Health IT and Electronic Health Activate your FREE membership today |  Log-in

Community Blog

Dec 11 2013   11:28AM GMT

Evaluate and enhance your core measures reporting process

Posted by: adelvecchio
abstraction, core measures, Meaningful use

BrendaBartkowski_AmphionMedicalGuest post by Brenda Bartkowski, clinical data abstraction manager, Amphion Medical Solutions

From meaningful use to value-based purchasing, too much is riding on core measures reporting to leave it to chance. Hospitals must have processes and resources that are capable of delivering timely and concise reporting.  They must educate clinicians and other staff on core measures and keep definitions and protocols up to date. All of these resources should be leveraged to improve performance rates and avoid financial penalties.

As the stakes get higher, so too does the level of difficulty involved in maintaining compliant reporting processes. The number of measures has continued to climb, increasing the level of difficulty of abstracting and validating the data. There is also a limited supply of internal resources and expertise that can be dedicated to reporting.

As such, to ensure effective core measures reporting, hospitals should evaluate the processes in place to identify and eliminate any aberrant patterns or areas of weakness contributing to backlogs or missed deadlines. Addressing these issues will do more than streamline reporting and improve compliance. It will also create a means by which documentation and processes can be enhanced and best practices put into place in order to drive improvements to publicly-reported core measures.

Three-pronged analysis

The evaluation of core measures reporting process should focus on three areas: deadline compliance, validation rates and regulatory comprehension.

Missed deadlines can almost always be traced back to a lack of resources. Integrating reporting requirements with the additional core duties for which quality departments are now responsible is a resource balancing act, particularly given the rapid rise in the number of metrics that must be reported under the Hospital Inpatient Quality Reporting Program.

When abstractors must divide their time and attention between core measures reporting and their regular responsibilities, backlogs can quickly and deadlines are often missed. Once one deadline is missed, the resulting domino effect makes it difficult to catch up unless additional resources are dedicated to the process.

Overextended abstractors may also struggle to maintain appropriate validation scores, which should be in the 90-95% range. Consistently low scores may signal the need for additional training, creating yet another Catch-22. How do you set aside time for training to bring scores up when heavy workloads are contributing factors to the performance issue?

Finally, regulatory policies and recommendations from the Centers for Medicare and Medicaid Services and The Joint Commission tend to change from one reporting period to the next, while protocols and guidelines are revised and expanded annually. It can be difficult to maintain compliant reporting processes without dedicating a resource to monitor regulatory change and educate clinicians and staff on current core measures and proper abstraction. Thus, an individual should be tasked with continuously monitoring and communicating any changes to guidelines, metrics or requirements so they can immediately be integrated into the reporting process.

Seek outside help

In many cases, weaknesses in any (or all) of these areas can be traced back to insufficient resources.  That is why a growing number of hospitals are outsourcing their core measures abstraction to qualified firms, thus freeing internal resources to focus on core responsibilities.

The success or failure of outsourcing core measure reporting rests on the quality of the selected partner. Look for a vendor that employs only credentialed abstractors with a minimum of three to five years of experience, all of whom should have passed a stringent proficiency test. The firm should be able to deliver an accuracy rate of no less than 95%.

Finally, the partner should provide additional services designed to strengthen the hospital’s core measures performance. These could include weekly and quarterly education sessions, regular evaluations and recommendations for process and documentation improvements.

Maximize value

Regardless of whether it is managed in-house or outsourced to a qualified vendor, reporting processes should be used to drive improved core measures performance by identifying gaps and recommending process enhancements to close them.

One example could be a hospital consistently failing the substance or tobacco use measure sets. An abstractor empowered to go beyond standard “pass-fail” core measure reporting could trace that failure to clinicians neglecting to ask patients about their smoking or alcohol use when completing admission documentation –a situation that can be fixed by simply adding or highlighting the query in the admission order set.

At a higher level, reports can be generated that identify every outlier in order to diagnose the documentation issue which caused the core measure failure. This report can also be used to identify problematic trends that can be corrected with adjustments to order sets or documentation processes. It can even help identify individual clinicians who may require additional education.

Improving core measure performance is a team effort. Providing information to those on the clinical front lines to improve documentation will ultimately drive quality outcomes. Doing so requires strong, compliant and comprehensive reporting processes that reveal the cause core measure failures which can be corrected and improved before they affects quality of care or the bottom line.

Brenda Bartkowski is the clinical data abstraction manager for Amphion Medical Solutions. She can be reached at

Comment on this Post

Leave a comment:

Forgot Password

No problem! Submit your e-mail address below. We'll send you an e-mail containing your password.

Your password has been sent to: