eCQM Implementation Checklist

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.

This account allows you to submit issues regarding eCQM implementation and receive feedback. Key topic areas include the CQM Issue Tracker, Quality Data Model (QDM) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, Bonnie Issue Tracker and Cypress Issue Tracker. Review JIRA instructions.

Signing up for an eCQI Resource Center account and subscribing to the Eligible Professional/Eligible Clinician and/or Eligible Hospital pages will provide you with alert when the EP or EH page has been updated.

For example, SNOMED CT 2016-09, by reviewing the eCQM Pre-Publication document and the VSAC download page

• Work with your coding department and health IT vendor to ensure your systems have been updated to the latest code versions
• Some value sets contain “legacy codes.” These codes will be inactive in the current code system version but will be considered active in one of the prior code system versions noted in the file.

• Work with your health IT vendor to ensure your systems are using updated technical standards and testing tools found in the eCQM Pre-Publication document and Standards and Tool versions.

Eligible Professionals/Eligible Clinicians or Eligible Hospitals

1. Review the updated eCQMs used in CMS quality programs for the current reporting/performance period in the sortable table on the Eligible Hospital or Eligible Professional/Eligible Clinician webpages
2. Download the eCQM annual update zip files and corresponding artifacts on the Eligible Hospital or Eligible Professional/Eligible Clinician webpages

1. Click into an eCQM on the online table to view detailed human-readable information on the measure
2. Download and open zip files for the individual eCQM your organization uses
3. Open the Hyper Text Markup Language (HTML) document that contains the measure specification description
4. Review Health Quality Measure Format (HQMF) document (Include specific reading instruction)

Download the corresponding annual update value sets from NLM’s VSAC using your UMLS license log in.

1. eCQM value set files with their associated data types and attributes are available on the Download tab at the VSAC website under the CMS eCQM Value Sets section.
2. Review the change files and retired code lists to confirm your patient record data is supported.

1. Perform a Gap Analysis
1. Review updated value sets
2. Use the United States Health Information Knowledgebase (USHIK) comparison tool which may be accessed directly from the measure tables located on the EP/Eligible Clinician and EH pages of the eCQI Resource Center. Select the most current version of the eCQMs and the version of the eCQM you are using. This side by side comparison provides a visual of all changes to a measure, identify the updates that require action on your part such as updating diagnosis codes and/or data fields available in your electronic health record (EHR) or an end user’s workflow.)
2. Read the Technical Release Notes. The Technical Release Notes provide a list of all changes to a measure. Identify the updates that require action on your part such as updating diagnosis codes and/or data fields available in your EHR or an end user’s workflow.
3. Read the Measure Logic Guidance. The Measure Logic Guidance provides general logic implementation guidance along with detailed information on topics such as measure versioning and time interval calculations.
4. Define what system requirements are needed to implement update.
5. Consider potential workflow impacts, review the workflow section of the eCQM 102 – How to Implement Quality Measure Updates presentation.
6. Compile list of system requirements across the measures the organization will report, as well as overall workflow impacts.
7. Implement system changes to support data capture for the updated measures.
8. Educate clinicians on changes to data entry or workflow, if any.

1. Review the QRDA Reference and Implementation Guides for eCQMs

1. For questions related to eCQM implementation, specifications, logic, data elements, standards, or tools, please go to JIRA (online tracking tool): https://oncprojectracking.healthit.gov
2. Submit eCQM tool and standards questions and provide feedback via JIRA Issue Trackers: QDM Issue Tracker, QRDA Issue Tracker, Bonnie Issue Tracker, and Cypress Issue Tracker
3. 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
4. For questions on the Medicare and Medicaid EHR Incentive Program (“Meaningful Use”) please contact the QualityNet Help Desk at qnetsupport@hcqis.org or call (866) 288-8912, Monday through Friday 7 am- 7 pm CT
5. For questions on the Quality Payment Program (QPP), please contact QPP@cms.hhs.gov or (866) 288- 8292