eCQMs

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 and on the CMS eCQM Library Page

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

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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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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) 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.

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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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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?

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: qnetsupport@hcqis.org and Phone: (866) 288-8912 TTY: (877) 715-6222

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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

Wednesday, January 18

  • 8:07am EST
      Bonnie is a tool for testing...

    Bonnie is a tool for testing electronic clinical quality measures (eCQMs) designed to support streamlined and efficient pre-testing of eCQMs, particularly those used in CMS quality incentive programs. This release adds the Measure History functionality. Measure History enables users to see how test case calculations change as the measure version changes. New capabilities that a user will see include:

    • An upload summary after a new version of a measure has been uploaded. This will show how many test cases’ calculations changed and which test cases changed.
    • A “Measure Upload History” button in the Measure Summary view. This will bring the user to the Measure Upload History view. This view contains:
      • A timeline of measure updates with test case calculation results
      • The ability to view the difference in measure logic between two versions of a measure (the “View Changes” button)
      • The ability to see details on how a test case calculates against two versions of a measure (the test case calculation icon)
      • A “Compare Patients Results to Last Measure Upload” button in the Patient Builder view. This will show the user how a test case calculated when the current version of the measure was uploaded and how that test case calculates now.

    More details on the Measure History functionality is included in the updated Bonnie User Guide in Section 6 found on the Bonnie tool website @ https://bonnie.healthit.gov/

     

    The core functionality of Bonnie has not been changed. We are always happy to receive any feedback, questions, or concerns through the Bonnie JIRA issue tracker at https://oncprojectracking.healthit.gov/support//browse/BONNIE.

  • 7:52am EST
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    This Outreach and Education webinar for participants in the Hospital Inpatient Quality Reporting (IQR) Program is scheduled for Monday, January 30, 2017 at 2:00 p.m. ET.
     
    This Outreach and Education webinar for participants in the Hospital Inpatient Quality Reporting (IQR) Program is scheduled for Monday, January 30, 2017 at 2:00 p.m. ET.
     
    The webinar, titled /Question and Answer Session I – CY 2016 eCQM Reporting/, will be presented by Jennifer Seeman, Hospital Quality Reporting (HQR) Electronic Health Record (EHR) Program Manager; Portfolio, Program, and Project Management (PM3) Support Contractor (SC) and Artrina Sturges, EdD, Project Lead, Medicare IQR-EHR Incentive Program Alignment;/ /Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education SC.
     
    The webinar, titled /Question and Answer Session I – CY 2016 eCQM Reporting/, will be presented by Jennifer Seeman, Hospital Quality Reporting (HQR) Electronic Health Record (EHR) Program Manager; Portfolio, Program, and Project Management (PM3) Support Contractor (SC) and Artrina Sturges, EdD, Project Lead, Medicare IQR-EHR Incentive Program Alignment;/ /Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education SC.
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Tuesday, January 17

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    2:53pm EST

    CY 2016 eCQM Reporting

    The Centers for Medicare & Medicaid Services (CMS) is notifying eligible hospitals and critical access hospitals participating in the Hospital Inpatient Quality Reporting (IQR) and/or the Medicare Electronic Health Record (EHR) Incentive Programs of a deadline extension. The extension is for the submission of electronic Clinical Quality Measure (eCQM) data for the Calendar Year (CY) 2016 reporting period, pertaining to the Fiscal Year (FY) 2018 payment determination. The deadline has been changed from Tuesday, February 28, 2017, to Monday, March 13, 2017, at 11:59 p.m. PT. This extension is being granted to provide hospitals additional time to submit eCQM data.

    For CY 2016 reporting, all other aspects of eCQM reporting requirements remain the same. Successful submission continues to be defined as reporting on at least four eCQMs utilizing certified EHR Technology (CEHRT), certified to the 2014 or 2015 edition. The reporting must be a combination of Quality Reporting Document Architecture (QRDA) Category I files, zero denominator declarations, and/or case threshold exemptions. This information is reported through the QualityNet Secure Portal. Data submitters will continue to have access to the Pre-Submission Validation Application (PSVA) for test and production QRDA I file format validation activities.  The deadline for hospitals submitting an Extraordinary Circumstances Extensions/Exemptions (ECE) request for CY 2016 reporting is April 1, 2017.

    NOTE: This extension applies to the eCQM submission requirement for the Hospital IQR Program and the CQM submission options (reporting by attestation or electronically) for the Medicare EHR Incentive Program for eligible hospitals and critical access hospitals. 

    CY 2017 eCQM Reporting

    For CY 2017 reporting, CMS intends to initiate the rulemaking process regarding modifications to the eCQM requirements established in the FY 2017 Inpatient Prospective Payment System (IPPS) Final Rule in response to concerns raised by stakeholders.  These intended changes would help reduce reporting burden while supporting the long term goals of these programs.  For additional information, please refer to the CMS blog released on January 17, 2017, at https://blog.cms.gov/.  

    For More Information:

    Visit the eCQM Reporting Overview page on QualityNet.org and the Hospital IQR Program Resources and Tools page on QualityReportingCenter.com websites to obtain additional information on reporting eCQMs for the Hospital IQR Program. The resources available there range from an overview of the CY 2016...

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  • 2:23pm EST

    The Centers for Medicare & Medicaid (CMS) would like to know more about your experience(s) submitting Quality Reporting Document Architecture (QRDA) Category I files containing electronic Clinical Quality Measures (eCQMs).  Whether your comments are in regards to submitting test or production files for the Hospital Quality Reporting (HQR) Program, your feedback is very important to CMS to improve the process.

    The survey is intended for hospital or vendor staff members responsible for submitting QRDA Category I files to CMS on the hospital’s behalf for quality reporting.  Survey responses are anonymous and will help CMS evaluate, as well as, improve the data-submission experience.  The survey should take approximately 5 – 10 minutes to complete.  Please complete the survey by close of business February 28, 2017.

    The direct link to the survey is available below.

    QRDA eCQM Submission Customer Satisfaction Survey

    For further assistance regarding the information contained in this message, please contact the QualityNet Help Desk at qnetsupport@hcqis.org or (866) 288-8912, Monday through Friday, 7 a.m. – 7 p.m. CT.

Monday, January 16

  • 11:18pm EST

    This Outreach and Education webinar for participants in the Hospital Inpatient Quality Reporting (IQR) Program is scheduled for Monday, January 30, 2017 at 2:00 p.m. ET.

    The webinar, titled Question and Answer Session I – CY 2016 eCQM Reporting, will be presented by Jennifer Seeman, Hospital Quality Reporting (HQR) Electronic Health Record (EHR) Program Manager; Portfolio, Program, and Project Management (PM3) Support Contractor (SC) and Artrina Sturges, EdD, Project Lead, Medicare IQR-EHR Incentive Program Alignment; Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education SC.

    This presentation is the first of two sessions devoted to addressing submitter questions related to the mandatory electronic Clinical Quality Measure (eCQM) submission process for the Hospital IQR and Medicare EHR Incentive Programs for calendar year (CY) 2016.

    The objectives of the presentation include having greater insight for troubleshooting common Centers for Medicare & Medicaid Services (CMS) Quality Reporting Document Architecture (QRDA) Category I file submission errors to reduce the likelihood of file rejection, locating and utilizing tools and reference materials to assist with submission activities, and performing the steps necessary for successful submission of QRDA Category I test and production files.

    The webinar slides will be available for download from www.QualityReportingCenter.com under Upcoming Events the day before the presentation.

    You may register for the webinar at the following link: https://cc.readytalk.com/r/vtjygq8gfsyp&eom.

    The Registration Flyer contains other details for this event.

    For further assistance regarding the information contained in this message, please contact the Hospital Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team at https://cms-ip.custhelp.com or (844) 472-4477.

Thursday, January 12

  • 10:37am EST
    Event Reminder: Public Health Task Force - eCQM Zika Preparedness : Jan 12 2017 - 11:00am Reminder: Public Health Task Force - eCQM Zika Preparedness : Jan 12 2017 - 11:00am Lessons Learned from Electronic Clinical Quality Measures (eCQMs) Relevant to Zika PreparednessTechnical Standards and how they relate to current Zika challenges with data captureeCQM example: Chlamydia data capture shares common challenge with capturing pregnancy statusStandardization of clinical workflow aligning Best PracticesExample of one best practice for Zika preparednessGroup discussion on relevance to eCQMs to task force workWeb Conference InformationWeb Conference Information Participate online: http://altarum.adobeconnect.com/ONCtf/Audio: US toll free: 1-877-705-2976International Direct: 1-201-689-8798

    Event Reminder: Public Health Task Force - eCQM Zika Preparedness : Jan 12 2017 - 11:00am

    Reminder: Public Health Task Force - eCQM Zika Preparedness : Jan 12 2017 - 11:00am

    Lessons Learned from Electronic Clinical Quality Measures (eCQMs) Relevant to Zika Preparedness

    1. Technical Standards and how they relate to current Zika challenges with data capture
    2. eCQM example: Chlamydia data capture shares common challenge with capturing pregnancy status
    3. Standardization of clinical workflow aligning Best Practices
    4. Example of one best practice for Zika preparedness
    5. Group discussion on relevance to eCQMs to task force work

    Web Conference Information

    Web Conference Information Participate online: 

    Audio: 

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Tuesday, January 10

  • 11:57pm EST

    The Joint Commission will kick off the year for the Pioneers in Quality program on Tuesday, January 24th. Continuing the eCQM conversation, this webinar will provide participants with actionable information regarding eCQM reporting in 2017. For this session,The Joint Commission has collaborated with the Centers for Medicare & Medicaid Services (CMS), and its contractors to discuss key technical updates impacting electronic clinical quality measure (eCQM) reporting in 2017. The objectives for this webinar are to discuss the addendum to 2016 eCQM specifications to update relevant ICD-10-CM and ICD-10-PCS eCQM value sets for the 2017 performance year and to discuss changes to measure specifications applicable for 2017 reporting, followed by a discussion of common questions and issues.   A Q&A session will commence at the conclusion of the formal remarks.

     

    Pioneers in Quality Webinar: “Kickoff to Hospital eCQM Reporting in 2017”

     

    Tuesday, January 24th, at 9 a.m. PT / 10 a.m. MT / 11 a.m. CT/ noon ET

     

    Please email any questions you would like to have the presenters address during the webinar to pioneersinquality@jointcommission.org.

     

    The Pioneers in Quality program was created to assist hospitals on their journey towards eCQM adoption. Ultimately, the program will guide hospitals to be able to accurately reflect the patient care being provided with the goal of being a “top performer” in this new measurement world. Space is limited. A replay with presentation slides will be available on The Joint Commission website following the program. Find out more information – including replays of previous webinars – and register.

  • 2:00pm EST
    Changes to Event Date
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    Wednesday, January 11, 2017 - 11:00am to Wednesday, January 11, 2017 - 12:30pm
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    Thursday, January 12, 2017 - 11:00am to Thursday, January 12, 2017 - 12:30pm
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Monday, January 9

Friday, January 6

  • 5:30pm EST

    The Centers for Medicare & Medicaid Services (CMS) and the National Library of Medicine (NLM) have published an addendum to the 2016 eCQM specifications (published in April 2016). This addendum updates relevant International Classification of Diseases (ICD)-10 Clinical Modification (CM) and Procedure Coding System (PCS) eCQM value sets for the 2017 performance year. These changes affect electronic reporting of eCQMs for the following programs:

    • The Hospital Inpatient Quality Reporting Program
    • The Medicare Electronic Health Record Incentive Program for eligible hospitals and critical access hospitals
    • The Merit-based Incentive Payment System (MIPS) for MIPS eligible clinicians

    What Changes are Included in the Addendum?

    Changes will only affect the value sets for eCQMs remaining in the programs listed above for 2017 reporting. The Health Quality Measure Format (HQMF) specifications, the value set object identifiers (OIDs), and the measure version numbers for 2017 eCQM reporting will not change.

    The changes to the ICD-10 value sets consist of deletion of expired codes and addition of relevant replacement codes. Newly available codes that represent concepts consistent with the intent of the value set and corresponding measure(s) were also added. CMS is prioritizing these ICD-10 updates. Updates for other terminologies will take place during the 2017 Annual Update.

    All changes to ICD-10 value sets are detailed in revised technical release notes, including the OIDs affected and information on the codes added or deleted from the value sets.

    Where is the Addendum posted?

    The following updated measure information is available on the eCQM library and the electronic Clinical Quality Improvement (eCQI) Resource Center websites, including:

    • eCQM specifications, which include only measures in use for 2017 eCQM reporting
    • eCQMs for Eligible Clinicians Table January 2017 and eCQMs for Eligible Hospitals Table January 2017, which include only measures in use for 2017 eCQM reporting
    • Revised release notes, which provide an overview of technical changes implemented in the addendum (two sets of release notes will be available)
      • The first set provides information on ICD-10 value set updates for measures affected by this addendum
      • The second set provides information on changes from this addendum and all other updates for the measures included for 2017 eCQM reporting

    All changes to the eCQM value sets are available through the NLM’s Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/. The value sets are available as a complete set, as well as value...

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  • 2:54pm EST
    Edna Boone updated EP
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    2:31pm EST
    Ian updated EH
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    Ian updated EP