Interoperability and Unified Patient Records: Two Keys to Meeting eCQM Requirements from CMS

The long journey toward healthcare data interoperability is occasionally punctuated by a new CMS regulation that catches everyone’s attention and triggers some degree of urgency or course correction. Most recently, that “shot across the bow” has come in the form of CMS’s new eCQM (electronic clinical quality measures) requirements. The proposed regulations will require ACOs to aggregate and electronically report clinical quality data—a prospect that has created consternation in the ACO community. 

Why the concern? Because that data capture must include 100% of the patient population, not just a sample of Medicare beneficiaries; and ACOs, like almost every healthcare provider, are typically using multiple EHR (electronic health record) and other HIT systems across different hospitals, groups, and care settings. ACOs know that the data aggregation and normalization process will be challenging, costly, and most certainly consume resources.

The benefits of interoperability remain clear, especially where more than 60% of all healthcare dollars are now tied into some form of value-based or alternative reimbursement model. But for those who’ve long grappled with the data interoperability challenge, this reaction to CMS’s eCQM announcement is reminiscent of previous struggles, specifically around MACRA. Once again, providers must confront a data interoperability challenge they did not cause but are being called upon to help solve.

A Brief eCQM Primer

eCQMs are measures of clinical quality designed to conform to a standard electronic format using data extracted from EHRs. CMS developed eCQMs to give eligible hospitals, clinicians, and critical access hospitals a digital way to measure, track, and report quality across a number of specific areas of healthcare services important in value-based care models. 

These quality measures will include:

• Clinical processes/effectiveness
• Patient safety
• Care coordination
• Efficient use of healthcare resources
• Patient and family engagement
• Population health

Medicare Shared Savings Program (MSSP) ACOs already manually report some CQM measures under the Alternative Payment Model Performance Pathway by Web interface. Over the next three performance years, however, ACOs will need to transition to the electronic or eCQM format, and submit a single aggregate quality reporting document.

Electronic submission is not the only challenge to MSSP ACOs in CMS’s new provision. Today, under the current requirement, the CMS requires all ACOs and groups, regardless of size, to report a minimum of 248 patients selected from a CMS sample of 616 Medicare beneficiaries for each measure. By 2025, ACOs will need to analyze 100% of patients and report on 70% of all patients who meet the measuring criteria, regardless of payer.

This means ACOs will need to aggregate data from multiple EHRs used by different hospitals, physician groups, and care settings. Today, 77% of ACOs have 6 or more EHRs, 37% use more than 16, and just 9% use a single EHR, according to the American Journal of Managed Care. To ensure accurate patient matching data, CMS will also require ACOs to deduplicate that patient data across providers and suppliers when submitting their reports.

These requirements get to the heart of the inherent challenge with EHRs and interoperability. Designed as billing systems, they lack formatting capabilities required to share data, and don’t readily lend themselves to quality measures reporting or easily facilitate data aggregation, normalization, and deduplication—not to mention the advanced analytics required to generate mandated reporting compounding that problem, the multiple EHRs within a single ACO might well be serviced by multiple vendors under multiple contracts, with different data formats across the platforms.

For providers tasked with analyzing quality information across their entire patient population and reporting on 70% of those patients, it will be crucial to tie all of those systems together using a data and analytics platform, so as to establish a unified (longitudinal) patient record as a single source of truth for each patient’s clinical information. This will eliminate data ambiguity and the need for expansive (and expensive) manual processes, while streamlining the collection and reporting of patient information. But that capability is only possible by integrating data from disparate EHRs and other sources.

Lacking an appropriate data platform, eCQM conversion will be a major multi-year undertaking requiring innovative solutions. At minimum, EHR systems, clinical workflows and administrative processes will need to be redesigned; staff retrained; and legal teams engaged to align EHR contracts—not to mention the burden on the IT organization to technically tie those systems together. While CMS has included financial incentives to encourage eCQM adoption, the effort and costs will inflict real financial pain on ACOs already struggling to preserve margins and alleviate burnout in the post-pandemic environment.

In a recent survey, NAACOS reported that ACOs are concerned about the eCQM program requirements, and hope that CMS will adopt a more phased-in approach when the requirements are finalized. It’s clear, however, that CMS’s goal is to ensure ACOs have a working database of all their patients and to do that well really does, by definition, mean making the leap to meaningful interoperability and advanced analytics. But many, if not most ACOs currently lack the unified digital infrastructure to accomplish this, and their history with EHR vendors tells them that it will not be fast, easy, or cost-efficient to build one. 

Echoes of the Past

In good ways and bad, the most apt historical parallel to the eCQM turmoil may be the 2015 passage of MACRA (Medicare and CHIP Reauthorization Act) which aspired to replace fee-for-service payment models with a quality payment program that rewarded value. 

At the time, even detractors viewed MACRA as the most consequential reform to U.S. healthcare since the introduction of Medicare and Medicaid in 1965. As with eCQM, participating providers needed to submit composite performance scores based on four domains of quality, including clinical improvement, resource use, progress in digitizing, and sharing clinical care information.

Critics had a range of complaints. The program’s focus on reporting would, they believed, reward providers for the sophistication of their reporting abilities, not their actual clinical performance. Variation across clinician circumstances and areas of specialization would also advantage some participants over others. 

But the fundamental concern was with EHRs. To participate, clinicians of any size organization, from solo practices to the largest health systems, would need to acquire an EHR system or possibly adapt or replace their current system—and then engage in intense data collection and analysis efforts. This was a daunting proposal they knew would absorb significant financial resources and require major changes to workflow.

While financial incentives and consequences were put in place to encourage compliance, many clinicians expressed their misgivings about EHR adoption vocally, and some lobbied for delays in the timeline and accommodations for smaller practices.

Back to the Future

No doubt that saga sounds familiar to those concerned about the eCQM provision, and whether the efforts will provide the expected outcomes. Arguments can be made on both sides. Again, perhaps it helps to reflect on how things turned out with MACRA.

Fears of the impact on workflow and the pressure on small practices to consolidate proved all-too prescient. But worries about data privacy and data breaches now seem to have been a little overblown. 

Regarding the primary objective to transition providers to value-based care, progress and the impact on care costs and quality remain elusive. Most providers still have one foot in the FFS and the other in value-based worlds. But most also agree that alternative payment processes are needed to correct healthcare’s misaligned incentives. 

Likewise, the goal of meaningful interoperability also remains elusive (even a dream) despite overwhelming progress in digitizing healthcare data, with 93-96% of hospitals now using certified EHR health IT systems. In that digitization effort, the industry understandably took the path of least resistance and leaned on EHR models already in place for billing purposes. This impressive progress has had one unintended outcome,  ultimately making it incredibly difficult to aggregate, access, and leverage clinical and financial data. The result has been the siloing and fragmentation of patient data all across healthcare.

In the light of those results, will eCQMs promote greater interoperability and value going forward? 

So long as most patients remain exempt from quality measures, providers will lack the urgency to fully embrace value. In that sense, eCQMs will help by motivating providers to track quality across their entire patient population. And since that quality data must be submitted in a single report, eCQMs will also motivate innovative providers to act on the fundamental problem of ingesting, aggregating, normalizing, and analyzing data across multiple EHRs—even when dozens of EHRs are in use. 

It would be misleading to minimize the effort and innovation required to make that transformation happen, especially on an accelerated basis, but the goals are laudable, achievable using modern HIT, and worth pursuing. In my third and final article on eCQMs, I’ll explain how Innovaccer’s end-to-end eCQM Reporting Solution is a game changer for MSSP ACOs. It can solve the problem of aggregating data across multiple sources and automate eCQM reporting.

But it can also establish a foundation that gives providers the ability to leverage a unified patient record for other business objectives, such as population health management, patient relationship management, and revenue cycle management in the future. Once the EHRs are integrated and a longitudinal patient record is established to solve for the eCQM reporting, many more doors open for MSSP ACOs.