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CMS Hospital Quality Reporting System Now Accepting CY 2019 eCQM Data

September 25, 2019 - 09:46pm

The Centers for Medicare & Medicaid Services (CMS) is notifying hospitals and vendors that the Hospital Quality Reporting (HQR) system is now accepting electronic clinical quality measure (eCQM) data for the calendar year (CY) 2019 reporting period. The system, accessible via the QualityNet Secure Portal, has been updated to accept Quality Reporting Document Architecture (QRDA) Category I test and production files utilizing the CY 2019 requirements.

NOTE: Test QRDA Category I data submissions are considered practice and do not count towards CMS program credit. Production QRDA Category I data submissions are provided by hospitals, or by health IT vendors on the hospital’s behalf, as final data submissions intended to fulfill the eCQM reporting requirements for the Hospital Inpatient Quality Reporting (IQR) and Promoting Interoperability Programs.

What are the CY 2019 eCQM reporting requirements?

Hospitals are required to submit at least four of the available 15 eCQMs for one self-selected quarter of CY 2019 data (Q1, Q2, Q3 or Q4) by the reporting deadline of March 2, 2020, 11:59 p.m. Pacific Time. The successful submission of eCQMs includes any combination of QRDA Category I files with patients meeting the initial patient population of the applicable measure(s), zero denominator declarations, and/or case threshold exemptions. Use of the zero denominators and case threshold exemptions only apply if the hospital has electronic health record (EHR) technology certified to report the eCQMs. The eCQM reporting requirements are posted on the QualityNet website.

Have the program overview and preparation checklists been updated for CY 2019 eCQM reporting?

CMS has developed and posted updated resources to assist with the reporting of CY 2019 eCQM data for the Hospital IQR Program and the Promoting Interoperability Program for eligible hospitals and critical access hospitals. You may view these documents under the eCQM Resources pages on the QualityNet and Quality Reporting Center websites.

The updated resources include:

Where can I find all of the technical materials for reporting eCQMs specific to the CY 2019 reporting period?

The eCQI Resource Center is the one-stop shop for the most current resources to support electronic clinical quality improvement. A number of reference materials are available for download including the CY 2019 QRDA Category I Implementation Guide, Schematron and sample files, eCQM specifications, an eCQM annual update implementation checklist, and the eCQM value set addendum.

Where can I learn about changes to the CY 2019 QRDA Category I Implementation Guide (IG) for HQR and updates to the Health Level Seven (HL7) base standard?

Visit the archive of the Quality Reporting Center website to review the CMS QRDA Category I Implementation Guide Changes for CY 2019 Hospital Quality Reporting March 27, 2019 webinar materials that outline the IG changes, document-level template changes and provide a high-level overview of updates to the HL7 base standard.

When will the Pre-Submission Validation Application (PSVA) become available?

The PSVA tool, updated with the CY 2019 Category I Schematron and standards, is now available. The PSVA tool contains the CY 2019 Schematron for hospitals and their vendors to conduct file format checks of test and production QRDA Category I files. The PSVA tool also provides a report to identify errors in the file(s) prior to file submissions. Visit QualityReportingCenter.com to locate materials from the August 8, 2018 webinar PSVA Overview for eCQM Data Submission in Calendar Year 2018.

Are there updates to the Next Generation of HQR features mentioned in the September 4, 2019 communication?

In a September 4, 2019 Listserve message, CMS shared information on new, enhanced features phasing into the QualityNet Secure Portal over the next several months as part of the Next Generation of HQR. We recommend hospitals and vendors refer to the eCQM Next Generation of Hospital Quality Reporting Navigation Guide (now available for download) to view their submitted eCQM data via three new features: 

  • Files History. This feature provides near real-time data, which allows you to track the status of your QRDA Category I file submissions (processing, completed, deleted, etc.). This screen will ultimately replace the information provided by the EHR Hospital Reporting–Submission Summary Report, which will no longer be available after the end of the CY 2019 eCQM submission period.

  • Data Accuracy. This feature will offer enhanced messaging when the system performs QRDA Category I file format validation. This screen will ultimately replace the information provided by the EHR Hospital Reporting–Submission Detail Report, which will no longer be available after the end of the CY 2019 eCQM submission period.

  • Measure Outcome. This feature will provide messages filtered by eCQM, submission type, and submission quarter. When the feature is fully implemented, it will also provide performance rates that will allow multiple quarter trending as the data are submitted; this screen will eventually replace the functionality provided by the EHR Hospital Reporting–eCQM Submission and Performance Feedback Report and the eCQM Performance Summary Report, both of which will no longer be available after the end of the CY 2019 eCQM submission period.

NOTE: During the phase-in period of the Next Generation updates, users will continue to access the QualityNet Secure Portal to perform CY 2019 eCQM data reporting by choosing the Hospital Inpatient Quality Reporting selection from the drop-down menu on the Choose Your QualityNet Destination screen.

Contacts

  • For questions concerning the QualityNet Secure Portal, PSVA tool, and file error messages, contact the QualityNet Help Desk at qnetsupport@hcqis.org or (866) 288-2912.
  • For questions regarding eCQM specifications, value sets, and appropriateness of mapping, contact the Office of the National Coordinator for Health Information Technology (ONC) eCQM Issue Tracker here.  
  • For questions regarding the Hospital IQR Program, contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contract team here or (844) 472-4477.
  • For questions regarding the Promoting Interoperability Program (formerly referred to as the EHR Incentive Program) contact the QualityNet Help Desk at qnetsupport@hcqis.org or (866) 288-2912.
Last Updated: Sep 26, 2019