Thursday, May 2, 2019

Prepping for 2019 Hospital Quality Reporting

Now that the 2018 reporting year has been wrapped up and submitted, this is a good opportunity to examine what worked and what areas need improvement to ensure a successful 2019 reporting year.

Rear-View Mirror

  • On the Quality Net site, we experienced issues with generating reports and site speed.  Apparently, others had the same issues.  Fortunately, CMS extended the 2018 deadline from February 28 to April 14.
  • To compound the frustration, Quality Net lacks an open forum for support tickets.  MIPS, Cypress, CDA 2.0 and C-CDA and FHIR all have open Jira or Google Groups for support, allowing developers, implementers, and users to comment and ask questions using a transparent process. CMS does not.
  • The support process is tedious and time-consuming.  Undisclosed reporting tool issues created “false alarms” for our calculations and turnaround on support tickets moved slowly.   Nonetheless, we worked with the CMS help desk and technical support to ensure that our CQMsolution calculations matched Quality Net.
  • In spite of these obstacles, our new ‘Submit to DHIT’ button made testing and submitting a much smoother process.   All clients submitted successfully prior to the deadline.


  • 2015 Certified EHR Technology (CEHRT) must be in place during the entire reporting period, although it is permissible for the certification to happen later, as long as it is posted on the ONC CHPL prior to the end of the reporting period. 
  • In case you still have doubts, 2014 Certified software is not acceptable for 2019 reporting.
  • 2019 Promoting Interoperability (formerly Meaningful Use) now has a MIPS-like scoring system, although unlike MIPS, Quality Measures are not part of the scoring.
  • The big challenge for EHR vendors and other suppliers of eCQM software is the transition to Clinical Quality Language (CQL) but, if done correctly, this transition should be transparent to software users.
  • Keep in mind that your CQM results are digested and posted to the Medicare Hospital Compare website.

Opportunities for Success

  • By submitting eCQMs to the IQR program, you will meet PI (MU) requirements for EHR submission.
  • Start running CQM reports early to identify problem areas and home in on CQMs that are best suited to your hospital.
  • In spite of CMS’ new “Meaningful Measures” initiative, the actual eCQMs and reporting period requirements are not changing for 2019:  You still choose a minimum of 4 eCQMs for one self-selected calendar quarter.
  • The overall list of hospital CMS eCQM measures in 2019 will stay the same, except for one adjustment:
    • CMS 55 is discontinued in the IQR program, but will remain in TJC (see below).
  •  For 2020, CMS is proposing to remove the 7 eCQMs (highlighted in blue, below) so you may want to take this into consideration when choosing your 2019 eCQMs:

  • For 2021, CMS is proposing to adopt two new opioid-related eCQMs: 
    • Safe Use of Opioids – Concurrent Prescribing eCQM, and
    • Hospital Harm – Opioid-Related Adverse Events eCQM. 

TJC Submission

  • The big news is that next year Joint Commission ORYX vendors will assist hospitals using their Direct Data Submission Platform (DDSP).  Additional communication regarding the transition is supposed to be released this Spring.
  • 2019 Measure selection was due on 12/31/2018. Hospitals that still need to select can do so by contacting .
  • 2019 Measures: (no changes from 2018), hospitals choose a minimum of 4 measures for 1 quarter.
  • We submitted to ORYX for a number of clients and found that the calculations from our CQMsolution software were consistent with TJC across the board.

We hope this helps with your 2019 reporting process and, as always, welcome your feedback.


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