Challenges with eCQMs in General

The AAMC is supportive of CMS’ efforts to improve the quality of care by developing measures on dimensions of patient harm or adverse patient safety events, but notes that CMS has previously recognized and responded to the challenges regarding the feasibility of electronically-submitted measures and has reduced the number of eCQMs hospitals must report for FY 2019 and 2020 payment. There is considerable burden required to map the necessary data elements from the EHR to the appropriate Quality Reporting Data Architecture (QRDA) format, and some vendors are not properly equipped to collect and transmit such data through the CMS portal.

Mandatory eCQM reporting depends on hospitals using the correct version of specifications, which is generally in the control of the EHR vendors, not the hospitals. The AAMC urges CMS to continue outreach to EHR vendors, hospital quality staff, and other affected stakeholders to identify underlying structural problems and barriers to successful reporting of these measures. With this in mind, the Association continues to have concerns that hospitals and vendors may not be adequately prepared to fully report eCQMs, and asks CMS to focus resources on sufficiently addressing current concerns with eCQM reporting rather than on developing additional eCQMs for inclusion in hospital reporting programs for the future. Focusing on the inclusion of a small number of measures in the eCQM program that are meaningful and not overly burdensome will provide hospitals with additional time and bandwidth to address the considerable challenges of electronic data reporting.

Finally, the AAMC advises that completed testing of these eCQMs under development should demonstrate reliability and validity in the acute care setting and these measures should be submitted to National Quality (NQF) for review and endorsement. CMS should vet these new eCQMs across a selection of vendors and hospitals prior to considering the measures for addition to a CMS quality reporting program for implementation.

Measure Comments: Acute Kidney Injury

The AAMC does not support the measure as currently developed to measure acute kidney injury (AKI) in hospitalized patients for several reasons, including the need for risk adjustment and ensuring that the measure is better tailored to measure AKI so that it is meaningful for patients and provides appropriate incentives for hospital improvement.

Without adequate risk adjustment, this measure is likely to ensure that any hospital that treats more complex patients and performs more complex surgeries and therapies will have a higher incidence of AKI. Comparing tertiary hospitals, which see these more complex patients and perform more complex procedures, from diagnostic (e.g., image guided studies requiring nephrotoxic contrast agents) to surgical (e.g., trauma and transplant), and more complex medical treatments (e.g., multi-drug chemotherapeutic protocols and septic patients), to community hospitals without adjusting for clinical case mix and co-morbidities will result in teaching hospitals having a greater rate of AKI. The AAMC would also appreciate more clarification on the measure’s future use in quality reporting programs.

AKI as measured by an absolute increase in serum creatinine at 1.5 times the baseline is one commonly used definition, though other absolute thresholds also commonly used. The developer should consider using either an absolute threshold or a combination, such as an increase by n% that results in the creatinine level being over a certain threshold level. In addition, creatinine levels may not be the best measure to use as its level varies by muscle mass, race and age. This measure will also need to be adjusted for those medical conditions that result in an overproduction of creatinine without incident acute kidney injury or in those circumstances where one would expect a lower creatinine such as pregnancy. eGFR is often used and most labs calculate it for all patients when creatinine is drawn. Did the measure developer consider using eGFR instead of creatinine value?

Defining a substantial increase in serum creatinine as greater than or equal to 1.5 times the baseline is likely to result in inaccurate reporting of acute kidney injuries. There are cases, such as in the wake of a major operation, with no sequelae where creatinine levels may increase transiently but still remain in the normal range. For example, following a CABG surgery the patient might be treated with diuretics to reduce likelihood of fluid retention in the lungs, resulting in a temporary increase from 0.6 mg/dL to 0.9 mg/dL (noting that the normal levels of creatinine in the blood ranges from 0.6 -1.2 mg/dL for adult males and 0.5-1.1 mg/dL for adult females) that would be reported as AKI even though it was temporary increase within the normal levels with no long-term sequelae as part of a standard clinical intervention post-operation. Including this case in the numerator is not going to reduce AKI (as it is a standard clinical intervention) and is not going to have an impact on reducing mortality or the future need for dialysis. The measure should be more tightly constructed so as to ensure it’s truly measuring preventable AKI where the AKI is associated with increased mortality risk and likelihood of the need for dialysis. Finally the developers have not provided sufficient information on what is considered preventable AKI. There is controversial literature on this particular topic and thus the introduction of this metric into use as an eCQM is troublesome.