CMS 131 presumes a level of interoperability/discrete data capture that does not currently exist, so is infeasible

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Done
    • Priority: Moderate
    • Component/s: Measure
    • Vendor/Epic
    • change to measure specifications
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      Thank you for raising this issue and for the proposed solution. NCQA has discussed this internally and have some concerns about what you propose. Our understanding of your proposal is that we should divide the denominator into two populations with different criteria for numerator compliance as follows:

      •Population A -diagnosis of retinopathy and would make in numerator if they got an annual eye exam
      •Population B – no diagnosis of retinopathy and would make in numerator if they got biannual eye exam
       
      With this approach, it seems that for both populations, there would still be a manual documentation burden to get the date of the annual or biannual eye exam into the EHR if the information came from outside of the system. It also seems to miss the intent of the measure which is for diabetic patients to receive annual eye exams unless they have received a negative diagnosis in the year prior.
       
      We understand the feasibility issue the eCQM version of this measure presents but the proposed solution doesn’t seem adequate. We welcome more discussion on how we might work together to develop a solution for this issue.
      Show
      Thank you for raising this issue and for the proposed solution. NCQA has discussed this internally and have some concerns about what you propose. Our understanding of your proposal is that we should divide the denominator into two populations with different criteria for numerator compliance as follows: •Population A -diagnosis of retinopathy and would make in numerator if they got an annual eye exam •Population B – no diagnosis of retinopathy and would make in numerator if they got biannual eye exam   With this approach, it seems that for both populations, there would still be a manual documentation burden to get the date of the annual or biannual eye exam into the EHR if the information came from outside of the system. It also seems to miss the intent of the measure which is for diabetic patients to receive annual eye exams unless they have received a negative diagnosis in the year prior.   We understand the feasibility issue the eCQM version of this measure presents but the proposed solution doesn’t seem adequate. We welcome more discussion on how we might work together to develop a solution for this issue.
    • CMS131v5/NQF0055
    • Measure is infeasible for even organizations who are sophisticated users of EHRs
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      ​After much discussion with EHR vendors, we agreed propose to use a diagnosis of retinopathy as a proxy for a positive eye exam.

      The rationale for this change is This means if that a patient with a diagnosis of retinopathy is required to have an eye exam yearly. Patients without that diagnosis are required to have an eye exam once every 24 months.

      We will update the numerator as follows:
      •If the patient has a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the measurement period.
      •If the patient does not have a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the 24 months prior to the end of the measurement period.

      Show
      ​After much discussion with EHR vendors, we agreed propose to use a diagnosis of retinopathy as a proxy for a positive eye exam. The rationale for this change is This means if that a patient with a diagnosis of retinopathy is required to have an eye exam yearly. Patients without that diagnosis are required to have an eye exam once every 24 months. We will update the numerator as follows: •If the patient has a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the measurement period. •If the patient does not have a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the 24 months prior to the end of the measurement period.
    • Hide
      Final Recommendation: Proposal to use a diagnosis of retinopathy as a proxy for a positive eye exam.
       
      Update the numerator as follows:
       
      • If the patient has a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the measurement period.
      • If the patient does not have a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the 24 months prior to the end of the measurement period.
      Show
      Final Recommendation: Proposal to use a diagnosis of retinopathy as a proxy for a positive eye exam.   Update the numerator as follows:   • If the patient has a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the measurement period. • If the patient does not have a diagnosis of retinopathy that overlaps the measurement period, the patient will be required to have an eye exam in the 24 months prior to the end of the measurement period.

      The specification of this measure makes the following assumptions regarding implementation:
      1. The results of an eye exam will be captured in a discrete, coded format.
      2. This discrete data is interoperable, so that if the eye exam is done at a facility outside of the EHR implementation of the primary care provider, the discrete data will be available. Of course, assumption #2 depends on assumption #1.

      Unfortunately, in the current state of EHRs and interoperability and discrete data documentation, neither of these assumptions are valid.

      Physical exam results are generally still not documented discretely, they are still largely documented as written non-discrete text, in the form of typed or dictated and transcribed notes. The only mechanism for creating discrete data from this text is through accurate natural language processing, which is in very limited availability. In the absensce of NLP, the only way to generate discrete data is for a provider to fill out a form, essentially to click buttons or select from menus, which is done in few provider organizations.

      Assuming that discrete data is available from the eye exam, we are still faced with the issue that many eye care professionals are outside the health system of the primary care provider, and that the current level of interoperability is really not close to enabling the free flow of physical exam data from one system to another. So even if discrete data is recorded, it would need to be sent as discrete and received and incorporated into the receiving system as discrete, and this is not happening. Why this is not happening is beyond the scope of this ticket, but it is not just something that can be fixed by the flick of a switch. Instead, what is much more common is that discrete data is not available, and that reports are being faxed or snail-mailed and received as a pdf or image file.

      The end result is that the only way that a primary care provider organization can have a shot at making this measure work is to jerry-rig a system where the receiving provider takes the non-discrete data they are getting and fills out a form themselves. This is the kind of workflow that all stakeholders want to avoid, but even sophisticated (meaning rich in technical resources) organizations have to do it.

      Our proposal to make this measure feasible is to abandon the two assumptions listed above and instead to look at the diagnoses on the record to determine the presence or absence of retinopathy, not the results of an exam, and to enable other, easier ways to document the performance of the eye exam. More details will be added to the comments.

            Assignee:
            Mathematica EC eCQM Team (Inactive)
            Reporter:
            Howard Bregman (Inactive)
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            10 Vote for this issue
            Watchers:
            14 Start watching this issue

              Created:
              Updated:
              Resolved:
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