The journey of the healthcare industry from a volume-based system to a value-based one has accelerated in the last couple of years. Today, federal agencies like the Centers for Medicare and Medicaid Services (CMS) have introduced Clinical Quality Measures (CQMs) to substantiate the claims of institutions and professionals before granting reimbursements requests.
These measures have been introduced primarily to provide physicians and healthcare institutions with tangible feedback on their healthcare processes, methodologies, and the subsequent outcomes. The CQMs ensure that healthcare providers prioritize, implement, and monitor improvements in their patient care services. If CQMs find evidence of overbilling or insufficient clinical validation, they flag the responsible healthcare institution for future audits.
To prevent this, healthcare organizations need to ensure compliance to these new regulations by relying on technology to keep pace. They can effectively use computer-assisted coding (CAC) and clinical documentation improvement (CDI) to digitize, maintain, and codify patient data as per regulations at an individual level.
The hospital’s computer-assisted CDI solutions can be augmented with electronic CQM add-on tools (eCQMs). eCQM tools measure the quality of patient care on the basis of various aspects such as patient and family engagement, patient safety, care coordination, public health, effective use of healthcare resources, and clinical processes or their effectiveness. Evaluating these parameters gives healthcare organizations and regulatory agencies a clear idea of the quality of care provided.
Common CQM Regulations
The overall objective for healthcare organizations and agencies alike, is to make healthcare more patient-centric, improve the overall health of the national population, and reduce the cost of access to healthcare. To be eligible for incentive payments, hospitals need to provide substantial proof to sponsors like the CMS. This requires the use of certified electronic health record (EHR) solutions that use standardized protocols for ailments, medications, allergies, lab results, and so on, all coded by standard CAC tools.
Hospitals need to keep a few parameters in mind while filing for reimbursements. For instance, flagging and reducing instances of hospital acquired conditions (HAC). The CMS HAC Reduction Program saves Medicare USD 350 million every year. An important element of reducing HAC involves diligently reporting and flagging patient safety indicators (PSI) at, both, provider and area levels as well as reducing cases of readmissions. Other parameters include physician quality reporting system, value-based modifier cost, and clinical practice improvement.
The Challenges of Incorporating CQMs
One of the most significant challenges facing clinicians and hospital administrators is the lack of awareness when it comes to the impact of clinician and HIM productivity on hospital performance. A lack of awareness or understanding of the metrics often leads to a failure to meet quality expectations, which in turn, prevents the receipt of reimbursements. Only two-thirds of physicians are aware of their performance quality and productivity levels. As a result, the possibility of human error in the documentation and coding process rises, which can have a detrimental effect on CQM data and, subsequently, bill reimbursements.
Another challenge is the lack of better tools and resources. Most eCQM platforms or solutions have complex specifications that are difficult to comprehend and access. Validation efforts are extensive but clinically invalid. They are not maintained in real time. Moreover, hospitals and clinics often have different vendors for EHR and the management of admissions, discharges, and transfers. A lack of interoperability between these solutions can cause an imbalance in the synchronization of patient data and CQM data. Additionally, the transition from ICD-9 to ICD-10 coding requirements did not happen smoothly for Coding and HIM professionals due to the sheer volume and complicacy of codes in the 10th revision.
The Way Ahead
For better clinical quality, organizations should prioritize initiatives that relate to outcomes and patient experience CQMs such as mortality, readmission, surgical site infection, or patient wait time. This will help them sail through regulatory approvals and become more patient-centric in the process.
Ensuring better clinical quality can also be achieved by a reliable eCQM platform or solution. A dependable eCQM solution should have an easily accessible dashboard that displays comprehensive, up-to-date clinical information for every case of the current reporting cycle. It should be able to collate health records from manual files into the system while the patient is still in the hospital. Having a real-time trending and analytics feature is ideal as it rectifies errors and missing information at the time of record collation. For easier reimbursement reporting, the solution should have all the core requirements of CMS, MIPS, and The Joint Commission (TJC), and should validate every document before submission.
A next-generation, computer-assisted CQMs solution should also support standards-based interoperability and incorporate patient-reported data which are either entered by patients themselves or generated from connected patient monitoring devices. A computer-assisted CQM facilitates the HIM’s contribution in patient data governance, standardization, validation, maintenance, and analytics. Organizations should take it as a chance to improve and take the healthcare industry of the US to the next level.
However, only adopting technologies will not help. For optimum functioning of healthcare institutions proper training of clinicians, nurses, and HIM specialists is imperative and they should be made aware of the importance of correct data entry into the EHR.
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