About electronic Clinical Quality Measures (eCQMs)
What are clinical quality measures (CQMs)?
CQMs measure health care:
CQMs quantify quality in our health care system. Measuring and reporting CQMs helps to ensure care is delivered safely, effectively, equitably, and timely. A compilation of measures used by CMS in various quality reporting and incentive programs is located on the CMS Measures Inventory Page.Back to top
What are electronic clinical quality measures (eCQMs)?
eCQMs use data from electronic health records (EHR) and/or health information technology systems to measure health care quality. The Centers for Medicare & Medicaid Services (CMS) use eCQMs in a variety of quality reporting and incentive programs.
Where can I find eCQMs?
Why are eCQMs used?
- For new payment systems that reimburse providers based on quality reporting and ultimately the quality of care provided
- For compliance with certification requirements
- For support of a Learning Health System
Where are eCQMs used?
- At the point of care delivery in the electronic health record (EHR)
- In reporting to CMS, the Joint Commission, and insurance payers
How are electronic clinical quality measures (eCQMs) structured?
So they can be reported from an EHR, eCQMs are made of electronic specifications. Health Quality Measure Format (HQMF), a Health Level Seven (HL7) standard, is used for electronically documenting eCQM content. These electronic specifications include:
- XML—Contains important details about the measure, how the data elements are defined, and the underlying logic of the measure calculation. The file uses HQMF XML syntax. The XML includes a Header and a Body. The Header identifies and classifies the document and provides important metadata about the measure. The HQMF Body contains eCQM sections, e.g., data criteria, population criteria, and supplemental data elements.
- Hyper Text Markup Language (HTML) file (.html) that displays the eCQM content in a human-readable format directly in a Web browser. This file does not include the underlying HQMF syntax
- Value sets—Convey what specific coded values are to be allowed for the data elements within the eCQM. Value sets are identified by an object identifier (OID), and include a number of metadata elements. This specifies a list of codes (i.e., the value set “expansion code set”), descriptions of those codes, and the code system from which the codes are derived, and the version of that code system.
- Direct Referenced Codes – Convey specific codes that are referenced directly in the eCQM logic to describe a data element or one of its attributes. Direct referenced code metadata include the description of the code, the code system from which the code is derived and the version of that code system
What are the eCQM naming conventions?
CMS created a unique “CMS eMeasure Identifier” to name eCQM files. The naming convention adds the eCQM/eMeasure identifier assigned to the eCQM in the Measure Authoring Tool (MAT) with the “eMeasure Version Number”. eMeasure is an old term that has since been replaced with eCQM.
“CMS” is placed in front. The eCQM Version Number is used to indicate the published version of the eCQM. Based on this naming convention, Eligible Professional measure (NQF0056-Diabetes: Foot Exam) would be CMS123v1 for the first version of the measure.
|eCQM Identifier (MAT)||123|
|eCQM Version number||1|
|CMS eCQM identifier||CMS123v1|
Who develops and uses eCQMs?
- Measure stewards
- Measure developers
- Health IT developers/vendors
- Quality Improvement Organizations
How are eCQMs reported?
An Eligible Hospital, Eligible Clinician, and/or Eligible Professional must use the version of eCQMs identified by the specific program when reporting eCQMs. Visit Quality Net for eCQM reporting guidance and the Quality Reporting Center for specific program reporting education.Back to top
How are eCQMs submitted to Registries?
Individual eligible professionals (EPs) and group practices participating in CMS incentive programs may be required to report eCQMs to a qualified registry. Visit the Registry Reporting page for more information.Back to top
How are eCQMs developed?Back to top
How is health IT certified for eCQM use?
The Office of the National Coordinator for Health Information Technology (ONC) certifies health information technology (IT) and eCQM reporting capabilities. Read more at Health IT Certification for eCQM Reporting.Back to top
Why are eCQMs updated annually?
CMS updates the eCQMs approved for CMS programs to reflect changes in:
- Evidence-based medicine
- Code sets
- Measure logic
How can I get involved in eCQM development and their updates?
CMS provides several opportunities to provide input on eCQM development and updates: public calls for measures, comments on measures under development, and participation on technical expert panels. Visit the CMS Measures Management System webpage and the Engagement webpage for a list of current opportunities.Back to top
How can I provide feedback on eCQM development and implementation?
CMS and ONC provide JIRA tracker tools to allow stakeholders to submit issues with eCQM implementation and development and receive feedback. Submit eCQM technical questions to the CQM Issue Tracker.
CMS program policy questions are not covered in JIRA and must be reported to the appropriate program helpdesk.Back to top
Where can I get help with eCQMs reporting and program issues?
For questions on the Hospital 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
For questions on the EHR Incentive Program (“Meaningful Use”), please contact the EHR Information Center (EHRIC) at (888) 734-6433 (7:30am – 6:30pm CT)
For questions on the Quality Payment Program (QPP), please contact QPP@cms.hhs.gov or (866) 288-8292
For PQRS Policy and Programs related questions, please contact the QualityNet Help Desk E-mail: firstname.lastname@example.org and Phone: (866) 288-8912 TTY: (877) 715-6222Back to top
Where can I learn more about eCQMs?
Resources and presentations on eCQMs and the standards and tools used in eCQI are located on the Education page.Back to top
Yesterday, February 21
- 11:40pm ESTEvent Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 22 2017 - 12:00am Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 22 2017 - 12:00am Clinical Quality Language (CQL)Bryn Rhodes11:00am-12:00pmQuality Reporting Document Architecture (QRDA)Michael Holck1:00-2:00pmQuality Data Model (QDM)Floyd Eisenberg2:00 – 3:00pm
- 12:37pm ESTEvent Reminder: eCQM Readiness and Challenges: An Essential Conversation : Feb 21 2017 - 1:00pm Reminder: eCQM Readiness and Challenges: An Essential Conversation : Feb 21 2017 - 1:00pm TJC has an education session at HIMSS this year. We’re taking advantage of a new format, the “Essential Conversation.” This format allows for a 20-minute lecture, followed by a 40 minute conversation with the audience. We’ll kick off discussion with some leading questions, including, “How do/will organizations derive value from eCQMs?” Title: eCQM Readiness and Challenges: An Essential ConversationTime: Tuesday, February 21, 1:00PM-2:00PMSession ID: 117Location: Room W311E (Note this session is onsite at HIMSS only.) It would be great to have some eCQM community members attend to contribute to the discussion! Also, if there is anyone who hasn’t registered yet, we were encouraged to share this discount code, worth 20% off the registration fee : DFUL20AC17
Monday, February 20
- 11:37pm ESTEvent Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 21 2017 - 12:00am Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 21 2017 - 12:00am Clinical Quality Language (CQL)Bryn Rhodes2:00-3:00pmQuality Reporting Document Architecture (QRDA)Michael Holck4:00-5:00pmQuality Data Model (QDM)Floyd Eisenberg5:00 – 6:00pm
Sunday, February 19
- 11:37pm ESTEvent Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 20 2017 - 12:00am Reminder: ESAC, Inc. Holding eCQM Standards Office Hours at HIMSS17 Booth #8248 : Feb 20 2017 - 12:00am Quality Reporting Document Architecture (QRDA)Michael Holck2:00-3:30pmClinical Quality Language (CQL)Bryn Rhodes3:30-4:30pmQuality Data Model (QDM)Floyd Eisenberg4:30 – 6:00pm
Friday, February 17
Thursday, February 16
- 10:37am ESTEvent Reminder: WEBINAR THIS THURSDAY, 2/16/2017 @ 11AM EST -- An International PCOR CDS Perspective: The Guideline Implementation with Decision Support Project : Feb 16 2017 - 11:00am Reminder: WEBINAR THIS THURSDAY, 2/16/2017 @ 11AM EST -- An International PCOR CDS Perspective: The Guideline Implementation with Decision Support Project : Feb 16 2017 - 11:00am The Patient Centered Outcomes Research Clinical Decision Support Learning Network (PCOR CDS-LN), an AHRQ supported initiative, is excited to announce the launch of the fourth installment in our new webinar series: An International PCOR CDS Perspective: The Guideline Implementation with Decision Support Project to be delivered by Stijn Van de Velde, PhD, this Thursday, February 16, 2017 @ 11AM EST. Computerized clinical decision support systems (CCDSS) are considered an important quality improvement intervention, and their implementation is growing substantially. However, the significant investments do not consistently result in a return on investment due to content, context, system and implementation issues. Caution is needed to apply CCDSS in the best possible way. The Guideline Implementation with Decision Support (GUIDES) project currently develops a checklist to support professionals that are responsible for CCDSS initiatives. By promoting thoughtful reflection over the diverse factors that affect CCDSS success, the checklist aims to improve the impact of CDSS and help reduce potentially avoidable failures. The project receives funding from the EU’s Horizon 2020 program (grant agreement No 654981) and will be completed by July 2017. This webinar will discuss the background and methods of the project, the factors that have been included to date and how the GUIDES checklist can support the skills of experts while dealing with the complexity of CCDSS. Please register at: https://attendee.gotowebinar.com/register/142003406321199105. After registering, you will re
- 10:07am ESTEvent Reminder: Register Now: Webinar on CMS’ Annual MIPS Call for Measures and Activities : Feb 16 2017 - 10:30am Reminder: Register Now: Webinar on CMS’ Annual MIPS Call for Measures and Activities : Feb 16 2017 - 10:30am Learn More about Submitting Measures and Activities for MIPSThe Centers for Medicare & Medicaid Services (CMS) opened the submission period for the Annual Call for Measures and Activities of the Merit-Based Incentive Payment System (MIPS) track of the Quality Payment Program (QPP).The Annual Call for Measures and Activities allows providers and measure stewards from stakeholder organizations to identify and submit measures and activities for three of the four MIPS performance categories. To be considered, proposals must include measure specifications, related research, and background.Submission DetailsQuality: Measures proposed for inclusion should be submitted through JIRA. Submissions should include the JIRA Measures Under Consideration (MUC) template and other associated documents CMS deems necessary for the submission process.Advancing Care Information: Measures proposed for inclusion should be sent using the Advancing Care Information Submission Form to CMSCallforMeasuresACI@ketchum.com.Improvement Activities: Activities proposed for inclusion should be sent using the Improvement Activities Submission Form to CMSCallforActivitiesIA@ketchum.com.Submission forms will be accepted for review through June. Read the Call for Measures Fact Sheet to learn more and to understand the process for submitting measures for the MIPS performance categories.Join a Webinar to Learn MoreCMS will host a webinar on Thursday, February 16, 2017 that will provide an overview of the Annual MIPS Call for Measures and Activities. Stakeholders and providers will have an opportunity to ask questions. To join the webinar, you will need to register by clicking on the registration link below. Space is limited, so register now to secure your spot. After you register, you will receive an e-mail confirmation that will include the webinar link. Webinar DetailsTitle: QPP MIPS Call for Measures and ActivitiesDate: Thursday, February 16, 2017Time: 10:30 to 12:00 pm ETRegistration link: https://engage.vevent.com/rt/cms/index.jsp?seid=690The audio portion of this webinar will be broadcast through the web. You can listen to the presentation through your computer speakers. If you cannot hear audio through your computer speakers, please contact CMSQualityTeam@ketchum.com. Phone lines will be available for the Q&A portion of the webinar.