Ascension’s Experience With eCQMs: Zoom Out Before Zooming In

During a panel session on the shift to electronic clinical quality measures (eCQMs) at the Spring NAACOS conference this week, Pranali Trivedi, senior director of Medicare performance for Ascension, said her health system learned it had to broaden the scope of its eCQM initiative beyond just the Medicare Shared Savings Program in order to gain traction and funding support internally.

Ascension has 10 accountable care organizations (ACOs) across the country. Trivedi explained that the nonprofit Catholic health system began its  journey into eCQM strategy and implementation over four years ago. The year 2021 was the first year that three of its ACOs began reporting eCQMs successfully. For 2025 it plans to submit eCQMs for all of them. 

“The big theme for us is heterogeneity. There is not a single ACO across our organization that looks the same. As a mission-based organization, sustainable long-term quality improvement is a core of our mission. We look at eCQMs as the driving force for us to really push forward all of these things,” Trivedi explained. “One, it aligns with our mission. Two, it allows us to look at the root cause of any discrepancies. We have a really big effort to understand our discrepancies across various populations. It allows us to standardize our clinical practice across the enterprise. As much as we think that we have clinical protocols in place, eCQMs allows us to go a few layers deeper and understand where there is variation, and why.”

One of Ascension’s medical directors told her that although the switch was really hard in the beginning, he was actually very glad they moved to the eCQM methodology, because it allows them to to practice what they preach — to deliver the same caliber of care to every single patient, regardless of their payer type. 

But Trivedi admitted that five years ago, they looked at all this with tunnel vision specific to the MSSP requirements. “We asked what is this? How do we do it? How do we get involved and what do we need to do?”

Ascension developed an eCQM strategy. They started going down the path of understanding their technology requirements and what it was going to take and what it was going to cost.

 “Pretty quickly, we realized it’s kind of hard to convince a lot of people to spend a lot of money for one program, so we had to go back to the drawing board and really consider what was the overall big picture we were trying to achieve,” Trivedi said. “We zoomed out quite a bit, and we started to understand that for us, the value-add of pursuing eCQMs is bigger than just the Medicare Shared Savings Program. If it is for all patients, all payers, it allows us to have this experience of a rising tide raising all those ships. It’s going to positively impact our performance with our other value-based arrangements, with our employee health plan, with our vulnerable populations that we’re focused on. It’s sort of multi-fold in that way.”

The other thing they started thinking about was their alignment with their acute enterprise. “Our hospitals are subject to eCQM reporting in various programs,” she said. “We were trying to align with our internal acute care leaders on how we can standardize this across the enterprise to communicate a common goal and a common movement?”

In that education phase of their approach, it was really about engagement and educating internal stakeholders about what this is, why it’s important, and what’s in it for them from every angle of the organization, whether it was population health or enterprise, compliance, quality, informatics, technology and so on. “Going door to door, and explaining the why and what’s in it for me was really critical for us,” Trivedi added.

In parallel, they had tactical projects in place to understand their environment. “We were doing a pretty massive inventory and gap analysis to understand, what kinds of needs we had, and every ACO is different. We have some that are single-instance EHRs, which are relatively straightforward,” she said. “We have other networks and ACOs that are very large clinically integrated networks that have every flavor of EHR under the sun. We had to have some strategy conversations around what’s the long-term plan for the participants in some of those complex networks? So we had those two parallel projects, as well as the third, which was the baseline performance assessments. We were including that in our initial landscape assessment and gap determinations.”

All of that is ultimately feeding the list of all of the things they had to do, which became very long very quickly. That began in 2021 and still is ongoing, because it’s ever-evolving. The education/engagement period was in 2021, 2022, and into 2023. Implementation and improvement is something that Ascension has entered into as of 2023, 2024 and now 2025. “For us, this is really about the constant audits that we do internally to look at mapping, the break/fixes, the clinical standards, the engagement of the specialists by measure, and really thinking about outside data interoperability as well,” she explained. 

Lessons learned

Trivedi distilled down several lessons learned at Ascension. The first is zoom out before zooming in. “Our experience was trying to do this in a small program-specific fashion, and we realized quickly that we needed to consider a much larger picture.”

Second is staying ahead of industry changes, — looking at their current state vs. where they’re trying to be, and really engaging all of those different facets, whether it’s tech or clinical or informatics or education. “This is a never-ending process, as it is in quality, right? We had to make sure that we have the processes and the structure in place to constantly evolve.”

Ascension also conducts regular audits on a monthly to quarterly basis, depending on the ACO. They create a sample of patients for every measure, and follow the trail and see what’s working, what’s not, what’s mapped, and what isn’t. They study where there are opportunities to standardize and where they need to fix things that are broken, but also what big-picture things could be improved.

The health system is using its CQM data for the purpose of not just reporting for the MSSP, but also looking at this to inform other strategies and and opportunities internally. 

All of this is complicated, so it requires a crawl/walk/run approach, Trivedi said. “We cannot solve for every single thing on the list in the very first step, and we learned that the hard way. Initially, we thought we would just plan this out, get the list, get it done. And very quickly, we realized that this was going to be an ongoing effort that required prioritization. Was technology the first priority? Was it the resources? Was it the clinical lens? “In different markets for our different ACOs, everyone has a little bit of a different answer and approach, but the important thing is to be able to prioritize.”