Stroke, VTE a no show in CMS proposed IPPS rule but added as TJC core measures
CMS says changes to proposed 2010 IPPS rule are 'minimal'
While measure sets on venous thromboembolism (VTE) and stroke were expected to be part of the Centers for Medicare & Medicaid Services' (CMS) recently released proposed 2010 rule for the inpatient prospective payment system (IPPS), the draft did not include those as required measure sets for reporting in 2010. But they did show up as two additional core measure sets from The Joint Commission and are outlined in the newest released specifications manual set forth from TJC and CMS.
"We were actually a little surprised" that stroke and VTE appeared in the IPPS proposed rule only as possible measure sets for the future but not required for reporting in 2010, says Brett Bennett, senior vice president, Quality Indicator Project, Maryland Hospital Association. In the specifications manual released jointly by CMS and The Joint Commission in April, VTE and stroke were added as core measures by TJC, and an informational-only ED measure set was added by CMS.
"Conversationally, most people assumed that those three additional measures [VTE, stroke, and ED measure sets] would be required" in the 2010 IPPS rule, Bennett says.
"I've learned over the years to never be surprised at what CMS proposes in its inpatient or outpatient rules. This might be cynicism coming out, but I would like to believe that somewhere, somehow there's a master plan for all of this," says Jerod M. Loeb, PhD, executive vice president for quality measurement and research at The Joint Commission.
"CMS doesn't talk only to us before they decide which measures to propose… It would be really nice if the decisions were made in response to a consensus forum in which the strategic discussions had taken place.
"[F]rom a quality perspective, onesie-twosie measures are not going to help organizations improve their quality," Loeb says. Rather than putting together a "constellation of measures," which would be more effective for quality improvement, he says CMS is "cherry picking a measure here and a measure here." He points out that The Joint Commission, before releasing a performance improvement measure, gains endorsement of the National Quality Forum (NQF). "And as you have seen in terms of what has come out of CMS, sometimes the measures are NQF-endorsed and sometimes they're not NQF-endorsed."
For its part, CMS explains that the "minimal" changes included in the 2010 IPPS proposed rule were minimal for a reason.
The dawn of EHR data collection?
CMS attributes the limited number of additional measures in the 2010 IPPS proposed rule to two major factors: workload and EHR adoption.
Had it added the VTE and stroke measure sets, Michael Rapp, MD, JD, CMS quality measures lead, says "it would have meant that hospitals would have had to do chart abstraction for those measures. The secretary indicated in the proposal that would increase the amount of chart abstraction and work involved for the hospitals at a time when we seek to move toward electronic health record collection of such measures."
He adds that the addition of two proposed SCIP measures would require very limited additional data abstraction, as the data gathered are from charts already being abstracted for other surgical care measures. "If we had moved to stroke or VTE measures, then [hospital staff] would have had to deal with a whole new set of patients."
Though it sounds like a benevolent gesture to hospitals to minimize additional work burden in 2010, Rapp reemphasizes the reason: CMS is preparing for the much simpler days ahead of collecting data from electronic health records.
But Loeb questions just how far into the future those days are.
He refers to a New England Journal of Medicine paper written by Ashish K. Jha, MD, MPH, associate professor of health policy and management at the Harvard School of Public Health.1 "[T]hat paper said the general level of implementation of an electronic health record in America's hospitals is extremely small. A very sophisticated EHR was found in something like 1.6% of the hospitals. And a very rudimentary EHR is in something like 7.5% or 7.6% of hospitals," Loeb says.
"And certainly the $20 billion plus or minus a bit that's being spent as part of the stimulus package, both in terms of physician office implementation as well as hospital implementation, is going to make an inroads here," he says. "But at the end of the day, I think there's a lot of hope and desire, which may or may not be balanced by the state of the art technically... In a perfect world, data collection would be a byproduct of health care delivery. We don't live in a perfect world today, and I don't think we're going to be living in a perfect world in two or three years, which is the timeline associated with this notice of proposed rulemaking through 2012."
Creating a "one-size-fits-all solution" to data collection is not so easily done when "we've got hospitals out there that are still at a crayon and paper stage," Loeb says. And given the financial climate of today, that perfect world of widespread and sophisticated EHR adoption may be even longer in coming, he adds.
(Editor's note: Comments on the CMS proposed 2010 IPPS rule will be accepted through June 30.)
Reference
- Jha AK, DesRoches CM, Campbell EG, et al. "Use of electronic health records in U.S. hospitals" NEJM 2009 Apr 16;360(16):1628-38. Epub 2009 Mar 25.
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