2018 CQM changes – what’s it all about?

Finding yourself unsure about recent developments in Clinical Quality Measures?  Join the club.

Each year, there are a host of changes to clinical quality measure logic, reporting requirements and CMS quality program policy. And currently, the usual cycle of CQM turnover is joined by an overhaul of CQM logic methodology for the 2019 CQM definitions: Clinical Quality Language (CQL).

Suffice it to say, there’s a lot to keep on your radar right now in the CQM world. And the deadline for eCQM submission will be here before we know it:

• Hospital Quality Reporting: February 28, 2019, 11:59pm PT
• Quality Payment Program (MIPS) eCQMs (non-Web Interface submission): April 2, 2019, 5pm PT

We prepared two posts to break down and interpret some of the changes that have occurred in 2018 and those that are coming in 2019. Our goal is to provide some action steps for CQM implementers.

The changes for 2018 submission fall into four categories:

1. Value Set: changes to official codes and code sets used by CMS quality measures
2. Measure Specification and Logic: changes in the manner of calculation and/or specific codes and code sets included in each measure
3. QRDA-I/III format and submission: changes in the XML requirements (QRDA-I or QRDA-III) for major CQM reporting programs (such as MIPS, HQR and Joint Commission)
4. Reporting: changes in high-level quality reporting program requirements

For those reporting Joint Commission (TJC) ORYX eCQM in addition to CMS, it’s important to note that TJC has aligned their measures closely with CMS, but there are some programmatic changes they we’ll note below.

As you dig into the changes, an invaluable resource is the eCQI Resource Center, hosted by CMS. The eCQI site also has an annual Implementation Checklist that is helpful in preparing for CQM submission. The Implementation steps contain a list of steps to understand year-over-year changes.

To varying degrees, these changes require workflow and/or back-end changes by EHR vendors. But take heart – if the data exists somewhere, Dynamic Health IT’s quality measure bolt-on software, CQMsolution, can take care of the rest.

Value Set Changes

The National Library of Medicine (NLM) maintains the Value Set Authority Center (VSAC), which releases value set updates annually. The entirety of these value set changes are incorporated into our CQMsolution application each release year, with backward compatibility maintained for previous reporting years.

The update of value set changes contains changes that have the potential to affect all eCQMs in a given release year. The only way to fully implement these changes is to be sure that value sets and their respective codes crosswalk perfectly to the VSAC release.

VSAC also includes some retired and legacy codes in order to accommodate a lookback period for measure calculation, so it’s important to keep in mind that the eCQM value sets do not always correspond to strictly the latest version of any code set (such as ICD-10 vs ICD-9). CMS makes a determination of which code system versions they will approve for use during the measure year.

Measure and Measure Logic Changes

While the high-level identifier (eg, “CMS 2”) and description for measures may stay the same across years, each year generally brings a new batch of measure versions.

The United States Health Information Knowledgebase (USHIK) offers a comparison tool for visualizing changes in measures across years. The tool is accessible directly from the eCQI Resource Center.

Changes to the measure specifications can range from adjusted wording in the measure overview to an adjustment to how a measure population is calculated. For instance, in 2018, CMS 128 added an exclusion for patients who were in hospice care during the measurement year.

Each measure release year also has a Technical Release Notes document attached. Where the USHIK compare tool has a side-by-side descriptive comparison, the Release Notes provide granular list of all changes to a measure. These changes must be incorporated into the measure logic used to power all reporting and this update is done within CQMsolution’s calculation engine 12-16 months in advance of measure reporting cycles.

QRDA-I/III reporting format changes

Each year, there are changes great and small to the formatting of XML documents that must be submitting for both eligible clinicians (ECs) and eligible hospitals (EH). Many of these changes are absorbed directly into the files themselves. However, here are the changes that have the potential to affect data capture and workflow on the provider side:

Eligible Hospital QRDA-Is (patient-level XML file):

• Medicare Beneficiary Identifier (MBI) is not required for HQR but can and should be be submitted if the payer is Medicare and the patient has an MBI
• CMS EHR Certification Identification Number is now required for HQR.
• TIN is no longer required

Eligible Clinician QRDA-IIIs (aggregate XML file or JSON via API):

• The performance period under MIPS can be reported at either of the following levels:
• The individual measure level for the MIPS quality measures and at the individual activity level for the MIPS improvement activities (IA), or
• The performance category level for Quality and IA performance categories
• Virtual Groups can now be reported in QRDA-III (under a CMS program name code created called “MIPS_VIRTUALGROUP”)
• Eight new Promoting Interoperability PI measures can be reported to indicate active engagement with more than one registry.
• The 2015 Edition (c)(4) filter certification criterion (45 CFR 170.315(c)(4)) is no longer a requirement for CPC+ reporting (practices must continue to report eCQM data at the CPC+ practice site level)

For eligible clinicians submitting via API to the Quality Payment Program (as opposed to file upload), the QRDA-III file is converted to JSON (or is submitted directly via JSON). In 2018, some technical changes have been made to that process and updates to measure names to include "Promoting Interoperability (PI)" in the identifiers. 

ECs can submit via API when using the Registry method. Dynamic Health IT is an authorized Registry with API submission privileges to QPP.

Reporting changes

For eligible clinicians, there were changes in 2018 related to both measures lists and measure count thresholds for reporting. The overall list of CMS-sanctioned eCQMs previously shrunk in 2017 and in 2018 CMS added two EP eCQMs:

• CMS347v1
• CMS645v1

Note that these measures are NOT available for Medicaid EHR Incentive Program for Eligible Professionals.

In 2017, clinicians could submit a minimum of 1 measure for 1 patient for 1 day. But for 2018 data, clinicians must submit at least 6 measures for the 12-month performance period (January 1 - December 31, 2018). The percentage of the overall MIPS score comprising quality has also been modified from 60 to 50%.

As in 2017, hospitals will still select at least four (4) of the 15 available electronic clinical quality measures (eCQMs) for one self-selected quarter of 2018 data (Q1, Q2, Q3, or Q4) during the same reporting period.

In 2017, the Joint Commission’s ORYX eCQM reporting was modified to require a minimum of four eCQMs, over a minimum of one self-selected calendar quarter. This will remain the same in 2018.

Bringing it all back home

The most important consideration for EHR vendors is to minimize workflow impacts for the user interface and user processes, while ensuring adequate data capture for CQM calculation and reporting. One virtue of using a calculation and analysis package such as CQMsolution is that once you’ve captured and mapped the data elements, we handle all of the changes described above. That means you can beginning running reports as soon as data is available.