Intermountain Healthcare Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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General Comment:
Healthcare facilities strive to support the best outcomes for our patients and communities. The mission statement of
Specific Comments:
Section VIII. A - Hospital Inpatient Quality Reporting (IQR) Program:
Section 9e. Form, Manner and Timing of Quality Data Submission: Reporting and Submission requirement for eCQMs
Intermountain supports the proposal to extend over a period of three years the number of quarters of eCQM data that hospitals will submit. Users of the data, both hospitals and public consumers, will learn more from presentation of trended data on the CMS Hospital Compare site. The majority of hospitals will not see increased burden due to the proposed increase in data submission and implementation of this proposal is likely to promote transparency with the caveat that the quality and accuracy of the eCQM measures have been thoroughly vetted.
Section 10f. Validation of Hospital IQR Program Data: Scoring Processes
Intermountain opposes this year's proposals to combine validation of the chart-abstracted and eCQM measures. Specifically, Intermountain has concerns about the weighting of the total score components. The proposed rule will weight the validation results of the eCQM measures at zero percent and results of the chart-abstracted measures at 100 percent in the total validation score. We suggest that the purpose of validation - to assure accurate and actionable data, whether chart-abstracted or electronically collected data - will not be served by this formula since it gives a pass to the information quality of the eCQMs. Intermountain would support developing instead a validation process and scoring system that identifies and educates on measurement errors equally well whether chart-abstracted or electronically captured in the electronic health record (EHR). Currently the apparent focus of the eCQM validation is hospital facility with the submission process itself and not with information quality. Weighting of the total score at zero and 100 percent would formalize that eCQMs can be less accurate measures and pass up an opportunity by CMS to ensure value to public consumers in hospital performance data.
Secondly, Intermountain takes this opportunity to suggest that eCQM validation by CDAC should be conducted using the electronic medical record. Currently validation is based on hospital-submitted pdfs from the medical-legal chart instead of being based on the QRDA files which have already been submitted. One of our facilities has received CDAC validation comments that clearly indicated that the reviewer was relying on physician documentation rather than on the elements of the electronic medical record which are required in the measure specification. The mismatch of submission and validation sources permits an unreliable validation process.
Finally, Intermountain strongly opposes the proposal for a combined HAC, eCQM and IQR-synchronized validation process on the grounds that this new process would leave hospitals open to devastating impacts on payment determination. Independent validation processes are also less burdensome to hospitals because multiple teams don't have to be deployed to manage the requests in the 30-day window.
Section 12b. Public Display Requirement: Proposed Public Reporting of eCQM Data
Intermountain has deep concerns about the proposed timing of the public reporting of the eCQM measures beginning with the CY 2021 reporting period/FY 2023 payment determination. While Intermountain is committed to transparency on behalf of the communities we serve, we point out that CMS has not shared any national data to date on any of the eCQMs. At this point in time hospitals have not seen national or state performance benchmarks to understand where their performance falls compared to other providers. In the past for other measures proposed for public release, CMS has produced a dry-run report to inform and prepare hospitals. Without a dry-run report for the eCQM data and with only the proposed, brief 30-day window for review of the data quarterly, hospitals will not, for instance, have time to work with vendors to identify how the EHR may be inadvertently contributing to performance differences. Especially in light of the previously discussed limitations of the eCQM validation process which does not reflect quality of the data but only completeness of the submission, Intermountain strongly suggests that the public reporting be delayed until changes in the validation process can be implemented and a dry-run report shared with hospitals.
Section VIII. D - Proposed Changes to the Medicare and Medicaid Promoting Interoperability Programs:
Intermountain thanks CMS for the proposal to continue the EHR reporting period as a minimum of any continuous 90-day period in CY2022 for new and returning participants in the Medicare Promoting Interoperability program and agree that hospitals would benefit from the consistency with CY 2021.
Intermountain also appreciates CMS for recognizing the complexity and still maturing development of the PDMP query. Intermountain supports CMS's proposal to maintain the Query of PDMP measure in CY 2021 as optional and worth 5 bonus points.
Thank you for your consideration of Intermountain's feedback on these measures.
Chief Quality Officer
Office: 801-442-3805
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0052-0002
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