Last week I reviewed some of the features contained within the NPRM for stage 2 of meaningful use. Today I’d like to walk through how HHS proposes to tweak the clinical quality measures (CQMs) in stage 2.
As you may recall, in the eyes of HHS, meaningful use consists of three foundational features:
- Use the EHR in a meaningful way, with eRx being the example frequently cited,
- Facilitate the electronic exchange of health information among providers of care, and
- Report quality measures to CMS.
In stage 1, the last feature is identified as a core objective without exclusions. To meet this objective in stage 1, providers are required to report three core CQMs along with three CQMs from a menu set. The stage 1 menu contains 38 CQMs, although most certified EHRs were selective and certified only those menu CQMs they felt were pertinent to their customer base.
The stage 2 proposal contains a few interesting twists. Reporting CQMs will still be required in stage 2, but it is being removed as a formal objective. Instead reporting CQMs will become part of the definition of meaningful use. As I noted last week, although stage 2 continues to require the provider to report 20 objectives, in reality you will be required to do much more than that.
Two options
The NPRM goes further and proposes two options for the provider when reporting CQMs. I think the option that will gain the most traction among nephrologists is the one that basically states, if you are successful reporting PQRS, you have fulfilled your CQM obligation. If you are not participating in PQRS, you should consider doing so. Developing fluency with this program will pay dividends as HHS moves to align its quality reporting programs.
The second CQM-reporting option requires providers to report 12 individual measures. Not only has HHS removed this as a standalone objective, they have doubled the number of measures the provider is required to report. HHS has asked for comments on two proposed suggestions for this second option. One is clearly directed at the world of the primary care provider and requires the provider to report 11 specific CQMs and one from the menu. The other option asks the provider to choose 12 from a broader list with some constraints. The proposed list contains 125 distinct CQMs. HHS clearly states they do not plan to include all 125 in the final rule but suggest the final rule will contain a subset of this list.
Nephrology CQMs
Of immediate interest to the practice of nephrology is the presence of four renal related CQMs on this list of 125 measures:
- Blood pressure control in late stage CKD patients with proteinuria.
- ESA use in late stage CKD patients.
- Adequacy of dialysis in hemodialysis patients.
- Adequacy of dialysis in peritoneal dialysis patients.
Those of you familiar with the PQRS program will recognize these four as existing individual PQRS measures. If any of these four make the final cut, this version of the second option will clearly be the more favorable version for practicing nephrologists.
One final note
I think the inclusion of dialysis-related quality measures in this proposed list of CQMs is further proof that all patient encounters outside of the hospital setting are included in the meaningful use framework. I continue to meet nephrologists who are being told they can exclude the dialysis patients from meaningful use because of the perception that the meaningful use program exists exclusively within the realm of the office-based practice. Nothing could be further from the truth.
The public comment period for the stage 2 NPRM remains open through early May. While I would encourage each of you to formally submit a comment to HHS, it’s much easier to submit one here. Let us know what you think.
RG says
What year do we have to be successful for PQRS? Did they say? Please give them positive feedback that this is a very reasonable and appropriate option.
I am just finishing up your book of the decade. It has made me wonder about all of these outcomes. Is there a name, or psychological principle, that defines the process of practicing outcomes at the expense of medicine? A simple example might be giving ASA for CAD. That is not on any PQRS outcome (that I have chosen), or MU outcome (that I have chosen), but any physician should be doing this, whether primary care or specialist. Perhaps the term “blind outcome bias” could be used to define the practice of medicine whereby the practitioner is blinded to focusing only on the outcomes—and nothing else that is important but not an outcome. Terry, do you know if this concept exists or has been studied in the psychological literature? I think the answer would be very obvious with some simple experiments, but a name provides a framework for discussion.
Terry Ketchersid, Vice President and Medical Officer at HITSG says
The proposed timing regarding PQRS is concurrent with the year the provider reports the stage 2 meaningful use objectives. I agree this will be a popular choice and I anticipate it will indeed make the final rule.
Regarding the remainder of your comment, the closest idea in my experience that addresses this sentiment is the concept of unintended consequences. These can be positive but are typically negative, and the consequence itself was not predicted by those deploying the action. I had the privilege to briefly serve as our local hospitals chief quality officer a few years ago. A commercial payer instituted an incentive program which targeted specific quality outcomes. The hospital was “successful” from the perspective of the measured targets, but one could argue those items outside the purview of that program suffered from a lack of attention. This does not fall into the classic category of the unintended consequence, but I think it is important for the organizations developing and deploying incentive programs to not only pay close attention to the propsect of unintended consequences but to also recognize there is usually a corollary to the oft quoted concept of “if you want to improve something, measure it.”