Clinical Quality Measures for Hospitals

AHIMA Meaningful Use White Paper Series
Paper no. 6b

Papers 5a and 5b in this series reviewed the health IT functionality measures for providers and hospitals as described in the meaningful use final rule. This paper offers an overview of the requirements for reporting clinical quality measures for eligible hospitals and critical access hospitals. A companion paper (6a) provides an overview of the requirements for eligible providers.

One of Congress’s goals in developing the meaningful use program was to improve the quality and efficiency of care for the Medicare and Medicaid populations. Accordingly, hospitals and providers that choose to participate in the voluntary program will be required to capture and report clinical quality measures in addition to the functionality measures they must report to prove they are using EHR technology in a meaningful way.

For purposes of the incentive program, CMS defines clinical quality measures as the “processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for health care such as effective, safe, efficient, patient-centered, equitable, and timely care.”

Stage 1 Clinical Quality Measures for Eligible Hospitals

CMS recognized that “considerable work needed to be done by measure owners and developers” on the clinical quality measures it had put forth in its proposed rule. Such work included completing electronic specifications for measures, incorporating those specifications into EHR technology to capture and calculate the results, and implementing the systems. As a result, CMS identified only 15 clinical quality measures in which clearly defined electronic specifications were finalized by the date of the final rule.

All of the selected measures are endorsed by the National Quality Forum (NQF), a nonprofit organization that ensures clinical quality measures are developed and maintained through a consistent and collaborative process.

CMS did not finalize Medicaid-specific measures as part of the final rule. As a result, all 15 clinical quality measures apply uniformly across both the Medicare and Medicaid EHR incentive programs. The proposed measures for hospitals appear on table 10 of the final rule (beginning on p. 44418).

The table lists the measure identifier, title, description, and owner or developer as well as a link to the electronic specifications. These measures are to apply to all patients, not just those covered in the Medicaid or Medicare programs.

The electronic specifications for the measures, detailed on the CMS Web site, are derived from the certification specifications for EHRs.

Hospitals must report clinical quality measures results to CMS to meet the program requirements. Details on reporting specifications are outlined on the CMS meaningful use Web site.

The requirements take effect September 27, 2010, and no further changes will be made to the list except through further rulemaking. However, CMS may make “administrative and/or technical modification or refinements such as revisions to the clinical quality measures titles and code additions, corrections, or revisions to the detailed specifications for the 2011 and 2012 payment year measures.”

CMS writes that the measures it selected:

  • Facilitate alignment with, or allow determination of satisfactory reporting in other Medicare programs, including Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU), Medicaid, and Children’s Health Insurance Program (CHIP) program priorities
  • Are widely applicable to eligible hospitals based on the services provided for the population of patients seen
  • Promote CMS and [Health and Human Services] policy priorities related to improved quality and efficiency of care for the Medicare and Medicaid populations that will allow the tracking of improvement in care over time
  • Have been recommended to CMS for inclusion in the EHR incentive by federal advisory committees including the Health IT Policy Committee
Proof through Attestation in 2011

In 2011 eligible hospitals will meet the reporting requirements through attestation. As described in the final rule, the process utilizes the same system used for meaningful use attestation.

In 2011 eligible hospitals will attest to the following:

  • The information submitted was generated from an identified certified EHR technology.
  • The information is accurate and complete to the knowledge and belief of the official submitting on behalf of the eligible hospital.
  • The information submitted includes information on all patients to whom the measure applies, for all patients included in the certified EHR technology.
  • The identifying information for the eligible hospital and [critical access hospital].
  • The numerators, denominators, and exclusions for each clinical quality measure result reported, providing separate information for each clinical quality measure including the numerators, denominators, and exclusions for all applicable patients contained in the certified EHR technology irrespective third party payer or lack thereof.
  • The beginning and end dates for which the numerators, denominators, and exclusions apply.

As noted, eligible hospitals are required to report clinical quality measure data on all patients regardless of payer type. Hospitals are only required to report results for each of the clinical quality measures and are not expected to satisfy minimum values for any of the measures. However, a value is required for each of the 15 clinical quality measures, even if the value is zero. For example, a children’s hospital would report zero in instances where it did not have any patients as described in the measure.

Electronic Reporting to Begin in 2012

CMS acknowledges that it cannot require program participants to submit measures electronically until it has the capacity to receive them. CMS does not anticipate it will have that capacity for the 2011 payment year (FY2011); however, it does anticipate that electronic reporting will begin in FY2012.

Any eligible hospital reporting in 2012 will be required to report electronically, whether or not the hospital is in its first or second year of participation in the program. In addition, CMS expects that states will have the capacity to accept electronic reporting of clinical quality measures by their second implementation year. However, if they do not, states may continue to rely on attestation methodology, subject to CMS prior approval via the State’s Medicaid HIT plan.

Duplication of Reporting Requirements

Within the final rule CMS clarifies its intent to avoid and address duplicate or redundant reporting of measures. The clinical quality measures selected for meaningful use stage 1 are not required measures under the RHQDAPU program; however, CMS will address and eliminate duplicative clinical quality measures in future rulemaking, as measures are defined for subsequent meaningful use stages.

CMS also expects to develop a process to solicit public input on Medicaid-specific clinical quality measures for future stages of meaningful use, if needed. However, because there are no Medicaid-specific measures in the stage 1 rule, and all measures apply uniformly across both the Medicare and Medicaid EHR incentive program, CMS did not propose a process at this time.

The next paper in this series will finalize coverage of the final rule and will discuss the processes for demonstrating meaningful use.

Download a PDF version of this paper. For more ARRA resources, visit AHIMA’s Advocacy and Public Policy Center.

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The White Paper Series
1. Overview of the Meaningful Use Final Rule 5b. Measures Reporting for Eligible Hospitals
2. Meaningful Use—Provider Requirements 6a. Clinical Quality Measures for Providers
3. Meaningful Use—Payments and Requirements 6b. Clinical Quality Measures for Hospitals
4. Meaningful Use and EHR Certification 7. Qualifying for Meaningful Use
5a. Measures Reporting for Eligible Providers 8. Preparing for Meaningful Use


1 Comment

  1. Excellent information in a meaningful and digested format. Thank

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