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Public Comment

Welcome to CMS Quality Measures Public Comment Page

This page serves as the designated site for CMS to solicit public comments on proposed quality measures that are included in the individual project pages. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Details of the Public Comment Period:

  • The public is encouraged to submit general comments relevant to both measures or comments specific to certain measures
  • Information about each measure is found in the Downloads section below
  • Do not include personal health information in your comments
  • At the end of the public comment period, all public comments will be posted on the website along with a public comment summary report

Instructions for Providing Comments:

  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information
  • If you are commenting as an individual, submit identifying or contact information
  • Please indicate which measure(s) you are commenting on
  • You may submit general comments on the entire set of measures or you may provide comments specific to individual measures

 

Public Comment Postings:

  • Reevaluation of Hospital-Acquired Condition (HAC) Reduction Program Scoring Methodology
  • Electronic Clinical Quality Measures for (1) Cognitive Impairment Assessment and Health Care Proxy and (2) Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis
  • Development of Measures of Payment for Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)
  • Days in Acute Care after Hospitalization for Heart Failure, Pneumonia, or Acute Myocardial Infarction (AMI)
  • Hospital Visits after Hospital Outpatient Surgery
  • Clinical Quality Measure for Human Immunodeficiency Virus (HIV) Infection Screening
  • Risk-Standardized Acute Admission Rates for Patients with Diabetes
  • Risk-Standardized Acute Admission Rates for Patients with Heart Failure
  • Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions
  • 2015 Draft PQRS #181 Elder Maltreatment Screening and Follow-Up Plan
  • Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data
  • Measure of Hospital Visits after Hospital Outpatient Surgery
  • Hospital-Wide All-Cause Unplanned Readmission Hybrid Electronic Clinical Quality Measure
  • All-Cause Acute Admission Rates For Patients With Heart Failure and Diabetes
  • Public Comment for ARRA HITECH EP Annual Wellness Assessment (AWA) and Functional Status Assessment (FSA) Measures

 

Project Title:

Reevaluation of Hospital-Acquired Condition (HAC) Reduction Program Scoring Methodology

Dates:

  • The Call for Public Comment period opens on November 20, 2014 and closes on December 18, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Centers for Outcomes Research and Evaluation (CORE) and CORE has subcontracted with Mathematic Policy Research, Inc. to reevaluate the HAC Reduction Program (HACRP) scoring methodology. The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I- T0001 Modification 000002. As part of its reevaluation process, CMS requests that interested parties submit comments on the HAC Reduction Program scoring methodology.

Project Objectives:

The project objectives are:

Obtain stakeholder input on proposed change to Domain 2 scoring methodology.

  • Current (Fiscal Year [FY] 2015 and FY 2016) Methodology: Hospitals receive a score for each Domain 2 measure according to the scoring methodology and the measure scores are averaged to provide a total Domain 2 score. If a hospital reports data for at least one of the Domain 2 measures, then their Domain 2 score is based on the measure(s) they reported. CMS chose this scoring methodology for FY2015 and FY2016 for the reasons outlined in the rationale below.
    • Rationale for Current Methodology: This approach was employed for the FY 2015 HACRP and will be applied for the FY 2016 HACRP because the applicable periods for those program years occurred prior to the announcement of the program. Because a hospital did not have the opportunity to change their reporting practices based on the measures that were to be included in the HACRP until well into the FY2016 applicable period, CMS did not feel that it was appropriate to penalize hospitals for non-reporting of data for the FY 2015 and FY 2016 program years. 
  • Recommendation for FY 2017 Methodology: We recommend CMS treat each Domain 2 measure independently when determining if a score of 10 (maximal score) should be assigned to the measure for non-submission of data without a waiver. For instance, if a hospital does not submit data for CLABSI and does not have a valid waiver, the measure will receive a score of 10, which will then be combined with the scores they received for the other FY 2017 Domain 2 measures (CAUTI, Surgical Site Infection or SSI for Colon Surgery and Abdominal Hysterectomy [to be added in FY 2016], Hospital-Onset Methicillin-Resistant Staphylococcus Aureus, and Hospital-Onset Clostridium Difficile Infection [both to be added in FY 2017]) to calculate the hospital’s total Domain 2 score.
    • Rationale for FY 2017 Methodology: The rationale for this change in methodology is to encourage hospitals to submit data as well as to discourage hospitals from selectively submitting data. It is recommended that this change be implemented beginning with the FY 2017 HACRP score calculations because the applicable period for the FY 2017 program occurs entirely after the program was announced and the measures were finalized. Please see pages 2-4 of the “Introduction to the Public Comment” document for a review of HAC Reduction Program scoring methodology and page 5 for a detailed description of and rationale for this recommendation.

Obtain stakeholder input on priorities for future HAC Reduction Program reevaluation work.

Given the complexity of the HAC Reduction Program and the ongoing evolution of the component measures, we are soliciting input on what ongoing reevaluation work should also be considered in the HAC Reduction Program. In addition, we are asking for public comment on additional HACs or patient safety events that CMS should consider for future inclusion in the HAC Reduction Program.

Project Specific Instructions:

  • The public is encouraged to read the following documents, provided for your reference:
    • Introduction to Public Comment on Reevaluation of the HAC Reduction Program Scoring Methodology
    • 2014 HAC Reduction Program Technical Expert Panel Summary Report for Reevaluation of the HAC Reduction Program Scoring Methodology
  • The public is encouraged to submit comments on the proposed change to Domain 2 scoring methodology and on what the priorities should be for future HAC Reduction Program reevaluation work.
  • At the end of the public comment period, all public comments will be posted on the website.
  • Please do not include personal health information in your comments.
  • If you are providing comments on behalf of an organization, please include the organization’s name and your contact information.
  • If you are commenting as an individual, please submit identifying or contact information.
  • Please indicate the question on which you are providing comments.
  • Email your comments to: cms_hacrp_scoring@yale.edu (gaps in email address represent underscores “_”). Comments are due by close of business December 18, 2014.

 

 

Project Title:

Electronic Clinical Quality Measures for (1) Cognitive Impairment Assessment and Health Care Proxy and (2) Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis

Dates:

The public comment period begins at 9:00 a.m. (EST) on November 18, 2014, and ends at 11:59 p.m. (EST) on December 23, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Mathematica Policy Research to develop provider-level measures based on data from electronic health records. The contract name is Electronic Clinical Quality Measures Development and Maintenance for Eligible Professionals. The contract number is HHSM-500-2013-13011I/HHSM-500-T0001. CMS requests interested parties to submit comments on three candidate measures being developed under this project.

Project Objectives:

The goal of this project is to create electronic clinical quality measures, including those to capture aspects of care quality that are not easily measured in claims. Such aspects of care quality include patient-reported outcomes and cognitive impairment care.

Documents and Measures for Comment:

CMS is requesting feedback on the following three proposed measures:

  • Cognitive Impairment Assessment Among At-Risk Older Adults
  • Determination of a Health Care Proxy for Patients with Cognitive Impairment
  • Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis

All comments are welcome, but we are particularly interested in feedback in the following areas:

  • Usefulness of the measures to assess the quality of care for Medicare or Medicaid beneficiaries
  • Appropriateness of the measures to assess performance by Eligible Professionals
  • Feasibility of data collection for the proposed measures using EHRs for the purpose of public reporting under the EHR Incentive Program

For each proposed measure, the following files are provided for your review. All are found in the Downloads section at the bottom of the site page:

  • A summary of measure specifications
  • Measure specifications from the  health quality measure format header (human-readable document)

Also, for the proposed measure of Functional Status Assessments and Goal Setting for Chronic Pain Due to Osteoarthritis, we provide the following file in the Downloads section at the bottom of the site page:

  • A measure background document

Instructions for providing comments:

The JIRA comment tool will be used to collect comments on the measure specifications listed above. Please use the following links to submit your comments:

If you are a current JIRA user with an active account:

http://jira.oncprojectracking.org

(Select “Log In” at the top right corner)

If you are new to JIRA and do NOT have an account:

http://jira.oncprojectracking.org/login.jsp

(Select “Sign up” to set up a new account and log into the JIRA tool)

Once logged into the JIRA tool:

  1. Select “Projects” at the top middle of the home screen.
  2. Select “View all Projects”
  3. Under Quality-Measures, select “Comments on eCQMs under development” project.
  4. To enter comments, select “Create issue” (Orange button) at the top middle of the screen.
  5. Select the type of issue from the “Issue type” drop-down menu.
  6. Please fill out the fields labeled: “Summary,” “Contact name,” “Contact email,” and “Contact phone.” 
    • In the “Summary” field, type in one of the following titles, based on the measure you are commenting on:
      1. Comment- CI Assessment
      1. Comment- CI Proxy
      2. Comment- FSA OA Pain
  1. Enter your comments in the “Description” field.
  2. Select the measure name you are commenting on from the “Draft measures” drop-down box at the bottom of form: 
    • For the Cognitive Impairment Assessment Among At-Risk Older Adults measure, select “CI_Assessment.
    • For the Determination of a Health Care Proxy for Patients with Cognitive Impairment measure, select “CI_Proxy.
    • For the Functional Status Assessments and Goal Setting for Chronic Pain due to Osteoarthritis measure, select “FSA_OA Pain.

Select “Create” at the bottom left to submit your comments. If you would like to enter more comments, select “Create another” and then “Create.”

Project Title: 

Development of Measures of Payment for Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

Dates: 

  • The Call for Public Comment period opens on October 21, 2014 and closes on November 21, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Systems Corporation/Center for Outcomes Research and Evaluation (CORE) to develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS requests interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

The purpose of the project is to develop an outcome measure that can be used to support quality improvement. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measure under development. Comments from the public can offer critical suggestions in additions to those identified by the measure contractors and their technical expert panel (TEP).

Project Objectives: 

  • To develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary THA/TKA.

Specific Project Objectives:

The goal of this project is to develop an administrative claims-based, hospital-level, risk-standardized measure for payment associated with a 90-day episode-of-care following an elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA).

The development process includes:

  • Identifying importance of outcome
  • Conducting a literature review and environmental scan
  • Defining and developing specifications for the measure
  • Obtaining evaluation of proposed measure by technical expert panel
  • Posting measure for public comment
  • Testing measure for reliability, validity, and feasibility
  • Refining measure, as needed

Details about the measure development process can be found in the Measures Management System Blueprint at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MeasuresManagementSystemBlueprint.html.

Documents and Measures for Comment: 

The following documents are provided for your review and comment. The files are found below in the Download section.

  • The measure specifications for the measure in the draft measure methodology report.
  • The comments provided by the TEP during our two TEP meetings in the TEP Summary Report.

Project Specific Instructions: 

CMS encourages you to submit general or specific comments on the measure. In particular, please provide feedback on:

  • Definition of the measure cohort
  • Calculation of the payment outcome
  • Risk-adjustment methodology

Instructions for Providing Comments: 

  • If you are providing comments on behalf of an organization, include the organization’s name and your contact information.
  • If you are commenting as an individual, submit identifying or contact information.
  • Comments are due by close of business November 21, 2014.
  • Please do not include personal health information in your comments.
  • Send your comments to paymentmeasure@yale.edu.
  • At the end of the public comment period, all public comments will be posted on the CMS Web site - https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/CallforPublicComment.html.

 

Project Title: 

Days in Acute Care after Hospitalization for Heart Failure, Pneumonia, or Acute Myocardial Infarction (AMI)

Dates: 

The public comment period closed on July 31, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, heart failure, and pneumonia. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure reevaluation, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to reevaluate three administrative claims-based, hospital-level, risk-adjusted measures of care transitions for patients hospitalized with AMI, HF, and pneumonia.
  • The public comment period provided an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).
  • At that stage of measure reevaluation and testing, we were seeking feedback on the preliminary measure specifications of the three revised measures of post-discharge acute care utilization, for patients hospitalized with heart failure, pneumonia, and AMI.

Comment Summary: 

The following document is found below in the Download section:

1.  Public Comment Summary Report and Verbatim Comments

 

Project Title:

Hospital Visits after Hospital Outpatient Surgery

Dates:

The call for public comment period closed on August 3, 2014.

Project Overview:
The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop quality measures that use patient outcomes to assess the quality of outpatient care. The contract name is Development of Ambulatory Care Outcomes Measures and the contract number is HHSM-500-2012-00025I. As part of this project, CORE is developing a quality measure for outpatient surgeries. Specifically, CORE is developing a measure of hospital visits after outpatient surgery conducted in hospital outpatient departments (HOPDs). As part of its measure development process, CMS invited interested parties to submit comments on the draft measure specifications.

Project Objectives:

  • The primary goal of this project is to develop an administrative claims-based, risk-standardized measure of hospital visits after hospital outpatient surgery.
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on the measure under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary:

The following documents are found below in the Download section:

1. Measure technical report for public comment
2. Technical expert panel (TEP) summary report
3. Public comment summary report, including verbatim comments

 

Project Title:

Clinical Quality Measure for Human Immunodeficiency Virus (HIV) Infection Screening

Dates:

The public comment period begins at 9:00 a.m. EST on September 22, 2014, and ends at 5:00 p.m. EST on October 20, 2014.

Project Overview

The Centers for Disease Control and Prevention (CDC) in the Department of Health and Human Services (HHS) is seeking public comment on a newly developed draft clinical quality measure for human immunodeficiency virus (HIV) infection screening.  The measure aligns with the recently released U.S. Preventive Services Task Force (USPSTF) recommendations that all individuals between the ages of 15 and 65 be screened for HIV. The measure was developed in collaboration with clinicians and quality experts. The goal is to develop a measure that will be nationally endorsed through the National Quality Forum (NQF) and included in the Centers for Medicare & Medicaid Services (CMS) programs.

To Provide Public Comments, Note the Following:

CDC is seeking public comment on this draft measure, with particular interest in feedback on relevance, usefulness, and feasibility of the measure. Based on the comments it receives through this process, CDC will revise and refine the measure as needed.

Documents and Measures for Comment:

A zip file containing the Measure Information and Measure Justification forms for the measure can be found in the Downloads area below.

Instructions for Providing Comments:

Please email your comments to hivscreening1565@cdc.gov . All comments on the measures must be received by 5:00 p.m. EST.

 

Project Title: 

Risk-Standardized Acute Admission Rates for Patients with Diabetes

Risk-Standardized Acute Admission Rates for Patients with Heart Failure

Dates: 

The call for public comment period closed on May 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with diabetes and heart failure. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (diabetes and heart failure).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Diabetes and Heart Failure Admission Measures
  2. Diabetes and Heart Failure Draft Measures Technical Report
  3. Diabetes and Heart Failure Measures TEP Summary Report

 

Project Title: 

Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions

Dates: 

The call for public comment period closed on June 19, 2014.

Project Overview: 

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with multiple chronic conditions. The contract name is Development of Ambulatory Care Outcomes Measures. The contract number is HHSM-500-2012-00025I. As part of its measure development process, CMS requested interested parties to submit comments on the draft measure specifications.

Project Objectives: 

  • The primary goal of this project is to develop administrative claims-based, risk-standardized measures of acute admission rates for patients with chronic disease (multiple chronic conditions).
  • The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Comment Summary: 

The following documents, including the draft measure specifications, TEP summary report, public comment summary report, and verbatim comments, are found below in the Download section.

  1. Public Comment Summary Report and Verbatim Comments for Multiple Chronic Conditions Admission Measure
  2. Multiple Chronic Conditions Draft Measure Technical Report
  3. Multiple Chronic Conditions Measure TEP Summary Report

 

 Project Title:

2015 Draft PQRS #181 Elder Maltreatment Screening and Follow-Up Plan

Dates:

• The Call for Public Comment period closed on 10/22/14

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Physician Quality Measures Management (PQMM) and Quality Insights of Pennsylvania (Quality Insights) to develop PQRS # 181 Measure 181 - Elder Maltreatment Screening and Follow-Up Plan. The contract name is Physician Quality Reporting System (PQRS) Quality Measures Maintenance (PQMM). The contract number is HHSM-500-2013-00177C. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

  • Because most cases of elder abuse are underreported by health care providers, in concert with a lack of strong evidence in the literature to support screening for elder maltreatment, CMS convened a national Elder Maltreatment & Care Symposium for all relevant stakeholders on March 8, 2013. The aim of this symposium was to assess the value of continuing the implementation and development of PQRS #181 Elder Maltreatment Screening and Follow-Up Plan.
  • Feedback from the Elder Maltreatment & Care Symposium was incorporated into the comprehensive review of the 2014 Elder Maltreatment Screening and Follow-Up Plan measure for use in PQRS. This comprehensive review also included a literature review, measure specifications review and an evaluation of the measure code sets.

Comment Summary:

The following documents, including a summary of public comments and the original measures are found below in the Download section.

  • Preliminary Public comment Summary Report Template
  • PQRS 181 Elder Maltreatment Screening and Follow-Up Plan

 

Project Title:

Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data

Dates:

The Public Comment period ran from July 14, 2014 to August 8, 2014

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop a hospital-wide all-cause unplanned readmission hybrid electronic clinical quality measure (HWR eMeasure). This is a hybrid measure in that it includes a combination of claims data describing patient’s conditions and clinical data from electronic health records. The contract name is Measure & Instrument Development and Support (MIDS). The contract number is HHSM-500-2013-13018I. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

Project Objectives:

The purpose of the HWR eMeasure was to enhance the original hospital-wide readmission measure by including clinical data elements captured at the start of an episode of care in electronic health records (EHR). This enhancement was in response to stakeholder feedback expressing a need for clinical information in risk adjustment models.

The measure uses the methodology from the original HWR measure but adds clinical data to the risk adjustment strategy. We only included clinical data elements that were found to be consistently captured under current clinical practice and feasibly retrieved from EHRs by a 2013 TEP. This measure has been tested in a dataset from an integrated hospital system consisting of 21 hospitals. At that stage of measure development and testing, we were seeking feedback on the measure concept and clinical data elements used in the risk adjustment models for each specialty cohort.

Further measure testing in a larger, more diverse data set will occur once such data is available. Similarly, the value sets and logic surrounding those value sets will be available for public comment in 2015.

Comment Summary:

The following documents, including a summary of public comments and the original measures; and documents for comment are found below in the Download section.

  • Public Comment Summary Report.

 

Measure of Hospital Visits after Hospital Outpatient Surgery

Dates:

The public comment period ends at 11:59 P.M. EDT on August 3, 2014

Project Overview

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE) to develop quality measures that use patient outcomes to assess the quality of outpatient care. As part of this project, CORE is developing a quality measure for outpatient surgeries. Specifically, CORE is developing a measure of hospital visits following outpatient surgery conducted in hospital outpatient departments (HOPDs).

The purpose of the project is to develop quality measures that can be used to improve the quality of care for Medicare beneficiaries. The public comment period provides an opportunity for the widest array of interested parties to provide input on measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP).

Specific project objectives: CORE and CMS are requesting public comment on an administrative claims-based, risk-adjusted measure of hospital visits following outpatient surgery conducted at HOPDs.

The Measure Development Process Includes:

  • Identifying important quality goals related to a topic/condition or setting of focus.
  • Conducting literature reviews and environmental scans.
  • Defining and developing specifications for the quality measure.
  • Obtaining evaluation of proposed measure by TEP.
  • Posting for public comment.
  • Testing measure for reliability, validity, and feasibility.

To Provide Public Comments, Note the Following:

Documents and Measures for Comment:

The following documents are provided for your review and comment, and are found in the Downloads section of this site:

  • Technical Report
  • TEP Summary Report

Instructions for Providing Comments:

 

Hospital-Wide All-Cause Unplanned Readmission Hybrid Electronic Clinical Quality Measure

Dates:

The public comment period begins at 8:00 A.M. EDT on July 14, 2014 and ends at 5:00 P.M. EDT on August 8, 2014

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation Center for Outcomes Research & Evaluation (CORE) to develop a hospital-wide all-cause unplanned readmission hybrid electronic clinical quality measure (HWR eMeasure). This is a hybrid measure in that it includes a combination of claims data describing patient’s conditions and clinical data from electronic health records. The purpose of the project is to develop quality measures that can be used to provide quality care to Medicare beneficiaries. The public comment period provides an opportunity for the widest array of interested parties to provide input on the measures under development and can provide critical suggestions not previously considered by the measure contractor or its technical expert panel (TEP)1.

1Since this measure builds off of the measure methodology of the hospital-wide readmission measure that is already in public reporting, a TEP was convened just to identify feasible data elements that we could include in risk model development and testing. A TEP has not been reconvened to review the eMeasure.

Specific Project Objectives:

The purpose of the HWR eMeasure is to enhance the original hospital-wide readmission measure by including clinical data elements captured at the start of an episode of care in electronic health records (EHR). This enhancement is in response to stakeholder feedback expressing a need for clinical information in risk adjustment models.

The measure uses the methodology from the original HWR measure but adds clinical data to the risk adjustment strategy. We only included clinical data elements that were found to be consistently captured under current clinical practice and feasibly retrieved from EHRs by a 2013 TEP. This measure has been tested in a dataset from an integrated hospital system consisting of 21 hospitals. At this stage of measure development and testing, we are seeking feedback on the measure concept and clinical data elements used in the risk adjustment models for each specialty cohort.

Further measure testing in a larger, more diverse data set will occur once such data is available. Similarly, the value sets and logic surrounding those value sets will be available for public comment in 2015.

The Development Process Includes:

  • Identifying important quality goals related to a topic/condition or setting of focus.
  • Conducting literature reviews and grading evidence.
  • Defining and developing specifications for each quality measure.
  • Posting for public comment.
  • Testing measures for reliability, validity, and feasibility.

To Provide Public Comments, Note the Following:

  • The public is encouraged to submit general comments on the entire measure set or comments specific to certain measures.
  • At the end of the public comment period, all public comments will be posted on the Web site.
  • Do not include personal health information in your comments.

Instructions for Providing Comments:

Please follow the instructions at the top of this webpage and email your comments to: HybridHWReMeasure@yale.edu. Comments are due by close of business August 8, 2014.

 

All-Cause Acute Admission Rates For Patients With Heart Failure and Diabetes

Dates:

The public comment period ended on May 19, 2014.

Project Overview:

The Centers for Medicare & Medicaid Services (CMS) has contracted with Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (CORE) to develop quality measures for patients with heart failure, diabetes, and multiple chronic conditions. We are developing claims-based risk-adjusted admission measures for patients in Accountable Care Organizations (ACOs). The purpose of this project is to assess the quality of care to Medicare beneficiaries and promote improvement.

This public comment period is for the heart failure and diabetes admission measures. We will hold a separate public comment period for the multiple chronic conditions measure later this spring.

Project Objectives:

• Identifying important quality goals related to these chronic conditions

• Conducting literature reviews and exploratory analyses

• Defining and developing specifications for each quality measure

• Convening a technical expert panel to provide input during development and evaluate the proposed measures

• Posting measures for public comment to solicit the widest possible array of input on the measures

• Testing measures for reliability, validity, and feasibility

• Refining measures as needed

Documents and Measures for Comment:

The following documents are provided for your review and comment and are found in the Downloads section of this site:

  • Heart Failure and Diabetes Draft Measures Technical Report
  •  Technical Expert Panel Summary Report

 

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Instructions/Information:

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