Webinar gives tips on improving next eCQM submissions

Health care compliance professionals who are involved in electronic clinical quality measures (eCQM) submissions should prepare now for their 2017 submissions, according to Catherine Gorman Klug RN, MSN, Director, Quality Service Line, for Nuance Communications. In a Health Care Compliance Association (HCCA) webinar titled, “eCQM Lessons Learned and How to Prepare for 2017 Submissions,” Klug warned attendees about hidden dangers, including the lack of experience for eCQM vendors, inaccurate data submissions, and the challenges posed by multiple types of electronic health record (EHR) data files generated from more than one system. She also gave recommendations for reducing risk and listed sample questions for the information technology (IT) department.

CMS requires hospitals to report eight of 15 eCQMs, with data reported for the entire year. According to Klug, the agency expects “one file, per patient, per quarter,” that includes all episodes for care and measures associated with the patient. Many hospitals use vendors to assist with the eCQM submissions, but Klug noted that vendors must have an adequate amount of time to respond to required changes before submission, and that although many vendors support a broad number of eCQMs, they may lack adequate depth of coverage. Hospitals should choose vendors who are experienced in the eCQMs they are reporting. Further, there is no way to validate the files submitted. Possible consequences include an annual payment update reduction, failure to receive the EHR incentive payment, or poor quality scores on CMS’ Hospital Compare site.

To reduce risks, hospitals should ask the core measures vendor to validate files before submission to CMS. They should also review file error reports from the vendor and make corrections before the data is submitted. Aggregated file error reports should also be reviewed to ensure that formatting or data elements don’t result in an inaccurate submission. Klug said that accurate coding is absolutely essential. Therefore, hospital IT departments should be prepared to explain how files are validated prior to submission to ensure accuracy, and if not, what the remediation strategy is. Further, compliance professionals should request a file error report, and any other reports to help understand the data being submitted.

The Joint Commission 2016 quality report shows gains, emphasizes easier reporting options

Hospitals have made significant progress in meeting quality measures newly added to The Joint Commission’s (TJC) annual report, and many measures have been retired due to hospitals meeting them so successfully. More flexible options for performance reporting that better align with CMS’ Hospital Inpatient Quality Reporting Program were implemented to ease reporting burdens, and TJC is committed to continually providing quality improvement resources for hospitals. In America’s Hospitals: Improving Quality and Safety – The Joint Commission’s Annual Report 2016, measures for inpatient psychiatric services, tobacco use treatment, substance use care, and influenza immunization have shown significant gains.


In 2015, TJC introduced flexible options for reporting electronic clinical quality measures (eCQMs) and chart-abstracted measures. The Pioneers in Quality™ program was introduced and coordinated with the Core Measure Solution Exchange® in order to support hospitals transitioning to eCQM reporting. The Pioneers in Quality program provides resources to hospitals, including educational content, an advisory panel, and outreach. The Core Measure Solution Exchange is a collaborative online network developed for TJC-accredited hospitals to promote performance measurement success stories.


TJC uses a composite score result that sums up individual results into a summary score in order to demonstrate improvement. The overall composite score declined from 97.2 percent in 2014 to 93.7 in 2015 due to the retirement of high-scoring measures, resulting in some difficulty in comparing results.

The inpatient psychiatric services composite score, made up of several underlying measures from admission screening to multiple antipsychotic medication justification, has improved by 3 percentage points since 2011, ending at 90.3 percent for 2015. The stroke care composite score was already high at 94.9 percent in 2011, but has improved to 97.7 percent. Perinatal care scores have improved drastically since 2011, from 53.2 percent to 97.6 percent. Tobacco and substance use treatment and care results have only been measured for two years, but have seen gains of several percentage points in all measures.