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The Weekly Quality Brief: Information Transfer Pro-PM, STEMI eCQM Updates, and eCQM Mapping Practices (4/23/26)

The Weekly Quality Brief: Information Transfer Pro-PM, STEMI eCQM Updates, and eCQM Mapping Practices (4/23/26)

The Weekly Quality Brief
• 32 min
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This episode covers questions from a Quality Academy Q&A session, focusing on regulatory updates, measure specifications, and implementation considerations. Program & Regulatory Topics - Status of Appropriate Use Criteria (AUC) software following CMS pause and considerations for contract renewal - Anticipated return of paused CMS requirements and implications for decision support tools - Inclusion of Medicare Advantage patients in CMS measures and current status for THA/TKA PRO-PMs - Planned removal of COMP THA/TKA from IQR and continued use in VBP and proposed payment programs Information Transfer Pro-PM - Availability of educational resources and planned future content - Definition and identification of Hospital Outpatient Departments (HOPDs) for measure inclusion - Handling anonymous survey data collection and patient linkage requirements - Workflow design for maintaining internal identifiers while preserving survey anonymity STEMI eCQM (2026 Updates) - Addition of new data elements, exclusions, and exceptions - New exception for documented reasons for not performing PCI within 90 minutes - Lack of CMS-defined acceptable reasons and reliance on clinical judgment - Use of broad value sets (e.g., contraindications, refusal reasons) - Guidance on mapping clinical documentation to structured fields - Considerations for capturing discrete data in EHR systems Sepsis (SEP-1) Specification Clarification - Use of radiology report “result date and time” versus “performed date and time” - Interpretation of specification guidance and implications for abstraction workflows - Need for EHR alignment to ensure correct date/time capture eCQM Mapping & Annual Update Process - Use of comparison spreadsheets and playbooks to identify value set changes - Importance of annual review and update of mappings in the EHR - Coordination between clinical, IT, and abstraction teams - Leveraging EHR-specific documentation and mapping guidance Benchmarking & Analytics - Current limitations of benchmarking tools (eCQMs only in Medisolv) - Use of Vizient CDB for chart-abstracted measure benchmarking - Lack of overlap between eCQM and chart-abstracted benchmarking datasets Quality Reporting Tools - Star Rating Analyzer tool functionality and limitations - Absence of hospital-specific percentile rank data from CMS