCQM standard for the CY 2019 reporting year.
  • Most complex – Proposed performance-based scoring methodology with measure changes that applies to Medicare and dual-eligible hospitals (EHs) and critical access hospitals (CAHs); however, CMS proposed to give states the option to adopt the proposal.  In addition, the proposed e-Prescribing measures add a new complexity to workflow, contracts, and measure calculations.
  • Most troubling – If CMS does not finalize the performance scoring methodology in the final rule expected in August, it will require eligible hospitals and CAHs to report the current Meaningful Use Stage 3 objectives and measures, plus the two new opioid proposed measures, if finalized.
  • Most interesting – CMS is seeking public comments on alternative proposals, specific inquires and other components of interoperability such as the trusted exchange framework and expanding interoperability to the post-acute care setting.
  • Also noteworthy – Even though CMS’ proposed scoring methodology would remove thresholds from individual Meaningful Use (MU) measures, eligible hospitals or CAHs that perform only at the previous MU Stage 3 thresholds, would not accumulate enough points to be considered a meaningful user under the performance scoring methodology.


From the hospital perspective, here are some considerations in planning for quality reporting in CY 2019.

eCQM Implications

  • In CY 2018 reporting period, some hospitals may have to perform measure maintenance on measures that would be removed in CY 2019.
  • The inclusion of an opioid harm eCQM, may present a challenge in data collection and would require organizations to review current documentation practices.
  • Organizations need to have a clear understanding of the new clinical quality language (CQL) standards to work with vendors in their reporting of eCQMs; and defining and revising the measure calculations.

Promoting Interoperability (PI) Implications / Meaningful Use

  • If the new Meaningful Use measures are approved, vendor upgrades will need to occur to accommodate the new measures.
  • For all required measures, one patient meets the numerator, however, to meet the performance score of 50 requires doing more than the MU Stage 3 minimum thresholds.
  • While organizations may think that taking an exclusion will reduce the burden of implementation, they will need to be cautious because exclusions will shift the weight of the scores to other measures requiring a higher performance rate on existing measures.
  • CMS has reweighted the whole program toward interoperability, which will challenge organizations to expand their network of other facilities with which they exchange information.
  • As noted in the Most Interesting statement, it is possible there will be additional health information exchange (HIE) measures required when the rule is finalized.
  • The reduction in the reporting period will take the pressure off organizations to work with vendors in implementing 2015 criteria by January 1, 2019.

For more information about these changes or about our Proposed Updates to eCQM Reporting and the Medicare and Medicaid Promoting Interoperability Programs contact us at info@emids.com.

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