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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
Because we believe that patient-level data would improve the data accuracy without increasing provider burden, we proposed to adopt patient-level data reporting for numerators only for the Hours of Physical Restraint Use HBIPS
2, NQF 0640 and the Hours of Seclusion Use HBIPS3, NQF 0631
for numerators and denominators for the following 9 chart-abstracted IPFQR
Program measures as detailed in Table 7: Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification NQF 0560;
Alcohol Use Brief Intervention Provided or Offered and SUB2a Alcohol Use Brief Intervention; Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB3a Alcohol and Other Drug Use Disorder Treatment at Discharge; Tobacco Use Treatment Provided or Offered and TOB2a Tobacco Use Treatment;
Tobacco Use Treatment Provided or Offered at Discharge and TOB3a Tobacco Use Treatment at Discharge;
Influenza Immunization NQF 1659;
Transition Record with Specified Elements Received by Discharged Patients discharges from an Inpatient Facility to Home/Self Care or Any Other Site of Care; Timely Transmission of Transition Record Discharges from an Inpatient Facility to Home/Self Care or any Other Site of Care; and Screening for Metabolic Disorders.
We believe that it is appropriate to transition to patient-level reporting incrementally. This would allow facilities to become familiar with the data submission systems and to provide feedback on any challenges they face in reporting data to us. Therefore, we proposed to allow voluntary patientlevel data submission for the FY 2023
payment determination that is, data submitted during CY 2022. We note that because participation in patientlevel reporting for these chart-abstracted measures would be voluntary for this one-year period, facilities would be able to choose whether to submit measure data in aggregate or at the patient level, and would not face a payment reduction as long as they submit all measure data either at the patient level or in aggregate for each measure for which reporting is required, and as long as they met all other IPFQR Program requirements.
Therefore, we are proposed to allow voluntary patient-level reporting prior to requiring such data submission for one year prior to the FY 2024 payment determination. We will ensure that facilities have guidance available through our standard communications channels that is, listserv announcements, educational webinars,
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and training material on the QualityNet website.
We also proposed to require patientlevel data submission for these chartabstracted measures for the FY 2024
payment determination that is, data submitted during CY 2023 and subsequent years.
We welcomed comment on our proposals to allow voluntary patientlevel data reporting for these chartabstracted measures for the FY 2023
payment determination and then to require patient-level data reporting for the FY 2024 payment determination and subsequent years.
We received the following comments in response to our proposal.
Comment: Many commenters supported the adoption of patient-level reporting. Many of these commenters supported initiating the process with one year of voluntary participation. One commenter observed that having patient level data would help accurately identify trends and improve outcomes and with demographic data could help identify health disparities. One commenter specifically supported the numerator only patient-level reporting for HBIPS2 and HBIPS3. One commenter observed that HBIPS2 was listed twice in the proposed rule 86 FR
19514.
Response: We thank these commenters for their support.
Comment: Some commenters recommended that CMS use a more gradual transition to patient-level reporting. One commenter specifically recommended two cycles of voluntary reporting to ensure that the data submission system works properly.
Others recommended that CMS provide additional guidance and education, including XML specifications or other reporting templates prior to the voluntary reporting period. One commenter recommended aligning guidance across programs. One commenter observed that the start date for collecting data for the mandatory reporting period is before the data submission timeframe for the voluntary reporting period.
Response: We recognize that IPFs will need additional guidance and education in preparation for patient-level reporting. We will provide templates, guidance, and education and outreach sessions prior to beginning patient level reporting. We note that, to the extent feasible, we will align guidance across programs. We do not believe that it is necessary to have a longer voluntary reporting period because many IPFs also have experience with these tools already and we have extensive experience with patient-level reporting, both using
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electronic data reporting systems, and using tools such as the CMS Abstraction & Reporting Tool CART in our other quality reporting programs and intend to provide templates, guidance and education and outreach to IPFs.
Comment: Some commenters recommended that CMS not require patient level reporting for measures proposed for removal.
Response: We note that the measure being removed from the IPFQR Program Timely Transmission of Transition Record Discharges from an Inpatient Facility to Home/Self Care or any Other Site of Care is being removed for FY
2024 payment determination and subsequent years. The first year of mandatory patient-level reporting is FY
2024 payment determination. Therefore, this measure will no longer be in the program when patient-level reporting is required. We further note that we are not finalizing our proposals to remove Alcohol Use Brief Intervention Provided or Offered and Alcohol Use Brief Intervention SUB2/2a and Tobacco Use Treatment Provided or Offered and Tobacco Use Treatment TOB2/2a;
and therefore these patient-level data reporting will be required for these measures beginning with the FY 2024
payment determination.
Comment: Some commenters oppose patient level reporting because of a lack of technology. Some commenters observed that CMS should assist with development of EHRs in the same way they did for acute care hospitals. One commenter observed that patient-level reporting would be burdensome without EHR technology.
Response: We disagree with commenters that EHR technology is necessary for patient level reporting and note that acute care hospitals reported patient-level data for the Hospital IQR
Program prior to the introduction of the HITECH act and associated meaningful use incentives. We further note that because IPFs must abstract the same data from patient records regardless of whether they are reporting at the patient-level or in aggregate, we do not believe that submitting patient-level data is more burdensome than aggregate data reporting for providers whether or not they have EHR technology.
Comment: One commenter requested clarification on the start date for voluntary patient-level data submission for FY 2023. This commenter specifically requested clarification on whether that would be for discharges beginning for FY 2023 or CY 2023.
Response: The voluntary patient-level data submission period is for FY 2023
payment determination. This applies to the data submitted during CY 2022

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