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ASCA Survey Provides Insight into Reporting ASCQR Measures
Surgery centers with and without EHR show different trends
BY ALEX TAIRA | AUGUST 30, 2024
ASCA’s August 2024 60-Second Survey asked questions regarding the time and resources necessary to report measures in the Medicare ASC Quality Reporting (ASCQR) Program. The survey received 321 responses from surgery centers in 46 states.
Survey Results
Overall, 97.5 percent (313/321) of survey respondents attested to their facility participating in the ASCQR Program. The facilities that do not participate are either new, not Medicare certified or do not meet the volume threshold (240 Medicare claims per year) required to participate.
ASCA asked about the time it takes to collect, summarize and submit data through the two portals required as part of the ASCQR Program. Seven measures—ASC-1: Patient Burn; ASC-2: Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; ASC-4: All-Cause Hospital Transfer/Admission; ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients; ASC-13: Normothermia Outcome and ASC-14: Unplanned Anterior Vitrectomy—are submitted via the Hospital Quality Reporting (HQR) portal. Almost 60 percent of respondents said that it takes staff less than 10 hours per year to collect, summarize and submit data via the HQR portal. However, 17.2 percent of respondents said that it takes greater than 20 hours per year.
One measure, ASC-20: COVID-19 Vaccination Coverage Among Health Care Personnel, is submitted via the National Healthcare Safety Network (NHSN) reporting tool, which is overseen by the Centers for Disease Control and Prevention (CDC). ASCA has written formal comments opposing this measure’s continued presence as part of the ASCQR Program. Almost 75 percent of respondents said that it takes less than 10 hours per year to collect, summarize and submit their staff’s COVID-19 vaccination data through the NHSN reporting tool each year; 10.4 percent responded that this task takes more than 20 hours per year.
In addition to the time necessary to collect, summarize and submit quality reporting data, a majority of facilities attested to having experienced technical issues with the HQR portal or the NHSN reporting tool. Almost 66 percent of survey respondents reported having experienced an issue with one or both systems that prolonged the process of submitting quality data.
Electronic Health Record (EHR) Usage
Fifty four percent of facilities reported that they use an electronic health record (EHR) system to facilitate their quality reporting. This proportion is in line with ASCA estimates of the proportion of surgery centers that use an EHR overall. Facilities that use an EHR did report slightly lower times to collect, summarize and submit quality data. For example, only 14 percent of facilities that use an EHR reported needing more than 20 hours to complete this task via the HQR Portal. The proportion of facilities that do not use an EHR and spend more than 20 hours per year collecting, summarizing and submitting data was 50 percent higher than facilities using an EHR (21 percent).
Proposed Additions to the ASCQR Program
In the CY 2025 OPPS/ASC proposed rule, the Centers for Medicare & Medicaid Services (CMS) proposed to add three measures to the ASCQR Program. The agency proposed to add a Facility Commitment to Health Equity (FCHE) measure beginning with the 2025 reporting period, as well as two Social Drivers of Health (SDOH) measures with mandatory reporting beginning in 2026. In formal comments on the proposed rule, ASCA will request that the measures be postponed to further refine their applicability to surgery centers. Particularly with regard to the FCHE measure, ASCA believes that with the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey set to become mandatory next year as well, it is unreasonable to add another measure to the ASCQR Program next year that has not yet been tested in the outpatient setting.
ASCA introduced the 60-Second Survey, a quarterly survey series, in spring 2021. As the name suggests, each survey takes 60 seconds or less to complete and asks fewer than 10 questions on a current topic. The topic changes survey to survey, but each aims to take the pulse of the ASC community and help ASCA better serve its members and the ASC community at large.
Write Alex Taira with questions about this survey or to propose topics for future surveys.