Eligible Hospital / Critical Access Hospital eCQMs
Select Reporting Period:
|For Use||eCQM Implementation Resources||Published|
|2021 Q1-Q4||2021 CMS QRDA I Implementation Guide for Hospital Quality Reporting||May 2020|
|2021 Q1-Q4||2021 CMS QRDA I Schematrons and Sample Files||May 2020|
|2021 Q1-Q4||Binding Parameter Specification (BPS)||May 2020|
|2021 Q1-Q4||eCQM Direct Reference Codes List||May 2020|
|2021 Q1-Q4||eCQM Annual Update Pre-Publication Document||Mar 2020|
|2021 Q1-Q4||eCQM Flows||Aug 2020|
|2021 Q1-Q4||eCQM Logic and Implementation Guidance v4.0||May 2020|
|2021 Q1-Q4||eCQM Specifications for Hospital Quality Reporting||May 2020|
|2021 Q1-Q4||eCQM Value Sets||May 2020|
|2021 Q1-Q4||Guide for Reading eCQMs v6.0||May 2020|
|2021 Q1-Q4||Hospital Quality Reporting Table of eCQMs||May 2020|
|2021 Q1-Q4||Implementation Checklist eCQM Annual Update|
|2021 Q1-Q4||Technical Release Notes||May 2020|
|2021 Q1-Q4||Technical Release Notes||May 2020|
Total number of EH/CAH eCQMs: 9
|Measure Name||Short Name||CMS eCQM ID||NQF ID||Meaningful Measure Area|
|Median Admit Decision Time to ED Departure Time for Admitted Patients||ED-2||CMS111v9||Not Applicable||Admissions and Readmissions to Hospitals|
|Exclusive Breast Milk Feeding||PC-05||CMS9v9||0480e||Care is Personalized and Aligned with Patient's Goals|
|Safe Use of Opioids - Concurrent Prescribing||Not Applicable||CMS506v3||3316e||Prevention and Treatment of Opioid and Substance Use Disorders|
|Intensive Care Unit Venous Thromboembolism Prophylaxis||VTE-2||CMS190v9||Not Applicable||Preventive Care|
|Antithrombotic Therapy By End of Hospital Day 2||STK-5||CMS72v9||Not Applicable||Preventive Care|
|Anticoagulation Therapy for Atrial Fibrillation/Flutter||STK-3||CMS71v10||Not Applicable||Preventive Care|
|Discharged on Antithrombotic Therapy||STK-2||CMS104v9||Not Applicable||Preventive Care|
|Discharged on Statin Medication||STK-6||CMS105v9||Not Applicable||Preventive Care|
|Venous Thromboembolism Prophylaxis||VTE-1||CMS108v9||Not Applicable||Preventive Care|
Each year, CMS updates the eCQMs for potential use in CMS quality reporting programs and publishes them on the eCQI Resource Center. CMS updates the specifications annually to align with current clinical guidelines and code systems so they remain relevant and actionable within the clinical care setting. CMS requires the use of the most current version of the eCQMs for the applicable reporting periods for all quality reporting programs.
The updated eCQMs are to be used by eligible hospitals and critical access hospitals to electronically report 2021 clinical quality measure data for CMS quality reporting programs. Measures will not be eligible for 2021 reporting unless and until they are proposed and finalized through notice-and-comment rulemaking for each applicable program.
CMS has updated eCQMs for potential inclusion in these programs
- Hospital Inpatient Quality Reporting (IQR) Program
- Medicaid Promoting Interoperability Program for Eligible Hospitals and Critical Access Hospitals
- Medicare Promoting Interoperability for Eligible Hospitals and Critical Access Hospitals
|eCQM Implementation Checklist to update your electronic health record and processes for eCQM use and reporting.|
Hybrid measures are quality measures that merge electronic health record data elements with claims data to calculate measure results. Currently, the Hybrid Hospital Wide Readmission (HWR) measure is the only hybrid measure adopted for use in a program.
The electronic specifications for the Hybrid Hospital Wide Readmission (HWR) measure are updated for the voluntary reporting period from July 1, 2021 through June 30, 2022 for the Hospital Inpatient Quality Reporting (IQR) Program. Hospitals that submit data for this measure during the voluntary reporting period would receive confidential hospital-specific reports that detail submission results from the reporting period, as well as the Hybrid HWR measure results. Data will not be publicly reported during the voluntary reporting period. CMS will begin the public reporting of the Hybrid HWR measure results beginning with data collected from the July 1, 2023 through the June 30, 2024 reporting period.
Each year, CMS makes updates to the Hybrid HWR measure adopted for reporting in the Hospital Inpatient Quality Reporting (IQR) program. Hybrid measures require updates to the electronic specifications, posted below, and to claims-based specifications, available on QualityNet. CMS requires the use of updated electronic specifications for all its quality programs because they include updated codes, logic corrections, and clarifications. Reporting data for the Hybrid HWR measure to the Hospital IQR program requires that a hospital or electronic health record vendor use the most current version of the electronic measure specifications (identified below) for the applicable reporting period.
- Use the Hybrid HWR Measure Materials and follow the eCQM Implementation Checklist to update your electronic health record and processes for Hybrid measure use and reporting.
- Read the 2023 Voluntary Reporting Key Dates and Resources document to view key dates and resources for hospitals participating in the 2023 voluntary reporting of the Hybrid HWR Measure.
|Measure Name||CMS eCQM ID||NQF ID||Meaningful Measure Area|
|Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data||CMS529v1||2879e||Admissions and Readmissions to Hospitals|