We reviewed the Hybrid CMS 529 HSR results of 25 hospitals in our health system. We found 5 out of 25 hospitals passed the 3 categories (labs, vital signs and linking variables). This is a 20% passing rate. We reviewed our findings with our EHR vendor and they determined that a large part of the failure was due to the #2 exclusion (FFS Medicare patients < 65 years of age). According to our vendor, this happened because the CMS specs did not ask for patient on FFS Medicare under the age of 65 years so they were not included in the patient records sent to CMS to be matched with the CMS claims data. This is only one of several issues we have encountered with this measure. There are workflows that seem to impact our lab and vital sign data, but the resources (the user guide and the Q&A) are not helpful. We simply cannot figure out why we are failing because the calculations on table III rows 25 thru 27 are not clearly explained.

Provide a hybrid measure webinar that explains the exclusions and the way the calculation formulas are applied to Table III. In the webinar allow sufficient time for questions and answers. Finally, we implore CMS to consider moving out the mandatory reporting date. This will give us the ability to perfect our data gathering and submissions and develop the necessary expertise in understanding the hybrid measures.