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. 

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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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 Inpatient Quality Reporting (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 Medicare and Medicaid EHR Incentive Program (“Meaningful Use”), please contact the QualityNet Help Desk at qnetsupport@hcquis.org or call (866) 288-8912, Monday through Friday 7am - 7pm CT

For questions on the Quality Payment Program (QPP), please contact QPP@cms.hhs.gov or (866) 288-8292 

For questions related to eCQM implementation, specifications, logic, date elements, standards or tools, please go to JIRA (online tracking tool): https://oncprojectracking.healthit.gov

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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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