5 Things Organizations May Not Realize About ECDS Measures

What Is ECDS?

ECDS measures have been a topic of conversation for quite a few years now in the managed care realm of healthcare organizations. For those readers who may not be familiar with ECDS, it stands for Electronic Clinical Data Systems. The National Center for Quality Assurance (NCQA) has developed this standard as a version of HEDIS (Health Effectiveness Data and Information Set) measures. It is important to know that NCQA is a non-profit accreditation agency, one of the largest ones in the United States, and is the steward of HEDIS, which is used to measure quality improvement for managed care organizations. More than 60% of the US population is enrolled in a health plan which reports on HEDIS measures and many states as well as the Centers for Medicare and Medicaid Services (CMS). Now we could have a whole discussion about HEDIS and NCQA, and I will probably write a post about it in the future. For now, if you want to know more about that, feel free to read it straight from the source; I posted a link to the NCQA website below.

ECDS measures define data sources and types as part of the measure logic and only accept electronic data sources. Many people associate it with Digital Quality Measures (dQMs) or Electronic Clinical Quality Measures (eCQMs), but they are very different. dQMs are quality measures that specify that data must be in a digital format and uses standardized definitions and language like Clinical Quality Language (CQL) or Fast Healthcare Interoperability Resources (FHIR). eCQMs are measures designed for meaningful use, the CMS EHR Incentive program for providers and hospitals.

The main topic of conversation for ECDS recently is the fact that NCQA is retiring the Breast Cancer Screening (BCS) measure in measurement year 2023 (MY23) and replacing it with the ECDS version (BCS-E). More importantly, the same is happening for Colorectal Cancer Screening (COL) in measurement year 2024 (MY24). Why is that a big deal? COL is the quality measure with the longest lookback period. One of the compliance criteria is having a colonoscopy within the past 10 years. Since ECDS requires data to come from an electronic source, you need electronic proof if you don’t have a claim from 10 years ago. Typically, most plan members haven’t been with that plan for 10 years, so the chances of having the claim in their system aren’t very good. This brings me to the first thing most managed care organizations (MCOs) may not realize about ECDS measures and the logic behind calculating them.

1. ECDS does not mean only standard supplemental data.

This is a very common misunderstanding of ECDS measures and the data allowed to be used for it. Supplemental data is any data that is not considered administrative data. Administrative data are that which are considered to be part of the MCO’s administrative processes, usually meaning claims. There are two types of supplemental data, standard and non-standard. An MCO must contract with an NCQA-certified auditor to perform their annual HEDIS audit, and a part of this audit is validating the organization’s data sources. All data sources are considered non-standard, no matter their source, data flow, or process, until this auditor approves for it to be treated as a standard source. The main reason is non-standard sources must go through primary source verification, where the auditor selects a random sample of the data set. The MCO must prove that the data is accurate and mapped to the proper diagnosis and/or procedure code. What typically ends up happening is any source that is well documented, automated, and does not require any manual intervention at all eventually becomes standardized per your auditor’s discretion. Whatever data requires manual intervention (like chart reviews) will always be non-standard data.

Because of the understanding that standardized data does not have a manual intervention by nature, these data sources are typically electronic. An example could be data received via a flat file or a standardized message received via an API from an Electronic Health Records (EHR) source. Immediately the assumption is that only standardized sources are usable for ECDS. This is NOT the case.

NCQA does not currently specify a method for a file format for the exchange of clinical information. This means that a record abstracted manually from an EHR can still be used for ECDS and classified as an EHR data source. It, of course, would fall under non-standard and would be subject to primary source verification by your auditor, but it is usable data. The data does not have to be from a standardized language or messaging format. So it does not have to be HL7 or FHIR (although NCQA HIGHLY recommends that it is) but can be in the form of a flat file or a Continuity of Care Document (CCD). As long as the source is electronic and can be categorized as either an EHR system, a health information exchange (HIE), a registry, case management software, or an administrative claim system, it is useable data for ECDS.

One call-out on EHR data sources, NCQA specifies that the data must be “…captured and stored in structured formats that use layouts and meet the data source requirements…” So a CCD meets this requirement, but a scanned image of a note from their prior PCP may not. To be sure, talk to your auditor and get their approval before using any data from an EHR that may give you pause or does not come from the EHR’s database.

2. CCDs are data sources, not proof for primary source verification.

We spoke a bit about CCDs in the prior section, but it is essential to call out that CCDs are excellent data sources. Some NCQA-certified analytic engines are even implementing file extracts that will ingest the CCD without the need for mapping it to a claim or supplemental file extract. But we need to think of them as just that, a data source; this is not the same as a physician’s note documenting the diagnosis or procedure done for a member, and therefore, it cannot be used during your audit as a form of the primary source of verification. It would be like trying to provide a SQL query of an EHR database as proof during this phase of your audit. This is important to keep in mind so that you can set the proper expectations with any provider or provider group supplying you with CCDs for supplemental data. Anything they send to you is subject to primary source verification by your third-party auditor, and you may need to circle back with them for notes.

3. Free and Low-cost data sources

EHRs often take the bulk of the attention for ECDS sources, which is expected, but there are many others. The HITECH act of 2009 was a catalyst for most states to implement and/or prioritize health information exchanges and registries. Most are offered at low or no cost to managed care organizations and providers for connection. In my state of Texas, for example, the Immtrac registry provides immunization data, which is incredibly helpful considering that many providers may not bill for immunizations, so it may not be represented in a claim. Still, the patient/member did receive the vaccination. Another excellent data source is EDEN (Emergency Department Encounter Notification) which provides live notifications of admission, discharge, and transfer along with important information like diagnosis, procedures, and even non-medical/social determinants of health (NDOH or SDOH). Check with your state for any HIEs or registries before connecting to higher-cost data sources.

4. Data aggregators can save you time and provide valuable data.

If you don’t have a state HIE available to you, or you are already connected, but you want additional data sources, be sure to look at the NCQA Data Aggregators available on their website; I will post a link below. Data aggregators are treated as HIEs but must undergo a certification process with NCQA. This program is excellent in that NCQA certifies these sources, and as such, they do not require primary source verification and are essentially usable right away; however, I say this with caution. There are a few callouts to keep in mind.

Look for only fully certified aggregators; their list shows vendors seeking certification in addition to those who are certified. You can still use the data if they fail certification, but it will be treated like any other supplemental data source. It must go through primary source verification by your auditor. Additionally, be sure to monitor that they keep their certification every year before using them in your project.

Also, when researching your aggregators, ask if all of their data streams are certified. NCQA certifies individual data streams; each can pass or fail certification individually. Be sure that you are clear that you only want certified data streams.

5. Increasing the number of accurate and quality data sources can improve overall reporting.

In chasing the measure requirements, it is easy to forget the primary purpose of what we are after here. At the end of the day, it is meant to support improving the quality of care for your members/patients and therefore improving outcomes. One of our most significant challenges to being effective is the inherent lag in our reporting. It is heavily dependent on claims data which has lag built-in simply because of timely filing, and chart reviews, which are resource-heavy and time-consuming. Leveraging electronic sources that are reliable, accurate, and audited by a third party at least annually, it helps to provide organizations with data much sooner than waiting for a claim would. Additionally, it shrinks down the number of gaps to be closed manually by chart reviews because if you no longer need to wait for a claim and can stand up an automated and electronic connection, there will be fewer and fewer inaccuracies in your gaps in care lists.

The last part of that last sentence is critical! I can’t count how many times I have heard the words, “this report is not correct; that patient did get XYZ screening.”

We can only produce reports as accurate as our data, and if our gaps in care lists have lag built in from claims, and providers and their staff are constantly chasing proof of compliance for a measure rather than actually treating and seeing members with genuine gaps in care, it will diminish your provider’s trust in your reporting and turn your quality improvement initiatives into a chore.

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