Electronic clinical quality measure (eCQM) standards are critical to data consistency, validity, and interoperability. Standards, in the context of health information technology (IT), refer to agreed-upon methods and terminology for connecting systems such as file formats for electronic documents, messages, and related healthcare data elements. Standards pertain to data transport, data format and structure, and the meanings of codes and terms. See the Interoperability Standards Advisory for the eCQI recommended standards.
Key standards for electronic transmission of health information used to support eCQMs are:
- CQL – Clinical Quality Language – is the expression language used to explicitly communicate the specific data to be retrieved along with the logic needed to evaluate eCQMs. Essential to the operationalization of CQL is the Expression Logical Model (ELM) file. The ELM file is the machine-readable representation of the CQL designed for sharing and implementation applications.
- HQMF – Health Quality Measure Format – is a standard format to describe eCQM metadata, such as numerator, denominator, exclusions, and exceptions, as an XML document.
- CQL-based Health Quality Measure Format (HQMF) – is a standard implementation guide that describes how to use the HQMF base standard using the QDM and CQL to author eCQMs.
- QDM – Quality Data Model – is a standard information model that describes the data to represent information necessary for electronic quality assessment.
- QRDA – Quality Reporting Document Architecture – is a standard format for reporting eCQM data in a structured, consistent representation. There are two forms of QRDA in use, QRDA I for individual patient data and QRDA III for aggregate patient data.
The figure depicts the use and flow of the eCQM transmission standards.
A key standard under consideration for use by CMS in eCQMs is Fast Healthcare Interoperability Resources® - FHIR®. Use of FHIR is much broader than eCQMs. FHIR is an exchange standard for all types of health information, including eCQMs.
Health Terminology Standards
Numerous organizations develop and maintain standard terminologies. The National Library of Medicine’s (NLM) Unified Medical Language System® (UMLS®) Metathesaursus is a large biomedical thesaurus organized by concept, or meaning, and it links synonyms to the concept from nearly 200 different terminologies. However, eCQMs use only a handful of these terminologies, e.g., SNOMED CT and RxNorm. NLM’s Value Set Authority Center (VSAC) is the official source of eCQM data elements and value sets.
eCQM Standard Tools
The use of eCQM-friendly tools provides standardization in developing eCQMs. Tool standardization facilitates implementation by minimizing burden.
The Measure Authoring Tool (MAT) is a web-based authoring tool required for developing and maintaining eCQMs for CMS programs. Use of the MAT is to ensure that eCQM developers are using the established health IT standards and clinical terminology code systems needed for eCQM implementation. Specifically, the MAT enables measure developers to author eCQMs in HQMF using the QDM data elements, CQL, and other standards to meet future measure authoring requirements.
Bonnie is a web-based tool used by eCQM developers to test eCQM logic during the measure development process.
VSAC provides the ability to develop value sets from the UMLS terminologies.
Cypress is an open-source testing tool used by health IT vendors to certify their electronic health records (EHRs) and health IT modules (CEHRT) for calculating eCQMs. The Cypress application includes the Cypress Validation Utility + Calculation Check (CVU+). The CVU+ facilitates real world testing, providing health IT vendors the ability to perform QRDA validation tests using their own test patients.
National Committee for Quality Assurance (NCQA) Testing Resource tests and validates the integrity of the software code that produces the eCQM results.
The figure shows the connections among eCQM standards and the tools used to help develop and test eCQMs.
Standards Update Cycle
Revisions to standards occur constantly to improve how data are captured, used, and shared. The standards update cycle figure provides an overview of the steps CMS standards contractors use to move through to support updates to standards used in CMS quality reporting and incentive programs.