Download - Meaningful Use + HIM = Quality Informatics
Meaningful Use + HIM = Quality Informatics
Phyllis A. Patrick, MBA, FACHE, CHC, CISM
Phyllis A. Patrick & Associates LLC
May 9, 2014
TopicsOverview of the Meaningful Use Program
Key Elements of an Effective MU Program
Role of HIM in Meaningful Use
The Ultimate Goal: Quality Informatics
Q & A/Discussion
2Phyllis A. Patrick & Associates LLC
Overview of the Meaningful Use Incentive Program
CMS and ONC Strategic Objectives
Certification Basics
Regulatory Requirements
Federal and State Programs
The 3 Stages of Meaningful Use
Risks and Challenges for Hospitals and Providers
Security Risk Analysis – The “Weak” Link – what is required?
3Phyllis A. Patrick & Associates LLC
The Vision for Health ReformHealth Care will be:
Patient-centered Evidence-based Prevention-oriented Efficient Equitable
Not “investments in technology, but efforts to improve health of Americans and performance of their health care system.”
4Phyllis A. Patrick & Associates LLC
CMS Goals
Improve quality, safety, and efficiency of health care and reduce health disparities
Engage patients and families
Improve care coordination
Improve population and public health, and
Ensure adequate privacy and security protections for personal health information.
5Phyllis A. Patrick & Associates LLC
Defining Meaningful Use
An EHR user must meet the following requirements:• Use of certified EHR technology in a
meaningful manner (e.g. e-prescribing)
• Use of certified EHR technology for electronic exchange of health information to improve quality of healthcare, such as promoting care coordination
• Use of certified EHR technology to submit Clinical Quality Measures (CQH) and other measures in a form & manner specified by the Secretary of HHS
6Phyllis A. Patrick & Associates LLC
Benefits of EHRs
Complete and accurate information Providers will know more about their patients and their health
history before they walk into the exam room.
Better access to information Facilitates greater access to the information providers need to
diagnose health problems earlier and improve health outcomes of their patients.
Information can be shared more easily among doctors, hospitals, and across systems, leading to better care coordination.
Patient empowerment Patients will play a more active role in their health and in the
health of their families. Patients can receive electronic copies of their medical records
and share their health information securely over the Internet with their families and others.
7Phyllis A. Patrick & Associates LLC
8
Federal Health Information
Technology Strategic Plan 2014 –
2018
Phyllis A. Patrick & Associates LLC
Beyond Meaningful Use of Data
Quality Reporting
Research – Secondary use of EHR data
Comparative Effectiveness Research Comparing treatment outcomes in two or more groups
taking different drugs this could negate requirement for large clinical trial recruitment
Platform for clinical trial recruitment use of clinical decision support alerts may increase enrollment
Increase sample sizes improve reliability and integrity of data
Recording of adverse events early identification of side effects not identified during clinical trials (integrating adverse event reporting into EHR workflow)
9Phyllis A. Patrick & Associates LLC
Facilitating Factors
Standards Interoperability
“When EHR vendors were initially approached with the ‘opportunity’ to add a new service for the research community, most of them figured out fairly rapidly that this was not a wise business decision. At that time, they realized that they would have to extract data and map them to every requested format, which varied by research study sponsor; or, the EHR system would need to be configured differently for each research study or research sponsor—not very feasible. In addition, there was a perception that the entire EHR would have to be validated to meet Good Clinical Practices (GCPs) and other regulations required of biopharmaceutical development companies such as 21CFR Part 11 in the U.S.—another relatively impossible option.”
R. D. Kush, Interoperability Review: EHRs for Clinical Research, American Medical Informatics Association, Winter 2011-2012, Vol. 2 No. 2.
10Phyllis A. Patrick & Associates LLC
Certification of EHRsONC and CMS post most-up-to-date list of EHR
products used for attestation to the CMS EHR Incentive Program at www.healthIT.gov
Dataset (April 2011 to present, updated monthly) intended for use by hospitals, physicians, researchers and other interested parties to “explore and apply data in the context of the growing trends in Health IT adoption…”
Capability to analyze at State levels and to view monthly trends.
11Phyllis A. Patrick & Associates LLC
Certification of EHRs: The Basics
1.Focus certification on Meaningful Use.
2.Leverage the certification process to improve progress on privacy, security, and interoperability.
3. Improve the objectivity and transparency of the certification process.
4.Expand certification to include a range of software sources, e.g., open source, self-developed, etc.
5.Develop a certification transition (short-term to long-term).
Privacy and Security: Consistent themes throughout regulations and guidance.
12Phyllis A. Patrick & Associates LLC
Privacy and Security ProtectionFederal Health Information Technology Privacy
Committee (HITPC) and Privacy and Security Tiger Team developed Stage 2 and Stage 3 recommendations for the health outcome priority – “ensure adequate privacy and security protections for personal health information.”
Phyllis A. Patrick & Associates LLC 13
Regulatory Requirements ARRA HITECH HIPAA and Omnibus ACA EHR Incentive Programs Final Rule HIT: Initial Set of Standards, Implementation
Specifications and Certification Criteria for EHR Technology Interim Final and Final Rules
Establishment of Temporary Certification Program for HIT Final Rule
Establishment of Permanent Certification Program for HIT Final Rule
Breach Notification Rule HIPAA Privacy and Security Rules Modifications to the HIPAA Privacy, Security, and
Enforcement Rules under the HITECH Act Proposed Rule
HIPAA Privacy Rule Accounting of Disclosures under the HITECH Act Proposed Rule (in limbo!)
Phyllis A. Patrick & Associates LLC 14
Roots in HITECHThe Health Information Technology for Economic
and Clinical Health (HITECH) Act provides the Department of Health & Human Services (HHS) with the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health IT, including electronic health records and private and secure electronic health information exchange.
15Phyllis A. Patrick & Associates LLC
4 Key Regulations
Regulations define meaningful use (2) Incentive Program for Electronic Health Records (issued
by CMS) – define minimum requirements that providers must meet through their use of certified EHR technology in order to qualify for payments for stages 1 and 2 of meaningful use.
Regulations identify technical capabilities required for certified EHR technology (2) Standards and Certification Criteria for Electronic
Health Records (issued by ONC) – identify standards and certification criteria for the certification of EHR technology, so eligible professionals and hospitals may be assured that the systems they adopt are capable of performing the required functions.
16Phyllis A. Patrick & Associates LLC
Regulations and StatutesAmerican Recovery & Reinvestment Act (February
2009) Medicare & Medicaid Electronic Health Record (EHR)
Incentive Program Notice of Proposed Rulemaking (NPRM) and Final Rule (July 28, 2012)
Stage 2 Meaningful Use Final Rule (August 23, 2012)Security Risk Analysis – 45 CFR 164.308(a)(1) (April,
2005)Health Information Technology for Economic and
Clinical Health (HITECH) Law – Interim Final Rule (February, 2009)
Omnibus Rule (January, 2013, Effective September 23, 2013)
17Phyllis A. Patrick & Associates LLC
Implications of the Final Rule (EHR Incentive Program)
Harmonizes MU criteria across CMS programs as much as possible
Closely links with ONC Certification and Standards Final Rules
Builds on recommendations of HIT Policy Committee and Public Commenters
Coordinates with existing CMS Quality Initiatives
Provides a platform that allows for staged implementation of EHRs over time
18Phyllis A. Patrick & Associates LLC
Key Players
CMS - Centers for Medicare & Medicaid Services• Established EHR Incentive Program (formal rule making) • Rule provides parameters and requirements for Medicare &
Medicaid EHR Incentive Programs
ONC - The Office of the National Coordinator for HIT• Resource to support adoption of Health Information
Technology (HIT) and promotion of nationwide Health Information Exchange (HIE) to improve health care
OCR - Office for Civil Rights• Responsible for HIPAA Enforcement (Privacy & Security)
19Phyllis A. Patrick & Associates LLC
Other Key PlayersQuality Reporting Groups
The Joint Commission – hospital quality measures Hospital Inpatient Quality Reporting (HIQR) Physician Quality Reporting System (PQRS) CMS Shared Savings Program National Council for Quality Assurance (NCQA)
Others?
20Phyllis A. Patrick & Associates LLC
Incentive Money for Meaningful UseMedicare EHR Program
Participation started FY 2011
EPs may receive up to $44,000 over 5 years
Must begin by 2012 to get maximum funds
Incentives for hospitals began in 2011 w/ $2 million base payment
Medicare EPs, hospitals and CAHs who do not show meaningful use have payment decrease beginning 2015
Medicaid EHR Program
Voluntarily offered by individual states
Began 2011; States on board 2012
EPs may receive up to $63,750 over 6 years
Incentives for hospitals began 2011
No payment adjustment for providers who do not show meaningful use
21Phyllis A. Patrick & Associates LLC
Eligibility – Medicare & MedicaidThe EHR Incentive Programs are available for
Medicare and Medicaid eligible professionals.
There are two (2) programs: a Medicaid EHR Incentive Program and a Medicare EHR Incentive Program.
Although the two programs are similar in many ways, there are also some differences between them.
Eligible professionals can only participate in one of the programs. If an eligible professional chooses to participate in the Medicaid EHR Incentive Program, then she or he can participate in only one state’s incentive program in any given year.
22Phyllis A. Patrick & Associates LLC
Clinical TransformationMU represents the means of clinical
transformation – managing information for better care, safer care, more effective and efficient care.
Stages 1 – 3 of MU progress from capture of health information and reporting of QCM and public health data (Stage 1) to information exchange and decision support (Stage 2) to systematic health care improvement (Stage 3).
24Phyllis A. Patrick & Associates LLC
Key Elements of an Effective MU Program
Governance
Interdisciplinary Process
Program Goals
Financial Reporting and Reconciliation
Outcomes Reporting – Plan for Quality Reporting Alignment
Documentation
Security Risk Analysis/Risk Management
25Phyllis A. Patrick & Associates LLC
GovernanceMonitoring, tracking, and managing compliance with
the various and ever-changing requirements requires a concentrated focus and effort.
A successful meaningful use program requires three foundational work streams:
incentive program compliance
organization performance, and
electronic health record (EHR) enhancement
The Meaningful Use Program requires comprehensive coordination and oversight to ensure current compliance and to establish capabilities for future health reform initiatives.
Charter Statement is important.26Phyllis A. Patrick & Associates LLC
Interdisciplinary ProcessSenior leader as sponsor and champion.
This is not an IT initiative.
Clinical leadership is key.
Areas involved should include: medical, nursing, and clinical staff; ancillary services; quality/performance improvement; risk management; legal services; information security and privacy; finance; health information management; practice managers, information technology; and other key stakeholders.
27Phyllis A. Patrick & Associates LLC
Consider adopting the following ….
Seek knowledge. People who are resilient are always curious, excited about life, and wanting to know more. They embrace the unknown and want to feel more knowledgeable about the world.
The more you know, the more equipped you are to deal with challenges and to be able to vision opportunities.
Ask questions!
29Phyllis A. Patrick & Associates LLC
Program GoalsFlow from the Charter and Governance Structure
Relate to organizational Mission, Vision, Values
Foundation in strategic plan, IT plans, quality plans
Outcomes reporting and plans for measures reporting alignment
Ongoing auditing and monitoring
Coordinating/directing activities for internal compliance audits
Managing preparation and responses to external compliance audits
Align MU improvement initiatives with current and future organizational quality initiatives.
30Phyllis A. Patrick & Associates LLC
Financial Reporting and Reconciliation
EHR technology is not critical to the delivery of patient services.
Incentive payments are similar to revenues derived from sources other than providing healthcare services.
How can management determine whether there is reasonable assurance that meaningful use has been or will be achieved for a particular period?
Set aside for contingency/pay-back?
HFMA Issues Paper (2011) Contingency Model IAS Grant Accounting Model
31Phyllis A. Patrick & Associates LLC
Outcomes Reporting/Clinical Quality Measures
CMS selected CQMs to align with DHHS’ National Quality Strategy priorities for health care quality improvement.
CMS Quality Domains: Patient and Family Engagement Patient Safety Care Coordination Population and Public Health Efficient Use of Healthcare Resources Clinical Processes/Effectiveness
32Phyllis A. Patrick & Associates LLC
Quality Professionals Need to be Involved
Stage 2 goals focus on ensuring that the meaningful use of EHRs supports the priorities of the National Quality Strategy. Use of Health IT for continuous quality improvement at
point of care Exchange of information in a structured format
Health Information Exchange requirements: E-prescribing becomes more demanding Structured lab results need to be incorporated Electronic transmission of patient care summaries to
support transitions in care across unaffiliated providers settings and disparate EHR systems.
INFORMATION FOLLOWS THE PATIENT.
33Phyllis A. Patrick & Associates LLC
OIG Interest in MU
“Early Assessment Finds that CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program”
HHS, OIG, November 2012.
Included review of self-reported MU use of certified EHR technology.
Phyllis A. Patrick & Associates LLC 34
OIG’s Comments
“CMS faces obstacles to overseeing the Medicare EHR incentive program that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements…. CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments post-payment is also limited.” (2012 Report)
35Phyllis A. Patrick & Associates LLC
OIG’s 2014 Report
CMS AND ITS CONTRACTORS HAVE ADOPTED FEW PROGRAM INTEGRITY PRACTICES TO ADDRESS VULNERABILITIES IN EHRs January 2014
“CMS and its contractors had adopted few program integrity practices specific to EHRs. Specifically, few contractors were reviewing EHRs differently from paper medical records. In addition, not all contractors reported being able to determine whether a provider had copied language or over-documented in a medical record. Finally, CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities. “
36Phyllis A. Patrick & Associates LLC
Vendor Technology Stability
Vendors under increasing pressure to deliver changes for Stages 2 and 3.
Providers need to stay in contact with vendors and understand their delivery timelines and limitations.
Due diligence and documentation re. vendor challenges and any failures to meet criteria.
Providers should not rely on vendors to perform risk analysis or substantiate that all criteria are met.
Management, clinicians, IT, and others need to be on same page.
37Phyllis A. Patrick & Associates LLC
Additional Resources Are Needed
MU is an ongoing, dynamic PROGRAM, not just a source of funds.
This is not another IT project.
Don’t assume that technology can lead to FTE reductions.
Support for MU will require additional resources. Key issues will include: Vendor management Implementation of software changes and system
modifications Infrastructure changes Interface development and maintenance Need for sound change management procedures Interface with HIEs and other provider organizations
38Phyllis A. Patrick & Associates LLC
Security Risk Analysis and Risk Mitigation:
Meeting Privacy & Security Requirements
39Phyllis A. Patrick & Associates LLC
The Weak Link: HIPAA RA/RM Requirements
“… conduct an accurate and thorough analysis of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI. Once have you completed the risk analysis, you must take any additional “reasonable and appropriate” steps to reduce identified risks to reasonable and appropriate levels.” (45 CFR 164.308(a)(1)(iii))
40Phyllis A. Patrick & Associates LLC
Security in Stage 2Core Objective 15
Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.Note: the preamble specifically addresses
encryption/security of data stored in Certified EHR Technology, and notes that a review of the assessment must be conducted each EHR reporting period.
Expectation is that security will evolve and change as needs change.
Expectation of robust security.
41Phyllis A. Patrick & Associates LLC
Stage 1 vs. Stage 2
Objective: Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities.
Security Risk Analysis must be conducted during each reporting period for Stage 1, Stage 2, and Stage 3.
42Phyllis A. Patrick & Associates LLC
Measure: Stage 1 vs. Stage 2Stage 2: Eligible professionals (and hospitals)
need to meet the same security risk analysis requirements as Stage 1, but must also address the encryption/security of data at rest.
43Phyllis A. Patrick & Associates LLC
Ensure Security Risk Analysis was conducted…..
Perform or review existing Security Risk Analysis of your certified EHR technology Do you have copies of your vendor’s security
policies? Has testing been thorough and documented
any potential security issues have been “fixed”?
Have you/vendor made any security updates (e.g., updated certified EHR software)?
Have you/vendor corrected any security deficiencies (workflow, storage, etc.)?
44Phyllis A. Patrick & Associates LLC
Additional Precautions
Don’t attest for EHR Incentive Program until you have conducted the security risk analysis (or reassessment) and developed a risk mitigation plan to correct any deficiencies identified during the risk analysis. You must implement the plan, which can be phased, but needs to be clear and documented.
Document changes/corrections in the security program.
Update policies as appropriate to reflect changes and improvements.
Communicate policies and changes.
45Phyllis A. Patrick & Associates LLC
Keep in mind….When a provider attests to meaningful use, it is
a legal statement that the provider has met the specific standards, including protecting electronic health information.
46Phyllis A. Patrick & Associates LLC
False Claim “Engaging in a conspiracy to defraud by the
improper submission of a false claim”
FCA strengthened by: Fraud Enforcement and Recovery Act (2009) -
redefined “obligation” to include “retention of any overpayments”
Patient Protection and Affordable Care Act (2010) - “… a person need not have actual knowledge … or specific intent to commit a violation” Providers will not be able to successfully argue that they did not know.
47Phyllis A. Patrick & Associates LLC
Recoupment of Funds
Failure to meet one (1) of the criteria can result in recoupment of all payments.
Some providers’ incentive funds been recouped and some have self-disclosed and paid monies back.
Be aware CMS has noted that “several providers” have been referred for possible fraud investigations, through direct reports to CMS.
48Phyllis A. Patrick & Associates LLC
Potential Bumps in the Road… The Attestation Process
“If you attest prior to actually meeting the meaningful use security requirement, you could increase your business liability for federal law violations and making a false claim. From this perspective, consider implementing multiple security measures as feasible, prior to attesting. The priority would be mitigating high-impact and high-likelihood risks.”
ONC Guide to Privacy and Security of Health Information
49Phyllis A. Patrick & Associates LLC
Final Statement in Attestation “I certify that the foregoing information is true,
accurate and complete. I understand that the Medicare/Medicaid EHR incentive program payment I requested will be paid from Federal Funds, that by filing this … claim for Federal Funds, and the use of any false claims, statements, or documents, or the concealment of a material fact used to obtain Medicare/Medicaid EHR incentive program payment, may be prosecuted under Federal or State criminal laws and may also be subject to civil penalties.”
50Phyllis A. Patrick & Associates LLC
Between You and Your Contractor…
If during attestation, you or your EHR contractor answered “yes” that you were in compliance with this MU criteria without first ensuring complete compliance with the Security Rule Risk Analysis requirements, not only is your incentive payment at risk, but you also may be subject to liability under the Federal False Claims Act.
51Phyllis A. Patrick & Associates LLC
The MU Audit ProgramThe Basics
Federal and State Programs
2014 and Beyond: What can we Expect?
45 CFR Section 164.308(a)(1)(ii)
52Phyllis A. Patrick & Associates LLC
Meaningful Use Audit Process Pre- and post-payment
audits (January 2013 )
Edit checks in EHR systems
Documentation audits
Source documents required
Appeals process (888-734-6433)
Comprehensive audits
Payment recoupment
53Phyllis A. Patrick & Associates LLC
Figliozzi & Company
Desk audits
Post payment audits for EPs and EHs
Pre payment audits for EPs
Candidate for audit after meeting MU for full year
Turnaround time for audit results can vary: Extent of audit activity at the time Degree to which your documentation submission is complete
CMS Audit Activity To Date
54Phyllis A. Patrick & Associates LLC
Supporting Documentation Required for pre- and post-payment audits
Must support meaningful use and clinical quality measure data that is submitted
All source material (paper and electronic) must be saved for at least 6 years from attestation
If using hospital cost report data, follow data retention policies and process
Documentation must support payment calculations (hospitals)
Reports must come directly from the certified EHR system/modules.
Don’t rely on vendor for documentation!
57Phyllis A. Patrick & Associates LLC
Additional Supporting Documentation
Primary documentation should include Numerators and denominators used for the
measures Time period the report covers Evidence to support that the report was generated
for the eligible hospital, eligible provider (NPI, CCN, provider name, practice name)
Documentation that demonstrates how data was accumulated and calculated.
58Phyllis A. Patrick & Associates LLC
Source Documents
Audit logs
Screen shots
Letters received from public health agencies
Summary of data that supports the information entered during attestation
59Phyllis A. Patrick & Associates LLC
Good Documentation Practices
Maintain all documentation for at least 6 years.
Review all supporting documentation for attestations, CQMs, payment verification, etc. BEFORE any audit request.
If contractor was used for Attestation process, review supporting documentation on a regular basis. Ask questions. Make sure you have all documentation.
60Phyllis A. Patrick & Associates LLC
Good Documentation Practices (Cont’d)
Verify that incentive payments were accurate (possible over-payments or under-payments).
Make sure you have proxy permission from your EPs to attest on their behalf.
SAVE EVERYTHING!
61Phyllis A. Patrick & Associates LLC
Future Audit Processes
Figliozzi current contract for 3 years (2012 – 2015).
Will CMS use another contractor for next phase?
Next phase will be more robust and comprehensive.
May be process oriented, include analysis of quality reporting, testing of EHR systems, etc.
MU is a dynamic, ongoing program and process!
62Phyllis A. Patrick & Associates LLC
Participation is key! Governance – Steering Committee and decision-making
processes
Documentation Policies and Practices – implementation and advisory roles
Security Risk Analysis/Mitigation requirements – advocate and participant roles
Menu Set Criteria/Measure Selection for hospital and eligible professionals
Tracking requirements and regulatory changes
Knowledge of data collection, data aggregation, data integrity issues
Interface with and train clinicians
Clinical Quality Measures – participation in strategy and working with Quality Officer/Performance Improvement group reporting and advisory
64Phyllis A. Patrick & Associates LLC
EHR: A Platform for QualityEHR Functionality is the beginning, not the
endpoint.
The quality of data and what providers do with the EHR is important and has to be carefully planned and vetted.
EHRs can be used to improve care. When will we get there? How do we get there?
Understanding the “BIG Picture” is key!
65Phyllis A. Patrick & Associates LLC
Quality Informatics
“the study of use of information in understanding and improving the quality and safety of health care. It seeks to measure the quality of health care.”
66Phyllis A. Patrick & Associates LLC
The “Classic” Quality Measurement Model
67
Donabedian, A., The 7 Pillars of Quality
Crossing the Quality Chasm, Institute of Medicine 2001
Phyllis A. Patrick & Associates LLC
Quality Programs – How many?Hospital Inpatient Quality Reporting HIQR)
The Joint Commission
Physician Quality Reporting System (PQRS)
CMS Shared Savings Program
National Council for Quality Assurance (NCQA)
Children’s Health Insurance Program Reauthorization Act
69Phyllis A. Patrick & Associates LLC
CMS Goals and Plans for Alignment
Hospitals may voluntarily submit clinical quality measure data electronically, beginning in 2014.
CMS Goal: to simultaneously satisfy quality reporting requirements for both Medicare EHR incentive program (MU) and Hospital Inpatient Quality Reporting programs.
Hospitals benefit: Collaboration among multiple teams and departments May reduce costs (reductions in chart abstraction
activities) Reduced regulatory reporting burden
70Phyllis A. Patrick & Associates LLC
Reporting for Eligible Professionals
“For EPs, we proposed a set of 12 clinical quality measures beginning in 2014 that align with existing quality programs such as measures used for the Physician Quality Reporting System (PQRS), CMS Shared Savings Program, and National Council for Quality Assurance (NCQA) for medical home accreditation, as well as those proposed under Children’s Health Insurance Program Reauthorization Act.”
“For eligible hospitals and CAHs, the set of 24 CQMs we proposed beginning in 2014 would align with the Hospital Inpatient Quality Reporting (HIQR) and the Joint Commission’s hospital quality measures.”
71Phyllis A. Patrick & Associates LLC
Harmonization of Quality Reporting
CMS goal is to harmonize all quality reporting programs with EHR electronic reporting.
In 2014 simultaneous reporting is voluntary. At some point (TBD), CMS will make this mandatory.
How are hospitals and physicians preparing???
72Phyllis A. Patrick & Associates LLC
Decisions Hospitals Must MakeWhen to begin to align CQM and MU reporting, i.e. in
2014 or continue to report measures separately
Separate reporting requires submission of 57 CQMs for calendar year via chart abstraction and 16 CQMs for selected reporting period via CMS attestation portal for MU
Alignment of reporting between the 2 programs – EHR incentive program requires reporting for 1 quarter
of patient-level data for 16 CQMs electronically and Inpatient Quality Reporting CQMs requires electronic reporting of 57 inpatient measures via chart abstraction
FY 2014 IPPS Final Rule, pages 50811-50819
73Phyllis A. Patrick & Associates LLC
Quality Reporting is a Strategic Decision
What resources and capabilities does the hospital have to align and report measures simultaneously?
What is the organization’s strategy on quality reporting? Are the different reporting requirements centralized and coordinated?
How does data align across departments? How is data integrity addressed with quality reporting requirements?
Is the EHR capable of creating and submitting reports for the various requirements?
What is the organization’s plan for simultaneous reporting - need to balance competing priorities and resources?
How do quality reporting, EHR development, and clinical priorities fit with the organization’s overall strategic plans and goals?
74Phyllis A. Patrick & Associates LLC
Security | Privacy | Culture
Phyllis A. Patrick, MBA, FACHE, CHCPhyllis A. Patrick & Associates LLC
914-696-3622
77