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eCQM Implementation Checklist

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The Centers for Medicare & Medicaid Services (CMS) requires an eligible clinician (EC), eligible hospital (EH), or critical access hospital (CAH) to use the appropriate version of the eCQMs for the designated reporting/performance period for quality reporting programs using eCQMs.

The Preparation and Implementation Checklists assume a health care practice/organization has determined which eCQMs to report. The eCQM Annual Update Implementation User Guide 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. Please check the eCQM Standards and Tools Versions table for which version of the eCQM you should use for a specific reporting/performance period.

Preparation Checklist

1. Sign up for a Unified Medical Language System (UMLS) account to view codes within the value sets in VSAC

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 an ONC Project Tracking Jira account to ask technical questions regarding eCQMs

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 allows you to use your account to obtain feedback on eCQM implementation questions by creating an issue ticket in the ONC Project Tracking System. Key topic areas include the eCQM Issue Tracker, eCQM Known Issues Tracker, Quality Data Model (QDM) Issue Tracker, Clinical Quality Language (CQL) Issue Tracker, Quality Reporting Document Architecture (QRDA) Issue Tracker, QRDA Known Issue Tracker, Bonnie and MAT Issue Tracker, and Cypress Issue Tracker.

3. Sign up for eCQM page change notifications on the eCQI Resource Center to receive updates on specific eCQMs

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

4. Review the code system versions used in the eCQM specification for the upcoming reporting/performance year

Review 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 to support the eCQM specification for the upcoming reporting/performance year

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.

Implementation Checklist

1. Access the appropriate eCQM Annual Update
  1. Review the updated eCQMs used in CMS quality programs for the upcoming reporting/performance period in the sortable tables on the Eligible Hospital/Critical Access Hospital and/or Eligible Clinician webpages.
    • Read and verify if the Telehealth guidance for Eligible Clinicians for the quality reporting period affects your reporting.
  2. Download the eCQM annual update zip files and corresponding implementation resources on the Eligible Hospital/Critical Access Hospital or Eligible Clinician webpages
2. Secure detailed information about each measure
  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 eCQMs 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 (including specific reading instructions).
  5. Reference eCQM data elements for each measure in the eCQM Data Element Repository (DERep).
    1. Navigate to the DERep.
    2. Filter on 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.

  1. 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.
  2. 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.
  3. Use the value set compare feature in VSAC to view changes in value sets used with eCQMs 

Note: Value sets to be used by a specific eCQM are linked from the individual measure specifications tab of the eCQI Resource Center.

4. Prepare to implement the updates by understanding changes to the eCQM
  1. Perform a Gap Analysis
    1. Review updated value sets.
  2. Read the Technical Release Notes. The Technical Release Notes provide an overview of technical changes, e.g., logic and terminology to each eCQM. 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 eCQM Logic and Implementation Guidance. This guidance provides general logic and 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 the update.
  5. Consider potential workflow impacts.
  6. Compile a 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.
5. Prepare to report the updated eCQMs
  1. Review the QRDA Reference and Implementation Guides for eCQMs.
  2. Review the eCQM Known Issues (eKI) Jira Tracker. The eKI dashboard provides implementation information for eCQMs with known technical issues for which a solution is under development but not yet available in a published eCQM specification.

 

6. Report eCQMs
7. Reach out for help

Visit the Contact Us page.

Send suggestions for improving this checklist to the eCQI Resource Center to ecqi-resource-center@hhs.gov.
Last Updated: Jul 13, 2023