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Federal Register / Vol. 86, No. 147 / Wednesday, August 4, 2021 / Rules and Regulations
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TABLE 7: Patient-level data submission requirements for FY 2024 IPFQR Program measure set NQF

Measure ID

Measure
0640

HBIPS-2

Hours of Physical Restraint Use
0641

HBIPS-3

Hours of Seclusion Use
0560

HBIPS-5

0576
NIA

FUH
SUB-2 and SUB-2a SUB-3 and SUB-3a
Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Follow-Up After Hospitalization for Mental Illness Alcohol Use Brief Intervention Provided or Offered and SUB-2a Alcohol Use Brieflntervention Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol and Other Drug Use Disorder Treatment at Discharge Tobacco Use Treatment Provided or Offered and TOB-2a Tobacco Use Treatment Tobacco Use Treatment Provided or Offered at Discharge and TOB-3a Tobacco Use Treatment at Discharge Influenza Immunization Transition Record with Specified Elements Received by Discharged Patients Discharges from an Inpatient Facility to Home/Self Care or Anv Other Site of Care Timely Transmission of Transition Record Discharges from an Inpatient Facility to Home/Self Care or any Other Site of Care Screening for Metabolic Disorders Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an Inpatient Psychiatric Facility Medication Continuation Following Inpatient Psychiatric Discharge COVID-19 Healthcare Personnel HCP Vaccination Measure
NIA

1659
NIA

TOB-2 and TOB-2a TOB-3 and TOB-3a IMM-2
NIA

NIA

NIA

NIA
2860

NIA
NIA

3205

Med Cont
NIA
NIA

No claims-based Yes Yes
Yes Yes Yes Yes
Yes
Yes No claims-based No claims-based
No calculated for HCP
Measure is no longer endorsed by the NQF but was endorsed at time of adoption. Section 1886s4Dii of the Act authorizes the Secretary to specify a measure that is not endorsed by the NQF as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. We attempted to find available measures for each of these clinical topics that have been endorsed or adopted by a consensus organization and found no other feasible and practical measures on the topics for the IPF setting.

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Submission of aggregate data requires facilities to abstract patient-level data, then calculate measure performance prior to submitting data through the QualityNet websites secure portal. For measures for which we would require patient-level data submission, we would allow facilities to submit data using a tool such as the CMS Abstraction &
Reporting Tool CART. This is the tool we use in our other quality reporting and value-based purchasing programs, and therefore, we believe that many facilities may already have familiarity with using this tool to abstract and report data. Additionally, the tool has been specifically designed to facilitate data reporting and minimize provider burden.

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We note that under aggregate data reporting, facilities submit aggregate numerators and aggregate denominators for all measures to CMS in the Hospital Quality Reporting HQR system. These aggregate numerators and denominators are generally calculated by manually abstracting the medical record of each included patient using the algorithm, a paper tool, or a vendor abstraction tool.
After each required medical record has been abstracted, the numerator and denominator results are added up and submitted as aggregate values in the HQR system. Under our patient level data reporting proposal, facilities would still manually abstract the medical record using either a vendor abstraction tool or an abstraction tool provided by CMS. The vendor abstraction tool or the
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CMS tool would then produce an individual XML file for each of the cases abstracted. Instead of submitting the aggregate data, the IPF would log into HQR and upload batches of XML files that contain patient level data for each measure with data from all patients whose records were abstracted, and CMS would calculate the aggregate numerators, aggregate denominators, and measure rates from those XML file submissions. Because facilities must abstract patient-level data as one step in calculating measure results, we do not believe that requiring patient-level data submission would increase provider costs or burden associated with measure submission.

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COVIDHCP

Patient-Level Data Submission Yes, numerator only Yes, numerator onlv Yes