eCQMs

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About electronic Clinical Quality Measures (eCQMs)

What are clinical quality measures (CQMs)?

CQMs measure health care:

  • Processes
  • Observations
  • Treatments
  • Outcomes

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.

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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.

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Where can I find eCQMs?

Eligible Hospital (EH) eCQMs and supporting documentation are on the EH page of this website. 

Eligible Professional (EP) and Eligible Clinician (EC) eCQMs and supporting documentation are on the EP page of this website.

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Why are eCQMs used?

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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
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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
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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 Information Value
    eCQM Identifier (MAT) 123
    eCQM Version number 1
    CMS eCQM identifier CMS123v1
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Who develops and uses eCQMs?

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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. 

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How are eCQMs submitted to Registries?

Individual eligible professionals (EPs) eligible clinician and group practices participating in CMS quality programs may be required to report eCQMs to a qualified registry. Visit the Registry Reporting page for more information.

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How are eCQMs developed?

Information on the CQM and eCQM development lifecycle is available in the Blueprint for the CMS Measures Management System (Blueprint) and on the eCQM Lifecycle webpage.

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What is the eCQM Measure Lifecycle?

The eCQM Lifecycle is a series of phases eCQMs progress through.

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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.

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Why are eCQMs updated annually?

CMS updates the eCQMs approved for CMS programs to reflect changes in:

  • Evidence-based medicine
  • Code sets
  • Measure logic
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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.   

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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.

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Where can I get help with eCQMs reporting and program issues?

Information on various helpdesks and tools for eCQM help is found on the eCQI Resource Center Contact Information page.

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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.  

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Recent Activity

Thursday, June 22

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    11:53am EDT
    Amira Elhagmusa updated CMS Proposes Quality Payment Program updates to increase flexibility and reduce burdens
     
    Too many differences to list. See Revisions for details.
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    11:52am EDT
    Amira Elhagmusa created CMS Proposes Quality Payment Program updates to increase flexibility and reduce burdens
      Proposed rule aims to simplify reporting requirements and offer support...

    Proposed rule aims to simplify reporting requirements and offer support for doctors and clinicians in 2018.

    Today (June 20, 2017), the Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would make changes in the second year of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS’s goal is to simplify the program, especially for small, independent, and rural practices, while ensuring fiscal sustainability and high-quality care within Medicare.

    “We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork. CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”

    The Quality Payment Program, updated annually as part of MACRA, is meant to promote greater value within the healthcare system. Clinicians who participate in Medicare serve more than 57 million seniors. Clinicians can choose how they want to participate in the Quality Payment Program based on their practice size, specialty, location, or patient population.  

    The proposed rule would amend some existing requirements and also contains new policies for doctors and clinicians participating in the Quality Payment Program that would encourage participation in either Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). Additionally, CMS has used clinician feedback to shape the second year of the program. If finalized, the proposed rule would further advance the agency’s goals of regulatory relief, program simplification, and state and local...

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Wednesday, June 21

Friday, June 16

  • 11:33am EDT
    Jessica Dulin Sanford updated Centers for Medicare & Medicaid Services 2017 Measures under Consideration (MUC) New Materials Available
     
    Changes to Body
     
    The April 2017 education and outreach webinar series of four meetings (Measures under Consideration Kickoff, Measurement Needs & Priorities, and the two open forum sessions) are now available at the CMS Pre-Rulemaking web site (click here) [1]. Scroll to the section titled “Educational Webinars.” The 2017 Frequently Asked Questions list has also been updated to include questions and answers from the webinars. This is on the same web site under “Additional Resources.”
    		 
    The April 2017 education and outreach webinar series of four meetings (Measures under Consideration Kickoff, Measurement Needs & Priorities, and the two open forum sessions) are now available at the CMS Pre-Rulemaking web site (click here) [1]. Scroll to the section titled “Educational Webinars.” The 2017 Frequently Asked Questions list has also been updated to include questions and answers from the webinars. This is on the same web site under “Additional Resources.”
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    The 2017 CMS Measures under Consideration User Guide has also been updated, and is available on the same web site under “The JIRA System.”
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    The 2017 Centers for Medicare & Medicaid Services (CMS) Measures under Consideration User Guide has also been updated, and is available on the same web site under “The JIRA System.”
     
     Please contact Michelle Geppi of CMS at 410-786-4844 or michelle.geppi@cms.hhs.gov [2] for more information.
    		 
     Please contact Michelle Geppi of CMS at 410-786-4844 or michelle.geppi@cms.hhs.gov [2] for more information.
     
     Contact MMS Support
    		 
     Contact MMS Support
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  • 11:30am EDT
    Jessica Dulin Sanford updated Centers for Medicare & Medicaid Services 2017 Measures under Consideration (MUC) New Materials Available
     
    Changes to Title
    -
    CMS 2017 Measures under Consideration (MUC) New Materials Available
    		+
    Centers for Medicare & Medicaid Services 2017 Measures under Consideration (MUC) New Materials Available
    Read more

Thursday, June 15

Saturday, June 10

  • 5:52pm EDT
    Edna Boone updated Now Available: MIPS number on Eligible Clinician Measures Page
     
    Changes to Body
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    The Merit-Based Incentive Payment System (MIPS) measure identifier has been added to the sortable table on the Eligible Clinician measures page [1] of the eCQI Resource Center. The MIPS identifier is available for the 2017 reporting year. The identifier will be associated with 2018 after the MIPS rule is finalized. 
    		+
    The Merit-Based Incentive Payment System (MIPS) measure identifier has been added to the sortable table on the Eligible Clinician measures page [1] of the eCQI Resource Center. The MIPS identifier is available for the 2017 reporting year. The identifier will be associated with 2018 measures when the updated MIPS program rule is published. 
     
    		 
     
    [1] https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms
    		 
    [1] https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms
    Read more
  • 5:50pm EDT
    Edna Boone created Now Available: MIPS number on Eligible Clinician Measures Page
      The Merit-Based Incentive Payment System (MIPS) measure identifier has been...

    The Merit-Based Incentive Payment System (MIPS) measure identifier has been added to the sortable table on the Eligible Clinician measures page of the eCQI Resource Center. The MIPS identifier is available for the 2017 reporting year. The identifier will be associated with 2018 measures when the updated MIPS program rule is published. 

Friday, June 9

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