How to prepare for ACOs’ mandatory shift to eCQM reporting
Carol Ann Hudson is assistant vice president, quality and clinical operations, population health, at Lifepoint Health, a national health care system and accountable care organization based in Brentwood, Tennessee.
Hudson’s career began as a programmer writing code to build hard drives for Digital Equipment Corporation. The hard drives were used in test rockets for DEC’s space program. The goal was to continually design smaller and smaller hard drives to save space and weight. She was one of the first women in IT at that organization, and that experience with space programs continues to serve her today.
We interviewed Hudson to gain insights from her experience as a female executive in healthcare IT, and to talk about the impending new Reporting requirements for electronic clinical quality measures for ACOs and others.
Q. Please outline your experience in healthcare IT, including as a woman in ACOs and public health.
A. A few years after Digital Equipment Corporation, I had the opportunity to implement an electronic practice management system and EHR for a local multi-location medical group. This is when my career in healthcare began. My physician mentor encouraged me to attend nursing school, which I completed in 1993, and since then I have earned several nursing and IT certifications.
After working as a nurse for several years in the emergency department, trauma and intensive care, I switched to nursing administration and nursing informatics. I have led several Meditech and MedHost implementations and subsequently worked in various IT leadership positions.
Ultimately, I was assigned to co-lead the Meaningful Use program for Health Management Associates, through which our team achieved Office of the National Coordinator (ONC) certification for our internally developed electronic health record and subsequently successfully achieved meaningful use goals. usage in 65 hospitals nationwide.
Once HMA was acquired by Community Health Systems, my focus shifted to clinical informatics with the responsibility of ensuring physician adoption of e-prescribing, adoption of automated order entry by providers and nurses, and overall compliance with all meaningful use criteria.
Building on my meaningful user experience, I became a member in 2016 Lifepoint Health, a diversified healthcare network consisting of more than 62 community hospital campuses, more than 60 rehabilitation and behavioral health hospitals, and 250 additional care locations, including managed acute rehabilitation units, outpatient clinics and post-acute care facilities.
The company has that too eight clinically integrated networks participating in the Medicare Shared Savings program. When I joined Lifepoint, I led the organization’s meaningful use program for both hospital and outpatient service lines.
As public health evolved in 2018, my team transitioned from IT to the Medicare Shared Savings program and helped us expand our AdvantagePoint Health Alliance networks. I currently serve as the assistant vice president for public health quality and clinical operations for the organization.
Advancing into computer science was a natural transition for me, based on my early computing experience at DEC. Unlike other nurses who struggled with the transition from paper to electronic documentation and EHRs, I found the transition easy and comfortable.
Q. What are the upcoming changes in quality reporting for ACOs, specifically the shift from web interface to eCQM reporting, by 2025?
A. Quality reporting for ACOs has historically been done through CMS’ web interface. CMS annually sends a random list of Medicare patients to each ACO and asks them to submit quality measurement results through this interface. ACOs would search participating practices’ EHRs, find the necessary data, and conduct the reporting.
The new eCQM reporting protocol changes the reporting process for ACOs and aims to better align ACO quality reporting with the Merit-based Incentive Payment System (MIPS). Here are specific changes:
No longer just Medicare patients. Quality reporting now includes all types of payers.
The denominator is now all patients who meet the criteria for each quality measure.
The number of measures is reduced to three mandatory clinical quality measures and three additional measures.
These include screening for depression and follow-up, hemoglobin A1C: poor control, and control of high blood pressure. The additional measures cover CAHPS surveys, readmissions and unplanned admissions.
CMS’ plan to transition to eCQM was released in 2020. But in response to industry opposition, CMS has made eCQM reporting optional for 2021-2024. It is now mandatory for 2025.
Here at Lifepoint Health, we have decided to make the transition to eCQM reporting sooner rather than later. Our decision paid off in countless ways: two of our networks were among the first eight early adopter groups, and we were the only ACO reporting quality measures from multiple EHR systems.
Q. What are the implications of this change and expansion in reporting for ACOs’ IT teams and quality departments – from a selection of measures to mandatory reporting on all patients. Can you elaborate on the implications of this change and the challenges ACOs may face?
A. Lifepoint Health adopted eCQM very early in the process. Other ACOs are only now catching up. Early adopters were given concessions by CMS to test the system, making it easier to achieve quality benchmarks. These concessions have been financially beneficial to Lifepoint while giving us time to expand reporting to all patients and continually improve our quality outcomes.
From a technology perspective, the change dramatically increases the amount of data that must be collected from participating providers. ACOs with one EHR for all participating providers should not have a huge challenge here.
But a single EPD is the exception rather than the norm. For example, Lifepoint Health now pulls data from 11 EHRs from all of our participating providers. This remains a challenge for most ACOs.
Q. Where is Lifepoint in the process?
A. To meet the quality reporting requirements of MIPS and our ACOs, Lifepoint Health partnered with FigMD, now MRO Corp., in 2019 to continuously pull data from all of our participating EHRs. By collecting all the data from the very beginning, we were prepared to meet eCQM requirements early, but also to consistently measure practice performance for every quality measure across all patients.
Now our efforts are focused on refining the documentation for each measure, streamlining the reporting process, and continuously improving quality of care.
We also have much greater transparency into our quality performance at all times and avoid fire drills when payers provide lists of gaps for review. Because all data is collected from practices, we only need to work on missing metrics in exceptional cases.
For example, mammogram results can be faxed from a participating physician’s office or entered into the EHR as separate data. We can easily identify the gap, find the missing information and quickly enter it into the EHR for quality reporting and other purposes.
Q. What impact do you see from a workflow perspective on Lifepoint’s day-to-day operations? Are there specific workflow nuances you’re preparing for? Or what other ACOs should do something about?
A. Because we have been collecting all data from our providers and EHRs since 2019, there will be no major workflow changes for Lifepoint Health on the IT and reporting side. All our eight networks already report via eCQM. However, for ACOs that have not yet started the process and have multiple EHRs, there will be significant workflow changes.
One area we are watching is a slow return of higher benchmarks to receive shared savings incentives. Our networks currently perform well above the 10th and 30th percentile levels, but we expect CMS to raise the bar again over time. We’ll be keeping an eye out for new rules released by CMS in 2024 regarding percentile benchmarks.
Q. As ACOs navigate the complexities of eCQM reporting, what strategies can ACOs use to ensure proper data collection across affiliated physician groups? Which data feeds need to be updated and how is this achieved?
A. In addition to data aggregation, the shift to eCQM is about education. ACOs must ensure that each practice is aware of the measures and how they will be held accountable. Each EPD must have a separate way to record measurement data within the system and must be certified for its functionality.
Practices should be thoroughly trained at each step to document all components of the measure (e.g., screening for depression) and also document follow-up for that measure, if warranted (e.g., treatment of depression for positive screens).
Whether it’s the screening measure for depression, the Hemoglobin A1C: Poor Control Measure, or managing blood pressure, healthcare providers and their teams need to know how to document this in their EHRs.
The change to eCQM is about properly documenting the quality that healthcare providers already deliver. None of the actual care falls outside of best practice medicine.
Q. Can you shed some light on the importance of education and training for providers and staff as ACOs prepare for eCQM reporting? What are some best practices?
A. A good practice is to focus on primary care providers for the majority of training. For example, we do not ask specialists to document depression screening because this is best done at the PCP level and pulled from the PCP’s EHR.
General practitioners and specialists often work together with the same patient, but the patient is only recorded once per ACO in a reporting year. That’s why we’re focused on eliminating redundancy in provider requirements and de-duplication of patients to ensure they are reported to CMS only once.
We have also created education sheets with best practices, tips and tricks for the quality documentation of each EHR. And we emphasize to physicians that meeting quality measures means providing evidence-based quality care for their patients. We simply verify that each healthcare provider is documenting the high-quality care he or she already provides.
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