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: Opioid-Related Adverse Events

The AAMC is supportive of measure concepts that assess the critical patient safety issues surrounding opioid use, but has reservations about the opioid-related adverse events eCQM under development. We urge the developer to consider potential unintended consequences of the measure that could be mitigated and consider the inclusion of risk adjustment as a component of the measure.

In regards to unintended consequences, including all uses of naloxone is a blunt instrument and may incentivize poor treatment. For example, in cases of an adverse respiratory event after the administration of opioids, it might incentivize the avoidance of naloxone in favor of a more invasive treatment option such as intubation. This is to say that there are important subclinical interactions with opioid administration, and including all uses of naloxone in the numerator for this measure might result in a reduction in the appropriate administration of naloxone, but at the cost of more invasive care for the patient. In addition, the use of naloxone is a standard treatment in hospitalized patients with a change in mental status even if opioids are not the final cause of the condition. Using the use of naloxone as an indicator may reshape currently accepted clinical practice inappropriately. The measure developer should consider ways to remove from the numerator certain cases of the administration of naloxone such to mitigate the unintended consequence of more invasive care in response to quality measurement of the use of naloxone.

It appears there is no consideration for risk adjustment, including for consideration of opioid sensitivity. Physicians should be able to take clinical risk factors into account for the appropriate administration of opioids, and the measure should be nuanced such that it is able to balance measurement with adequate pain control.