Clinical Quality Measures: CAH’s and Eligible Hospitals

1. Clinical Quality Measures: CAH’s and Eligible Hospitals What’s New for 2012 and Beyond

2. CQM Changes • 2012 Reporting Options • Stage II Meaningful Use • 2014 Certified EHR Technology • 2014 and Beyond • Challenges • Resources • Q & A

3. CAH and Eligible Hospital CQM Reporting Options - FY 2012 • Attestation • CQM Results as calculated by certified EHR technology • Submitted via Attestation Tool • EHR Reporting Pilot • Participation Voluntary • Hospital Inpatient Quality Reporting (IQR) Program – MyQualityNet • Both of the Above • Payment will be based on Attestation results

4. Stage II Meaningful Use: S2MU • Proposed Rule Released February 27, 2012 • Published in Federal Register on March 7th • “Public” comment period 60 days • Via HealthBridge REC -http://tristaterec.org/s2mu • “Send us your thoughts!” • Electronically: http://www.regulations.gov • Search: CMS-0044-P • Via Mail: Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-0044-P P.O. Box 8013, Baltimore, MD 21244-8013.

5. Stage II Proposed Changes FY 2012 • Propose 34 Additional Clinical Quality Measures • CQM Measures and Specs: • www.cms.gov/QualityMeasures • CQM’s proposed to be used in Clinical Decision Support Objective – “Implement 5 clinical decision support interventions related to 5 or more of the CQM’s at a relevant point in patient care for the entire report period”

6. Stage II Proposed changes cont.. Beginning FY 2013 • Eliminate Core Measure – “Report hospital clinical quality measures to CMS or, in the case of Medicaid eligible hospitals, the States.” • Clinical Quality Measures will be included in the definition of “Meaningful EHR User”

7. …FY2014 Proposed Changes • Reporting timeline for Stage II begins - FY 2014 • CQM Data submitted electronically via certified EHR • EHR must be certified for “reporting” CQM’s • Report only CQM’s which EHR is explicitly certified for • 49 potential CQM’s (includes pedi, OB & cardiac measures) • Must report on 24 – at least 1 from each domain • Proposed Domains:

8. Proposed Domains • Six Proposed Domains: • Clinical Process/Effectiveness • Patient Safety • Care Coordination • Efficient Use of HealthCare Resources • Patient and Family Engagement • Population and Public Health

9. Reporting and Certified EHR Technology - 2014 • Stage 1 - Reporting Period for First Year of MU • 90 consecutive days • Stage 1 - Submission Period for First Year of MU • Anytime immediate following the end of the 90-day reporting period • NLT - November 30, 2014 (July 1, 2014 to avoid penalty) • Earliest submission period could begin Dec 30, 2013 • Submission Period for Subsequent Years of MU (Stage 1 and Subsequent Stages) • 2 months following the end of the EHR reporting period (October 1 – November 30)

10. 2014 and Beyond FY 2014 Quality Goal • Align all Quality Programs • Hospital Inpatient Quality Reporting (HIQR) • Joint Commission’s Hospital (JCHO) Quality Measures • Goal is to improve quality, not to demonstrate actual improvement Stage III • Promoting improvements in quality

11. Challenges • Vendor’s ability to meet HITSP Technical Requirements by 2014 • Workflows • Interpreting Requirements • Others? • Question?

12. Resources • CMS – Quality Measures Web Site • www.cms.gov/QualityMeasures • National Quality Forum (NQF) • www.qualityforum.org • Hospital Inpatient – EHR Reporting Pilot • http://qualitynet.org • Health Information Technology Standards Panel – Quality Measures Technical Note • http://www.hitsp.org/ • Tri-State Regional Extension Center – Stage II MU Resource • http://Tristaterec.org/s2Mmu