October 2018

HIT Happenings: Quality Data Key to New Payment Rule
By Barbara Antuna, MD, FACEP, ABPM-CI
For The Record
Vol. 30 No. 9 P. 6

In early August, the Centers for Medicare & Medicaid Services (CMS) issued its new payment rule with provisions aimed at advancing patient-centered care. The good news is that the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital Prospective Payment System (LTCH PPS) includes changes to existing requirements and new specifications that should advance this goal.

Foundationally, the nearly 2,600-page rule is designed to advance interoperability and reduce growing administrative burdens placed on providers amid an increasingly complex value-based regulatory front. Among the changes is an overhaul of the Medicare and Medicaid Promoting Interoperability Programs (formerly Meaningful Use).

By eliminating reporting measures that do not fall into the priority areas of "interoperability" and "electronic exchange of information," CMS hopes to alleviate some of the existing reporting pressures placed on providers—a subject of growing discontent across the industry.

In a statement, CMS Administrator Seema Verma said, "We're excited to make these changes to ensure care will focus on the patient, not on needless paperwork. We've listened to patients and their doctors who urged us to remove the obstacles getting in the way of quality care and positive health outcomes. Today's final rule reflects public feedback on CMS proposals issued in April, and the agency's patient-driven priorities of improving the quality and safety of care, advancing health information exchange and usability, and removing outdated or redundant regulations on health care providers to make way for innovation and greater value."

Advancing Interoperability, Patient Access
The new rule aligns with CMS' Meaningful Measures initiative, connecting national programs and goals with the highest priorities for quality measurement as identified by industry stakeholders. Within the new reporting framework, a performance-based scoring methodology consisting of a smaller set of high-impact measures was developed to align with Meaningful Measures parameters. Measures were defined by whether they safeguard public health, are meaningful to patients and providers, reduce burden for providers, and offer significant opportunity for improvement.

The following are the categories of Meaningful Measures:

• Promote Effective Communication and Coordination of Care;
• Promote Effective Prevention and Treatment of Chronic Disease;
• Working With Communities to Promote Best Practices of Healthy Living;
• Making Care Affordable;
• Making Care Safer by Reducing Harm Caused in the Delivery of Care; and
• Strengthening Person and Family Engagement as Partners.

Data interoperability plays an important role in each of these categories, especially in the areas of care coordination and addressing chronic diseases.

In line with this movement, communication and patient access to health data are a focal point of the new Medicare and Medicaid Promoting Interoperability Programs. New policies call for the implementation of the White House–led MyHealthEData initiative introduced earlier this year, which aims to give patients full control of their EHR data by breaking down barriers to health data access and use. For instance, MyHealthEData aims to allow patients to receive discrete data that are critical to their care, share these data with anyone they choose, and put themselves at the center of the health care system.

The 2019 IPPS/LTCH PPS reiterates that all eligible hospitals and critical access hospitals are required to use the 2015 Edition of Certified EHR Technology (CEHRT) beginning with the 2019 EHR reporting period. Notably, updated CEHRT technical requirements focus on interoperability and the ability of patients and care providers to better share health care data through application programming interfaces (APIs).

Other key provisions of the overhaul to the Medicare and Medicaid Promoting Interoperability Programs include the following:

• The EHR reporting period would be a minimum of any continuous 90-day period in each of 2019 and 2020 for new and returning participants attesting to CMS or their state Medicaid agency.
• There are two new ePrescribing measures related to the ePrescribing of opioids (Schedule II controlled substances).

1) The Query of Prescription Drug Monitoring Programs measure will be optional in 2019 and required beginning in 2020 to allow additional time to develop, test, and refine certification criteria and standards and workflows while taking an aggressive stance to combat the opioid epidemic.

2) The Verify Opioid Treatment Agreement will be optional in both 2019 and 2020. CMS believes that extending the optional reporting status will allow health care providers additional time to research and implement methods for verifying the existence of an opioid treatment agreement, expansion of the use of such agreements in practice, and development of system changes and clinical workflows.

Reducing Provider Burden
To address growing frustrations over provider administrative burden, the final rule removes unnecessary, redundant, and process-driven measures from several pay-for-reporting and pay-for-performance quality programs. Specifically, 18 quality measures and 25 duplicate measures were eliminated from reporting programs. In total, CMS estimates that the changes will eliminate more than 2 million hours of work, saving providers about $75 million annually.

While 43 total quality measures were removed from federal reporting programs, only seven are electronic clinical quality measures collected via an EHR system. The following electronic clinical quality measures were eliminated from the Hospital Inpatient Quality Reporting Program as part of Meaningful Measures because the costs associated with each measure outweigh the benefit of its continued use:

• Primary PCI (percutaneous coronary intervention) Received Within 90 Minutes of Hospital Arrival;
• Home Management Plan of Care Document Given to Patient/Caregiver;
• Median Time From ED (emergency department) Arrival to ED Departure for Admitted ED Patients;
• Hearing Screening Prior to Hospital Discharge;
• Elective Delivery;
• Stroke Education; and
• Assessed for Rehabilitation.

Data Quality Moves Center Stage
CEHRT and technology that promotes interoperability and information sharing are an important step toward patient-centered care. Unfortunately, these provisions take the industry only so far—many health care organizations still struggle with the basics of data quality even when these required infrastructures exist.

For example, information needed for accurate quality measures reporting, population health initiatives, and patient engagement often remains "locked" within EHRs and other clinical systems due to the inability of disparate systems to communicate via a common language. Consequently, providers are unable to accurately aggregate all data needed for quality measures reporting or to advance patient engagement initiatives that promote greater sharing of data.

The solution to this conundrum is a "single source of truth" that ensures data coming from disparate systems are normalized to an industry standard for meaningful sharing. The good news is that major strides have been made to implement standards that advance meaningful information exchange. Providers must now advance their data normalization strategies to ensure disparate patient information is cleaned and mapped to these standards for accurate analytics and reporting.

Technology is an important consideration. While EHRs are great repositories of information, they are not designed to address this level of semantic interoperability. Health care organizations need access to infrastructures that support data normalization—addressing both structured and unstructured patient data—to ensure key patient information is not excluded from analytics.

Advanced solutions exist that automate and streamline the complexities of data normalization by addressing the following:

• Content: Establish a single source of truth for all terminology-related maps, value sets, and code sets.
• Applications: Enable interoperability and increase the quality of analytics with mapping support, custom content modeling, and code group management.
• Web-based APIs: Integrate reference data into existing data warehouses or analytics platforms by utilizing a suite of cloud-based APIs.

The 2019 IPPS/LTCH PPS underscores the industry's commitment to advancing patient-centered care. Advancement of interoperability and a smarter approach to quality measures reporting represent a positive shift toward transparency, lower costs, and better outcomes.

— Barbara Antuna, MD, FACEP, ABPM-CI, is a medical informatics specialist at Wolters Kluwer, Health Language/Wolters Kluwer.