Beginning an Era of Clinical Quality Measure Alignment: Are You Ready?

by Robin Raiford and Anantachai (Tony) Panjamapirom


Starting in 2014, CMS allows hospitals to voluntarily submit clinical quality measure (CQM) data electronically that will simultaneously satisfy quality reporting requirements for both the Medicare Electronic Health Record Incentive and the Hospital Inpatient Quality Reporting programs. While CMS is very clear that it intends to make an electronic submission of CQM data a regulatory requirement in the future, in 2014 hospitals may choose to continue to separately report CQMs for each program. 

The Opportunity

Alignment of electronic quality reporting between these two programs could become a new strategic initiative for many hospitals because it involves resources and collaboration among multiple teams and departments such as clinical, quality improvement and IT. Leaders from these teams will need to work together and determine whether to begin to align electronic CQM reporting or continue to separately report CQMs for the Inpatient Quality Reporting and Medicare EHR Incentive programs.

While this marks the beginning of the quality reporting alignment journey, there are still major differences between the two programs. For example, the Inpatient Quality Reporting Program will require hospitals to report 57 CQMs across one full calendar year, whereas the meaningful use program requires only 16 CQMs for one quarter of a federal fiscal year.

CQM Reporting Options in 2014

Based on the modifications CMS included in the 2014 Inpatient Prospective Payment System Final Rule, CMS will allow hospitals to submit aggregate CQM data via attestation to meet the meaningful use requirements, but CMS will accept only the patient-level CQM data for electronic submission.

In 2014, hospitals have two options to report CQM data:

  1. Continue to separately report CQMs for each program, delaying alignment. Selecting this approach, hospitals must report 57 CQMs for a full calendar year via chart abstraction to meet the Inpatient Quality Reporting requirements (if a participant) and separately submit aggregate-level 16 CQMs for your selected reporting period via CMS' attestation portal to meet the meaningful use program. Hospitals could also choose to electronically submit CQM data just for the EHR Incentive program; however, that data could only be submitted in patient level format, not in aggregate level format.
  2. Align electronic reporting between the two programs. Hospitals need to report one quarter (i.e., CY Q1, CY Q2, or CY Q3*) of patient-level data for 16 CQMs electronically for the EHR Incentive Program and meet the Inpatient Quality Reporting Program requirements if all or some of those CQMs are included in the specified measure sets (i.e., seven stroke measures, six venous thromboembolism measures, two emergency department measures and one perinatal care  measure). Hospitals still will be required to report a full calendar year data for the remainder of the 57 Inpatient Quality Reporting CQMs (i.e., those Inpatient Quality Reporting CQMs not electronically reported) via chart abstraction in order to fully satisfy the Inpatient Quality Reporting program requirements. CMS has clarified that it will not publicize the data submitted electronically until such a time that data validation has been completed. (For more information, see pages 50811-50819 of the FY 2014 IPPS Final Rule)

 *Note: CY Q4 is not acceptable because the EHR Incentive Program data must be reported by November 30, 2014.  

Making a Strategic Decision

Organizations choosing the electronic reporting alignment approach may benefit from both reducing costs in chart abstraction and decreasing their regulatory reporting burden. However, before taking on such initiative, they must consider many factors, including current resources and capabilities, organizational strategy on quality reporting, alignment of data capture across multiple departments, and capabilities of their certified EHR technology to create and submit electronic reports.

CMS' ultimate goal is to harmonize all quality reporting programs with EHR electronic reporting. Hospitals should anticipate this change in the near future, since it is not a question of "if" but "when" CMS will issue such a mandate. For 2014, organizations should balance competing priorities and resources (i.e., time, money and staff capacity) with the decision to start aligning electronic quality reporting initiative. 

The table below illustrates the 29 CQMs that are included as an option in 2014 Edition certified EHR technology grouped by National Quality Domain. Organizations that choose the electronic reporting option need to ensure their EHR technology is certified for those exact CQMs.

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