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Survey: Majority of Hospitals Face Challenges, Lack of Readiness for eCQM Data Reporting

July 26, 2016
by Heather Landi
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More than three-fourths of hospitals, or 78 percent, still have work ahead of them in order to successfully submit electronic clinical quality measures (eCQM) data as part of the Hospital Inpatient Quality Reporting (IQR) program by the Feb. 28, 2017 deadline.

In the fiscal year 2016 final hospital Inpatient Prospective Payment System (IPPS) rule, the Centers for Medicare & Medicaid Services (CMS) finalized the requirement for hospitals participating in the hospital Inpatient Quality Reporting (IQR) program to submit four electronic clinical quality measures (eCQMs) for patients discharged during either the third or fourth quarter of 2016 by Feb. 28, 2017.

The American Hospital Association (AHA) and the Federation of American Hospitals (FAH) partnered with The Join Commission to survey hospital leaders about their experiences and challenges with meeting the 2016 hospital IQR program requirements. The organizations surveyed 319 hospitals about the perceived importance and priority of eCQM submission, barriers to reporting in 2016 and the tools and resources that would be helpful for submitting. Of the respondents, the majority were quality improvement/patient safety professionals, with about half identifying as clinical informatics. In addition, 16 percent identified as senior C-suite leadership and 24 percent identified as corporate office/health system leadership.

The survey found that 98 percent of the hospital respondents are required to report data to CMS as part of the hospital IRP, and the vast majority of respondents (86 percent) plan to report eCQM data to CMS by the Feb. 28, 2017 deadline. Of the respondents, 26 percent are unsure if they will report or not and 3 percent are planning to not report and risk losing a 2018 incentive payment.

Less than one percent of hospitals responding to the survey said they would request extraordinary circumstances waiver, citing reasons such a the electronic medical record (EMR) system is not ready or they are changing EMR systems and may not have a full quarter or be able to produce eCQM data by the time of submission, or their current system is unable to produce a quality reporting document architecture (QRDA) 1 file.

As noted above, 78 percent of hospitals are not ready to successfully submit eCQM data to CMS, with 17 percent reporting that they are in good shape and just need to make some improvements, and 2 percent report a high state of readiness, saying that they could submit tomorrow.

More than half of respondents were optimistic that their electronic health record (EHR) vendor would provide support with submitting eCQM patient-level data.

The survey results also indicate that hospitals are not informed about the cost to implement and report eCQMs. Almost one-third (29 percent) of hospitals said it would be financially worth it to opt out of the reporting period and accept the penalty. Thirty-seven percent said it would be more costly to accept the incentive payment reduction than implementing and reporting eCQMs, and another one-third (32 percent) said they didn’t know which would be more costly.

Despite these challenges, 68 percent of respondents believe the Feb. 28, 2017 deadline is achievable for fully reporting eCQM data, while 18 percent feel that the deadline is not feasible.

The hospital respondents’ confidence in meeting the eCQM reporting deadline may be connected to their confidence about whether they have the resources needed, such as health IT tools and people with the required skills, to extract the eCQM data.

More than half (56 percent) of hospitals reported that they have the budgets to purchase the health IT needed to implement and report eCQMs and 76 percent report have the necessary knowledge and skill for implementation. However, only about half (48 percent) are confident that their hospital can extract all the data that’s required to successfully report eCQM patient-level data, with 22 percent reporting that they cannot extract all the data and 30 percent are unsure.

The survey results indicate that hospitals have mixed reviews on whether eCQMs accurately reflect quality of care and most would not implement eCQMs if it were not mandatory. Only 18 percent of respondents said that eCQMs accurately reflect quality of care, with 30 percent being neutral and 44 percent disagreeing.

Many respondents also voiced a lack of confidence and awareness about the process of submitting eCQM data. The survey indicates that 58 percent have not or don’t know if they can generate a QRDA 1 document, while 79 percent have not or don’t know if they have successfully generated a QRDA 1 document. And, 87 percent have not successfully submitted eCQM patient level data.

Hospital respondents also provided insights into the biggest challenges their organizations face when considering the CMS requirements for eCQM reporting. According to hospital respondents, they are challenged with the timeline to have eCQMs successfully transmitted while also ensuring the data accurately reflects the quality of care as well as the IT work involved and mapping for accurate data.

Other challenges that were cited include significant unplanned expenses for resources of IT, clinical staff and training of new workflow, cost and maintenance and EMR development for discrete charting requirements that eCQM data needs while not compromising care at the bedside. And, respondents also cited changing EHR systems as another challenge.

Respondents also cited producing a QRDA 1 document as a challenge, which may require changing vendors.


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