eCQM Addendum Checklist

Pre-Check

1) Sign up for UMLS account

This account will allow you to access the National Library of Medicine’s (NLM) Value Set Authority Center (VSAC) to view all codes included in eCQM value sets.

2) Sign up for a JIRA account

Create an account by going to the ONC Project Tracking System (JIRA) website and selecting the link in the upper right of the page to Create an Account. Once you have an account, the ONC Project Tracking System has the link to allow you to use your account to obtain feedback on your eCQM implementation topic by creating an issue ticket in the ONC Project Tracking System. Key topic areas include the CQM Issue Tracker, Quality Data Model (QDM) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, Clinical Quality Language (CQL) Issue Tracker, Bonnie Issue Tracker, and Cypress Issue Tracker. Review JIRA instructions.

3) Review the versions used in the Addendum

Work with your coding department and health IT vendor to ensure your systems have been updated to the latest code versions.

Checklist

1) Access the eCQM addendum files

a. Select the performance/reporting period from the drop-down menu on the Eligible Hospital/Critical Access Hospital or Eligible Professional/Eligible Clinician eCQM webpages.

b. Review the addendum notes column of the sortable table on the webpage to view which measures had value set content updates.

c. Download updated technical release notes (TRNs) through the hyperlinks in the eCQM Materials table. The TRNs are available as individual Excel files for each measure and aggregated into PDF files that contain all measures. The Excel files are compiled in zip files for download. There are two sets of TRNs: 1) a set that shows only changes made during the addendum and 2) a set that shows all changes to the measures for a given performance/reporting year.

2) Review detailed information about value set changes for each measure within the TRNs

a. Access the TRNs using the links in step 1 or click into an eCQM on the online table to view detailed information on the measure including TRNs.

b. Review the TRN files for the individual eCQMs your organization uses. Use the TRNs to identify the addendum value set changes, such as updates to diagnosis codes that may impact data fields available in your organization’s Electronic Health Record (EHR) or workflow.

3) Download value sets

a. Click on the eCQM Value Sets Addendum hyperlink in the eCQM Materials column of the table on the Resource Center eCQMs webpage.
b. Download the corresponding addendum value sets and Binding Parameter Specification (BPS) from NLM’s Value Set Authority Center (VSAC) under the CMS eCQM Value Sets section using your UMLS® license log in.
c. Review value sets and BPS to identify relevant changes to eCQMs your organization uses.

4) Prepare to implement the updates by understanding changes in value set content

Perform a Gap Analysis

a. Using the TRNs as a guide, review the updated codes in the value sets on the VSAC.

b. Define what system requirements are needed to implement the update.

c. Consider potential workflow impacts.

d. Compile a list of system requirements across the measures the organization will report, as well as overall workflow impacts.

e. Implement system changes to support data capture for the updated value set content.

f. Educate clinicians on changes to data entry or workflow, if any.

5) Reach out for help and/or Provide feedback

a. For questions related to eCQM implementation, specifications, logic, data elements, standards, or tools, please go to ONC Project Tracking Tool (JIRA).

b. Submit eCQM tool and standards questions and provide feedback via JIRA Issue Trackers: Clinical Quality Language (CQL) Issue Tracker, Quality Data Model (QDM) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, Bonnie Issue Tracker, and Cypress Issue Tracker.

c. For questions on the Hospital Inpatient Quality Reporting (IQR) Program requirements, policy, and alignment, refer to the Inpatient Support Team (844) 472-4477 (8:00am – 8:00pm ET) or submit questions via the Q&A Tool: https://cms-ip.custhelp.com

d. For questions on the Medicare and Medicaid Promoting Interoperability programs (formerly EHR Incentive Programs) please contact the QualityNet Help Desk at qnetsupport@hcqis.org or call (866) 288-8912, Monday through Friday 7 am- 7 pm CT.

e. For questions on the Quality Payment Program (QPP), please contact QPP@cms.hhs.gov or (866) 288- 8292