June 24, 2019
Seema Verma, Administrator
Center for Medicare & Medicare Services
7500 Security Blvd.
Baltimore, MD 21244
Attention: CMS-1716-P
Dear Administrator Verma:
Thank you for the opportunity to comment on the proposed inpatient prospective payment system and long-term acute care hospital proposed rule for 2020. The National Committee for Quality Assurance (NCQA) believes your proposal to require electronic health record (EHR) technology certification for all available electronic clinical quality measures (eCQM) is critically important. However, not all such certification is equal.
NCQA’s rigorous certification program builds on NCQA’s extensive quality measurement expertise. It is the only certification program that focuses directly on eCQMs and the only program that conducts testing via multiple use cases for 100% of the logic in each measure to ensure accurate and valid eCQM results.
We therefore urge you to require certification through NCQA’s more rigorous, eCQM-focused program and annual recertification to ensure that systems are up to date.
We also are responding to the request for information on improving EHR efficiency. NCQA is working diligently to move to a system that automatically extracts data for quality measures from EHRs, registries and other electronic sources. This will substantially reduce reporting burden, improve the accuracy of results and allow for more meaningful measures.
We therefore urge you to increase incentives and requirements for electronic reporting and to develop a measure assessing how well EHRs accommodate automatic clinical quality measure data extraction.
Finally, we support adding opioid measures to “Promoting Interoperability” but understand there are concerns with the data elements and logic in the proposed measures that require time to address.
We suggest adding these measures for mandatory reporting, but not including results in public reporting or payment adjustments until testing of the data demonstrates validity and reliability.
Detailed comments on these and other issues in the proposed rule are below.
Certification for eCQMs: The proposal to require EHR technology to have certification for all eCQMs is critically important. However, not all eCQM certification is equal. The Office of the National Coordinator for Health IT’s (ONC) Project Cypress certification tool until recently covered only 80% of each measure’s logic. The current version still covers as little as 95% of the logic, which leaves room for error. Most of the Authorized Testing Laboratories (ATLs) approved by ONC also rely on the Project Cypress tool. Systems certified at 80% do not have to recertify or retest to the upgraded system, nor do they have to validate for new measure specification releases that affect rates.
This is a serious problem, given that measurement results will redirect billions of payment dollars in value-based payment systems and inform the Physician Compare website. Failure to ensure greater accuracy and validity of measurement results could misdirect vast sums of money and severely undermine confidence in the nationwide movement toward paying for value rather than volume.
NCQA is the only ONC-approved ATL with:
- Extensive quality measurement expertise,
- A concentrated focus on eCQM validation with testing via multiple use cases for 100% of measure logic, and
- Mandatory annual recertification for HEDIS®[1] measures to ensure that systems have the proper updates for code-set changes.
NCQA’s ONC-approved testing has been endorsed by both the Premier healthcare alliance and Oklahoma’s MyHealth Access Network.
- Premier stated that NCQA’s program is “considerably more robust and rigorous” and “easier to use” than Project Cypress. That is because we use industry-standard messaging formats, multiple test decks per measure with automated test results, web-based interface to conduct testing and streamlined validation of any discrepancies found.
- MyHealth Access Network stated that NCQA’s program provides “the assurance of validity and the process controls necessary to detect issues early and communicate clearly with interested parties when issues arise.” NCQA’s program is “highly robust” because of our “locked-box” methodology, which ensures integrity of results; industry-standard messaging formats; multiple test decks per measure with automated results; easy to use web-based interface to test and score results; and streamlined validation with a team of experts for any discrepancies.
We therefore urge you to require certification through NCQA’s more rigorous, eCQM-focused program and annual recertification to ensure that systems are up to date.
EHR Efficiency Measures: NCQA is working diligently to translate our clinical quality measures to digital formats and move to a system that automatically extracts data from EHRs, registries and other electronic sources. Moving to automated quality measure reporting is a top priority for NCQA, your agency and many other key stakeholders. Doing so will:
- Substantially reduce the effort required to report measures,
- Improve the accuracy of results and
- Let us develop more meaningful measures with the much richer clinical data in electronic sources that is not in claims used for most reporting today.
However, some EHR technologies and systems do not yet have the capability or sophistication to support automatic data extraction of quality measure data. Providing greater incentives, such as bonus points in value-based payment systems for end-to-end electronic reporting, can help. Developing a measure to assess how well hospital and other electronic system accommodate automatic data extraction, and incorporating it into the Promoting Interoperability category, would provide an additional powerful incentive for health IT systems to develop this ability.
We therefore urge you to increase incentives and requirements for end-to-end electronic reporting.
We further urge you to support development of a measure assessing how well electronic systems accommodate automatic data extraction for clinical quality measures.
We would be happy to work with you to develop such a measure.
Patient-Generated Data: Integrating patient-generated health data into EHRs, using certified EHR technology (CEHRT), is vital for optimizing high-quality patient-centered clinical care and for incorporating more patient-reported outcomes measures (PROM) into value-based payment models.
The rapid growth of patient-generated data—and technology to capture and share it—could improve quality by directly correlating how well a patient’s care meets the patient’s needs directly from patients. Incorporating PROMs and other patient-generated data into EHRs will allow extraction of this valuable information for quality measurement, and thus increase the value and relevance of measurement results. Adding more valuable and relevant measures into value-based payment models will increase their ability to drive quality improvement and make the models more meaningful to patients, clinicians, payers and other stakeholders.
Person-Driven Outcomes Measure: NCQA is developing a person-driven outcome (PDO) measure that is a promising case for capturing patient-generated data. PDOs are goals identified by a patient or their caregiver, such as managing symptoms, staying at home, playing with grandchildren, etc., for use in care planning and quality measurement. The PDO measure can apply to people who are at high risk of bad outcomes, have multiple chronic conditions and/or are near the end of life. Care managers ask individual patients or their caregivers to report progress in meeting their goals (much better, better, as, less than or much less than expected). They enter the data into an iPad app, which an EHR could upload.
Measuring how well care meets goals patients have chosen—as opposed to narrow clinical goals that may not have relevance to them—is much more patient-centered. It also can help to motivate patients to be more engaged in their own health and health care because they understand how it relates to what matters most to them in goals they identified themselves.
Pilot testing shows that the PDO measure is feasible, adds value to care planning, appears to increase patient activation and could improve outcomes. Once ready for public use, it can help support value-based payment initiatives targeting more complex patient populations.
EHR Safety: We support use of “SAFER” guidelines to promote EHR safety. SAFER provides a thorough checklist for inpatient facilities and systems (although it is not likely appropriate for many ambulatory care settings). We suggest, however, requiring vendors and health systems to proactively test with SAFER as they implement EHRs or make any changes or upgrades.
Opioid Measures: We support including measures in the Promoting Interoperability category to address the opioid crisis and have made development and use of opioid-related measures a priority in HEDIS. We understand from other stakeholders, however, that data elements and logic in the proposed eCQMs (Mandatory Reporting of the Safe Use of Opioids—Concurrent Prescribing and Hospital Harm—Opioid-Related Adverse Events) are highly complex. It will take time to map the necessary data elements from EHRs to the appropriate format and to learn how to collect and transmit such data.
We suggest adding these measures for mandatory reporting, but not including results in public reporting or payment adjustments until testing of the data demonstrates validity and reliability.
Thank you again for the opportunity to comment on the draft. If you have any questions, please contact NCQA Director of Federal Affairs, Paul Cotton, at (202) 955-5162 or cotton@ncqa.org.
Sincerely,
Margaret E. O’Kane
President
[1] HEDIS, the Healthcare Effectiveness Data and Information Set, is a registered trademark of NCQA.