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 is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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