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Standards Harmonization for eCQI

Clinical Decision Support (CDS) & Electronic Clinical Quality Measures (eCQMs)

Clinical Decision Support (CDS) and electronic clinical quality measures (eCQMs) are closely related, share many common requirements, and support health care quality improvement. It is important to also understand the differences between them and the efforts to help them work together (harmonization). Initially developed separately, the standards for the electronic representation of CDS and eCQMs used different data models and computable expression languages. The use of different standards

  • makes re-using or sharing machine readable logic between eCQMs and CDS specifications  very difficult
  • creates a burden for health information technology (IT) developers and those who provide technical support for implementation

Beginning with eCQMs specified for use in 2019, Health Level Seven International® (HL7®) Clinical Quality Language (CQL) replaced the Quality Data Model (QDM) as the eCQM expression language. CQL is an authoring language standard that provides the ability to express clinical logic that is both human-readable and machine-readable via a structured representation. Since CDS also uses CQL, this closes the gap on the differences between CDS and eCQMs.

Clinical Quality Framework (CQF) Initiative

The CQF Initiative is an HL7 project led by the CDS and Clinical Quality Information Work Groups to identify, develop, and harmonize standards that promote integration and reuse between CDS and eCQMs.

Harmonization of CDS and eCQM standards will improve the ease of implementation. Harmonization will also make it easier to integrate and facilitate health IT-enabled clinical quality improvement since the functions of CDS and eCQMs are complementary. An emerging HL7 standard, Fast Healthcare Interoperability Resources® (FHIR®), and CQL provide a common foundation for representing CDS and eCQMs to

  • suggest care to clinicians and care teams when there are opportunities to improve care quality
  • measure if appropriate care was provided

The HL7 FHIR specification is a standard for exchanging healthcare information electronically. The CQF Initiative has developed various FHIR resources, profiles, and implementation guidance to represent quality measures and decision support artifacts. These resources are

  • Consistent with the Common Metadata Standard, and can use CQL to represent expression logic and the QI-Core Framework profiles to represent clinical information
  • Defined and introduced as part of the Clinical Reasoning Module of the Standard for Trial Use (STU) 3 version, currently R4 (Mixed Normative and Trial Use), of the FHIR standard 
  • Used and tested in a variety of settings, including FHIR Connectathons and ongoing pilots, to validate that these resources can effectively fulfill the need for a single set of standards to support delivery of both decision support and quality measurement artifacts

For more information about use of FHIR in quality measurement, read the informative whitepaper, HL7 FHIR® Guidance: Quality Reporting, Release 1- US Realm. Note that access to this document requires a HL7 account, but not HL7 membership.

To learn more about FHIR, please visit FHIR pages.

Common Shared and Differing Standards Between CDS and eCQMs

The table outlines the common areas and differing standards currently used in CDS and eCQMs.

  Patient and Clinical Data Computable Expression Logic Metadata and Structure Evaluation Model

Quality Improvement (QI)-Core (for FHIR-based CDS)


FHIR Clinical Reasoning

FHIR Clinical Guidelines

CDS Hooks (for FHIR-based CDS)




Health Quality Measure Format

Quality Reporting Document Architecture

Common Shared Standards

Common Shared Standards

The strategy employed by the CQF Initiative is to identify the common components used by each domain and define common standards for each of the core components.  

QI-Core is a US Realm Implementation Guide (IG) of the FHIR Specification that defines a uniform way for quality measurement and decision support knowledge to refer to clinical data. The profiles align as much as possible with the Data Access Framework and incorporate content from the QDM and the vMR specifications.

The QI-Core IG defines a set of FHIR profiles with extensions and bindings needed to create interoperable, quality-focused applications. The profiles in this IG derive from and extend the US Core profiles to provide a common foundation for building, sharing, and evaluating knowledge artifacts across quality improvement efforts in the US Realm.

As an HL7 FHIR IG, changes to this specification are managed by the sponsoring workgroup, Clinical Quality Information, and incorporated as part of the standard balloting process. The current roadmap follows closely behind the base FHIR roadmap and the US Core IG.

CDS Hooks is an HL7 published specification for clinical decision support. This specification describes a hook-based pattern for invoking decision support from within a clinician's workflow. The API supports synchronous, workflow-triggered CDS calls returning information and suggestions and launching a user-facing SMART app when CDS requires additional interaction.

Last Updated: May 03, 2021