CMS HQR System Now Accepting CY 2021 eCQM Data

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) 2021 reporting period. The HQR System has been updated to accept Quality Reporting Document Architecture (QRDA) Category I test and production files utilizing the CY 2021 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 Medicare Promoting Interoperability Programs.

What are the CY 2021 eCQM reporting requirements?

Hospitals are required to submit data on four self-selected eCQMs of the available nine eCQMs for two self-selected quarters of CY 2021 data (Q1, Q2, Q3 or Q4) by the reporting deadline. The reporting deadline was extended from Monday, February 28, 2022, 11:59 p.m. Pacific Time (PT) to Thursday, March 31, 2022, 11:59 p.m. PT. The self-selected eCQMs must be the same eCQMs across quarters in a given reporting year. The successful reporting of CY 2021 eCQM data will apply towards the Hospital IQR and Medicare Promoting Interoperability Programs.

Successful submission of eCQM data 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. Hospitals are required to use technology certified to the existing 2015 Edition criteria for Certified Electronic Health Record Technology (CEHRT), technology certified to the 2015 Edition Cures Update criteria or a combination of the two in order to meet the CEHRT definition. CY 2021 program requirements are posted on the QualityNet and CMS.gov websites.

Note: The Medicare Promoting Interoperability Program requirements and attestation deadline for eligible hospitals and critical access hospitals has similarly been extended from Monday, February 28, 2022, 11:59 p.m. PT to Thursday, March 31, 2022, 11:59 p.m. PT.

Where are the technical materials for reporting eCQMs for the CY 2021 reporting period?

The Electronic Clinical Quality Improvement (eCQI) Resource Center is the one-stop shop for the most current resources to support electronic clinical quality improvement. Reference materials available for download include an eCQM annual update implementation checklist, CY 2021 QRDA Category I Implementation Guide (IG), Schematron and sample files, eCQM specifications, eCQM Flows, and the eCQM value set addendum. In addition, the Measure Collaboration Workspace offers the eCQM Data Element Repository for users who need additional clarification regarding definitions and clinical focus for all eCQM specification data elements.

Where can I learn about changes to the CY 2021 QRDA Category I IG for HQR and updates to the Health Level Seven (HL7) base standard?

Visit the archived events page of the Quality Reporting Center website to review materials from the CMS QRDA Category I Implementation Guide Changes for CY 2021 Hospital Quality Reporting webinar. The presenter outlined the IG changes, showed document-level template changes, and provided a high-level overview of updates to the HL7 base standard.

Will there be a webinar to demonstrate the eCQM data submission process and review enhancements to the HQR System?

A webinar is scheduled for Thursday, December 16, 2021, to demonstrate the steps to successful eCQM data submission for CY 2021 hospital reporting. Registration information was communicated through Listserve notifications. Visit the Event Calendar of the Quality Reporting Center website for details.

Contact Information

• For further assistance regarding the Hospital IQR Program and policy information contained in this message, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Contractor at https://cmsqualitysupport.servicenowservices.com/qnet_qa or (844) 472-4477.
• Questions regarding any aspect of the attestation process and the Medicare Promoting Interoperability Program can be directed to the QualityNet Service Center at qnetsupport@hcqis.org or (866) 288-8912. The QualityNet Service Center can also assist with questions regarding the Hospital Quality Reporting (HQR) System, which includes user roles, reports, data upload, and troubleshooting file errors.
• For questions regarding eCQM specifications, value sets, and appropriateness of mapping, please submit questions to the Office of the National Coordinator for Health Information Technology (ONC) CQM Issue Tracker at https://oncprojectracking.healthit.gov/support/projects/CQM/summary.