eCQM Implementation Checklist | eCQI Resource Center

The Centers for Medicare & Medicaid Services (CMS) requires an eligible professional (EP), eligible clinician, eligible hospital (EH) or critical access hospital (CAH) to use the most current version of the eCQMs for quality reporting programs.

This Pre-Check and Checklist assume that a health care practice/organization has determined which measures to report on. It provides the necessary technical steps health information technology (IT) developers, implementers and health care organizations must take to update their systems and processes with the eCQM Annual Update for the upcoming reporting and performance periods. The most recent eCQM Annual Update should be applied to your system for use in electronic quality reporting.

Pre-Check

1) Sign up for a Unified Medical Language System (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 hand of the website 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, Clinical Quality Language (CQL) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, Bonnie Issue Tracker, and Cypress Issue Tracker.

3) Sign up for eCQM page change notifications on the

Signing up for an eCQI Resource Center account and subscribing to the Eligible Professional/Eligible Clinician and/or Eligible Hospital/Critical Access Hospital pages by selecting 'Receive updates on this topic' at the top of the page will provide you with alert when the EP/EC or EH/CAH page has been updated.

4) Review the code versions used in the Annual Update

For example, SNOMED CT 2019-09, 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.

5) Review the standards, tools, and documents used in the Annual Update

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 eCQM Standards and Tools versions table.

Checklist

1) Access the appropriate eCQM Annual Update

Eligible Professional/Eligible Clinician or Eligible Hospital/Critical Access Hospital

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

2) Secure detailed information about each measure

Click into an eCQM on the online table to view detailed human-readable information on the measure.
Download and open zip files for the individual eCQMs your organization uses.
Open the Hyper Text Markup Language (HTML) document that contains the measure specification description.
Review Health Quality Measure Format (HQMF) document (including specific reading instructions).
Reference eCQM data elements for each measure in the eCQM Data Element Repository (DERep).
1. Navigate to the DERep.
2. Filter on EP/EC eCQMs or EH/CAHs eCQMs.
3. Select eCQM of interest.
4. Review data elements used by eCQM to obtain additional information for use when implementing measure.

3) Download value sets

Download the corresponding annual update value sets and Binding Parameter Specification (BPS) from NLM’s VSAC using your UMLS® license log in.

eCQM value set files with their associated data types and attributes and the BPS are available on the Download tab at the VSAC website under the CMS eCQM Value Sets section.
Review the BPS and value sets to track retired code lists and confirm your electronic health record is ready to support the most current eCQM release.

4) Prepare to implement the updates by understanding changes to the eCQM

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 Eligible Professional/Eligible Clinician and Eligible Hospital/Critical Access Hospital 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.
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.
Read the Measure Logic Guidance. The Measure Logic and Implementation Guidance provides general logic and implementation guidance along with detailed information on topics such as measure versioning and time interval calculations.
Define what system requirements are needed to implement the update.
Consider potential workflow impacts.
Compile a list of system requirements across the measures the organization will report, as well as overall workflow impacts.
Implement system changes to support data capture for the updated measures.
Educate clinicians on changes to data entry or workflow, if any.

5) Prepare to report the updated eCQMs

Review the QRDA Reference and Implementation Guides for eCQMs.

6) Reach out for help

For questions related to eCQM implementation, specifications, logic, data elements, standards, or tools, please go to ONC Project Tracking Tool (JIRA).
Submit eCQM tool and standards questions and provide feedback via JIRA Issue Trackers: 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.
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.
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.
For questions on the Quality Payment Program (QPP), please contact QPP@cms.hhs.gov or (866) 288- 8292.

Send suggestions for improving this checklist to the eCQI Resource Center to ecqi-resource-center@hhs.gov.