While the proposal won't require hospitals to implement new EHR functionality for the purposes of PI reporting next year, CIOs aren't completely off the hook. That's because CMS proposed significant changes for the electronic clinical quality measure (eCQM) reporting requirements under both PI and the Inpatient Quality Reporting (IQR) program. Specifically, the proposal increases the timeframe and visibility of eCQM data:
Promoting Interoperability (PI) Toolkit
- Hospitals must report two self-selected calendar quarters in 2021, compared to one quarter in 2020. In future years, CMS plans to quickly expand the requirement to three quarters in 2022 and all four quarters in 2023.
- For the first time, CMS will make eCQM data publically available on Hospital Compare—starting with data reported for the 2021 program year.
How the proposed eCQM policies impact CIOs
It's clear that CMS is continuing to move away from paper-based reporting. The proposal "doubles-down" on eCQM quality reporting requirements. CIOs may need to allot additional resources to support their hospitals' efforts to report two calendar quarters of eCQM data in 2021. That means collecting, generating, and validating twice as much eCQM data compared to the requirement in 2020.
At the same time, CMS proposes to make that data publically available on Hospital Compare. Whether eCQMs data reflects well on the hospital can have reputational impact. That means it'll be more important than ever to focus on eCQM data accuracy and performance. Those efforts can be resource-intensive and will require IT leaders to work closely with quality leaders.
Underlying both challenges, uncertainty and limited resources due to Covid-19 will make compliance more difficult. When we've talked to CIOs, the number one thing they want in upcoming regulations is predictable relief and breathing room to meet compliance deadlines as they work to support their hospitals and systems in response to the epidemic.
What CIOs can do now to prepare
In response to this year's IPPS proposal, CIOs should take three actions:
- Submit comments to CMS highlighting timing concerns. Request an extension from CMS if you have concerns about increasing the volume of eCQM data reported next year or the publication of eCQM data to Hospital Compare. Specifically, when it comes to Hospital Compare you may wish to request that CMS consider additional factors in choosing to make eCQM data available to the public. For example, CIOs can ask for more time for data validation and for additional eCQMs to be introduced, since not all hospitals find that the eight available eCQMs are applicable to their patient population.
- Evaluate your current eCQM performance to determine reputation risk. If finalized, eCQM data transparency could be problematic for hospitals that have not yet focused on eCQM data accuracy or performance. It's important to understand your current performance and identify performance gaps to prepare to address any concerns when data is shared publically.
- Start winning buy-in to support interdepartmental eCQM initiatives. This proposal makes clear that CMS wants to increase the use of eCQMs. To support a stronger eCQM initiative, you'll need to work closely with the quality department and secure sufficient resources. This could take some time to establish, so it's best to start winning buy-in now.
The comment period for the proposed rule is open until July 10. We expect the final rule will be published around Sept. 1.
Learn more: 6 key takeaways from the IPPS proposed rule
For broader coverage of the IPPS proposal, view our recent blog post Our 6 takeaways from the 1,602 page Inpatient Prospective Payment System proposed rule.