eMeasurement of Health Data for Quality, eCQM Adoption Issues

eMeasurement is the application of electronic health data for quality improvement has not yet been realized. Quality is the objective, but technology ability, education of clinician and administrative staff, and alignment of incentives must come first. Electronic clinical quality measurement (eCQM) is another label that CMS has placed on the eMeasurement initiative. eMeasurement will require a lot of change the health care industry, but alignment of incentives isn’t as clear as it was with Meaningful Use of electronic health records. Before one becomes taken with this next wave of change, remember that clinical documentation improvement (CDI) initiatives, which ensure enough uniform data exists, is another precursor.

The development of the electronic highway of health data is still in its infancy. It took over $30 billion in ARRA HITECH Act stimulus funds to allow the switch to Electronic Health Records. As a result, quality initiatives are coming to the forefront. There are opportunities, but not with the same degree of financial incentives to quickly move to eMeasurement.

eMeasurement innovation examples:

1. eMeasurement data warehouses that truly combine and allow useful claims and clinical data for eCQM insights.
2. eMeasurement data validation to ensure standardized data types that can be analyzed for eCQM. 
3. eMeasurement of unstructured data using natural language processing (NLP).

Two significant challenges to realizing eMeasurement include:

1. eMeasurement is different for the payor and the provider. Payor data is well structured while clinical data is standardized within provider’s and their EHR but not as easily across multiple providers. Until standard HIPAA EDI claims transactions were mandated (and recently updated with HIPAA 5010), this did not occur on the payor side. This, most likely, will need to occur on the provider side.
2. eMeasurement is different, depending on the patient setting. 

Data exchange via DIRECT messaging is one standard that is clearly defined. ARRA HITECH Act meaningful use imperatives of Core Measures for Stage 1 and Stage 2 are also expressed. 

Real World Example of eMeasurement Adoption Challenges – Diabetic patients

It is no secret that diabetic patients can be costly to care for unless care is properly coordinated. CMS policy, dating back to risk adjustment for Medicare Part C, included a focus on diabetics. It then added diabetics with co-morbid conditions (CC) or major co-morbid conditions (MCC).  If we look at the ICD-10 code E08.22 – Diabetes mellitus due to underlying condition with diabetic chronic kidney disease and the related MIPS Quality Measure.

 The Merit-based Incentive Payment System (MIPS) is part of the Quality Payment Program (QPP), which was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  It replaced the Physician Quality Reporting System (PQRS) beginning in the performance year 2017.  Quality, which is one category of MIPS, can be reported if an eligible CPT or ICD-10 code is reported for an encounter.  Learn more about MIPS at qpp.cms.gov.

The MIPS associated quality measure is #119 Diabetes: Medical Attention for Nephropathy.  This measure,  which was initially part of PQRS, may be reported six different ways as part of the Diabetes Mellitus Group.  The numerator is, “The denominator is, “Patients 18 through 75 years of age who had a diagnosis of diabetes with a visit during the measurement period.”  The denominator is, “Patients with a screening for nephropathy or evidence of nephropathy during the measurement period (nephropathy screening test or evidence of nephropathy).” 

The performance measure is, 

Performance Met: CPT II 3060F: Positive microalbuminuria test result documented and reviewed
Performance Met: CPT II 3061F: Negative microalbuminuria test result documented and reviewed
Performance Met: CPT II 3062F: Positive macroalbuminuria test result documented and reviewed
Performance Met: CPT II 3066F: Documentation of treatment for nephropathy (eg, patient receiving dialysis, patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a nephrologist)
Performance Met: G8506: Patient receiving angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy

Nephropathy Screening not Performed, Reason not Otherwise Specified

Append a reporting modifier (8P) to CPT Category II code 3060F or 3061F or 3062F to report circumstances when the action described in the numerator is not performed and the reason is not otherwise specified.
Performance Not Met: 3060F or 3061F
or 3062F with 8P: Nephropathy screening was not performed, reason not otherwise specified

 We presume that eMeasurement and eCQM will have to comprehend and prioritize all of the following reporting methods for #119:

1. Claim 
2. Group
3. Registry
4. EHR 
6. Survey

Each year, the Centers for Medicare & Medicaid Services (CMS) updates the electronic Clinical Quality Measures (eCQMs) for potential inclusion in CMS quality reporting eMeasurement program.  All of these require EHR usage for providers.  

Conclusion: It is very early in the eMeasurement and eCQM Game.

When we watched a recent CMS presentation from the Office of the National Coordinator for Health IT, we sensed a bit of hesitation from the webinar speakers about what this all really means. That tells us it is truly early going in the eMeasurement and eCQM game.

Image Credit:
The Office of the National Coordinator for Health Information Technology. (2016, April 19). Interoperability Measurement for the MACRA Section 106(b) [Digital image]. Retrieved June 12, 2017, from https://dashboard.healthit.gov/evaluations/library.php

Electronic Medical Records
Expert witness for Medical Billing Coding
CMS Merit Based Incentive Payment System (MIPS) in 60 Day Comment Period, Sunsetting of Meaningful Use

Michael F. Arrigo

Michael Arrigo, an expert witness, and healthcare executive, brings four decades of experience in the software, financial services, and healthcare industries. In 2000, Mr. Arrigo founded No World Borders, a healthcare data, regulations, and economics firm with clients in the pharmaceutical, medical device, hospital, surgical center, physician group, diagnostic imaging, genetic testing, health I.T., and health insurance markets. His expertise spans the federal health programs Medicare and Medicaid and private insurance. He advises Medicare Advantage Organizations that provide health insurance under Part C of the Medicare Act. Mr. Arrigo serves as an expert witness regarding medical coding and billing, fraud damages, and electronic health record software for the U.S. Department of Justice. He has valued well over $1 billion in medical billings in personal injury liens, malpractice, and insurance fraud cases. The U.S. Court of Appeals considered Mr. Arrigo's opinion regarding loss amounts, vacating, and remanding sentencing in a fraud case. Mr. Arrigo provides expertise in the Medicare Secondary Payer Act, Medicare LCDs, anti-trust litigation, medical intellectual property and trade secrets, HIPAA privacy, health care electronic claim data Standards, physician compensation, Anti-Kickback Statute, Stark law, the Affordable Care Act, False Claims Act, and the ARRA HITECH Act. Arrigo advises investors on merger and acquisition (M&A) diligence in the healthcare industry on transactions cumulatively valued at over $1 billion. Mr. Arrigo spent over ten years in Silicon Valley software firms in roles from Product Manager to CEO. He was product manager for a leading-edge database technology joint venture that became commercialized as Microsoft SQL Server, Vice President of Marketing for a software company when it grew from under $2 million in revenue to a $50 million acquisition by a company now merged into Cincom Systems, hired by private equity investors to serve as Vice President of Marketing for a secure email software company until its acquisition and multi $million investor exit by a company now merged into Axway Software S.A. (Euronext: AXW.PA), and CEO of one of the first cloud-based billing software companies, licensing its technology to Citrix Systems (NASDAQ: CTXS). Later, before entering the healthcare industry, he joined Fortune 500 company Fidelity National Financial (NYSE: FNF) as a Vice President, overseeing eCommerce solutions for the mortgage banking industry. While serving as a Vice President at Fortune 500 company First American Financial (NYSE: FAF), he oversaw eCommerce and regulatory compliance technology initiatives for the top ten mortgage banks and led the Sarbanes Oxley Act Section 302 internal controls I.T. audit for the company, supporting Section 404 of the Sarbanes Oxley Act. Mr. Arrigo earned his Bachelor of Science in Business Administration from the University of Southern California. Before that, he studied computer science, statistics, and economics at the University of California, Irvine. His post-graduate studies include biomedical ethics at Harvard Medical School, biomedical informatics at Stanford Medical School, blockchain and crypto-economics at the Massachusetts Institute of Technology, and training as a Certified Professional Medical Auditor (CPMA). Mr. Arrigo is qualified to serve as a director due to his experience in healthcare data, regulations, and economics, his leadership roles in software and financial services public companies, and his healthcare M&A diligence and public company regulatory experience. Mr. Arrigo is quoted in The Wall Street Journal, Fortune Magazine, Kaiser Health News, Consumer Affairs, National Public Radio (NPR), NBC News Houston, USA Today / Milwaukee Journal Sentinel, Medical Economics, Capitol ForumThe Daily Beast, the Lund Report, Inside Higher Ed, New England Psychologist, and other press and media outlets. He authored a peer-reviewed article regarding clinical documentation quality to support accurate medical coding, billing, and good patient care, published by Healthcare Financial Management Association (HFMA) and published in Healthcare I.T. News. Mr. Arrigo serves as a member of the board of directors of a publicly traded company in the healthcare and data analytics industry, where his duties include: member, audit committee; chair, compensation committee; member, special committee.

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