The Quality Digest
January 2022
Happy New Year!
Client Corner
Make the Most of Encor Reports: a Game Plan for Reviewing & Improving Rates
What's Next
2022 Hospital IQR Program Requirements
Start thinking about the 2022 CMS updates now so you’re prepared in advance. Your advisor will be in touch to review education and changes for 2022.
Requirement:
-
Hospitals must report three quarters of data for at least four of the available nine eCQMs. Hospitals MUST submit the Opioid eCQM as one of their four eCQMs.
Each year the CMS Inpatient Quality Reporting (IQR) program makes changes; sometimes slight and sometimes more drastic. In 2022, there are a few changes coming your way. For instance, did you know that hospitals must submit the Opioid eCQM as one of their four eCQMs this year? And instead of reporting two quarters of eCQM data you must now submit three quarters followed by an increase to all four quarters in 2023?
*Retired in CY 2024/FY 2026
|
SHORT |
MEASURE NAME |
DISCHARGE |
SUBMISSION |
|
CMS506 |
Required: Safe Use of Opioids – Concurrent Prescribing |
Any three quarters |
Feb. 28, 2023 |
|
PC-05 |
Exclusive Breast Milk Feeding* |
||
|
STK-02 |
Discharged on Antithrombotic Therapy |
||
|
STK-03 |
Anticoagulation Therapy for Atrial Fibrillation/Flutter |
||
|
STK-05 |
Antithrombotic Therapy by the End of Hospital Day Two |
||
|
STK-06 |
Discharged on Statin Medication* |
||
|
VTE-1 |
Venous Thromboembolism Prophylaxis |
||
|
VTE-2 |
Intensive Care Unit Venous Thromboembolism Prophylaxis |
||
|
ED-2 |
Admit Decision Time to ED Departure Time for Admitted Patients* |
*Retired in CY 2024/FY 2026
|
NEW MEASURES |
|||
|
SHORT |
MEASURE NAME |
VOLUNTARY |
MANDATORY |
|
HWR |
Hybrid Hospital-Wide Readmission |
7/1/22 –6/30/23 |
7/1/23 -6/30/24 |
|
HWM |
Hospital-Wide Risk-Standardized Mortality Measure (HWM) |
7/1/22 –6/30/23 |
7/1/23 -6/30/24 |
|
CMS816 |
Hospital Harm –Severe Hypoglycemia |
CY2023 |
|
|
CMS871 |
Hospital Harm –Severe Hyperglycemia |
CY2023 |
|
Education
Resources
Resources to help with your data validation
It’s time to prepare for 2022 eCQM reporting! Some of you may be adding new eCQMs to your submission list or you want to brush up on the measure logic and value sets. There are a couple great websites available with information you will find helpful when reviewing your 2022 eCQM reports.
The eCQI Resource center has links to view eCQM workflows, value sets and the measure specifications. There is a section outlining the differences between the current and previous year’s specifications and data elements. In addition, you can find information on the new Severe Hyperglycemia and Hypoglycemia measures.
VSAC, or Value Set Authority Center, provides the codes in all the value sets for the eCQM and Hybrid measures. You will need to sign up to access this website. Once you have access you will find it helpful to export the value sets you need for your selected measures.
TIPS & TRICKS
Please - No PHI!
2022 is here and soon you will start your e-CQM measure validation. Typically with data validation, the time comes when you have questions for your Quality Advisor. This is a reminder to never send PHI (Protected Health Information) in a non-secure email. You can send the Medisolv Identifier in regular email, but none of the other patient information you see below. This means no account numbers, visit IDs, encounter IDs, or medical record numbers!

Getting to Know your Medisolv Team
Kristen's 50 before 50
Hi everyone!
I’m Kristen Beatson, VP of Electronic Measures here at Medisolv. I’ve been with Medisolv for over 10 years so I’ve worked with many of you in some way over those years.
I’m supposed to share a little bit about myself, which is really awkward to do, but here goes! I graduated with my BSN from Clemson University in 1994 (eek!) and held many jobs in Pediatrics as I moved around lot (PA, GA, MD, FL…then back to MD where I am today). While working at Children’s National in DC in the late 90s, I somehow became the go-to person for computer issues and application training (we didn’t have a 24hr help desk at that time)…therein began my love for informatics and the rest, as they say, is history. Professional experience aside, in my spare time, my husband and I are busy with 2 teenage boys (Solomon 14, Liam 15), I sit on the board of directors for a local non-profit (Kindness Grows Here) and am heavily involved with K-9 Lifesavers Dog Rescue where I assist with administrative work and foster dogs (we just fostered our 22nd pup!).
I started my 50th trip around the sun this past November and as a part of that have created a “50 b4 50” list, 50 things I want to do before I turn 50. One of the items on the list was to jump off the top of The Stratosphere in Las Vegas which I did on November 16th! It was the scariest thing I’ve ever done, that first step was a doozy. The rest of the list isn’t as adventurous thank goodness, and I’m looking forward to tackling them in 2022.
As we start the New Year, I want to express my thanks for everything you do for healthcare and for your patients; you’ve been on my mind daily over the past few difficult years. I hope that 2022 brings you joy and love, and good health.
-Kristen
Trivia
Trivia
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