CMS Clarifies ED Measures Time Difference Calculation Methods for CY 2017 eCQM Hospital Quality Reporting

March 1, 2018 - 7:12pm

The Centers for Medicare & Medicaid Services (CMS) is notifying data submitters that the CMS data receiving system within the QualityNet Secure Portal is calculating the absolute value for three emergency department (ED) electronic clinical quality measures (eCQMs). This impacts Calendar Year (CY) 2017 reporting to the Hospital Inpatient Quality Reporting (IQR) and Electronic Health Record (EHR) Incentive Programs.

Issue: The CMS data receiving system within the QualityNet Secure Portal is using the absolute value when calculating time differences specified in measure observation of the three ED eCQMs, rather than using the submitted number:

As a result, users may notice differing times when comparing ED measure observations generated by the eCQM Submission and Performance Feedback Report (546) to ED measure observations calculated outside of the CMS receiving system. In the cases where the calculated time difference has a result less than 0, the cases will not show as a negative value.

On the eCQM Performance Feedback Report (547), where ED cases are included that have a measure observation of less than 0, the median times displayed for ED measures may be slightly higher when compared to those calculated outside the CMS receiving system.

Note: The accuracy of CY 2017 eCQM data submitted for validation in spring 2018 willnot affect a hospital’s validation score for the FY 2020 payment determination.

Resolution: CMS is aware there are a few instances where a negative value is an accurate result when calculating the value of the departure time minus the arrival time for ED measures. The CMS data receiving system will be modified to use submitted numbers for the three value calculations mentioned above (instead of the absolute value) for CY 2018 eCQM reporting. Once the system is updated for CY 2018 eCQM reporting, hospitals that see negative values when the time difference is calculated should take steps to ensure they are not encountering an EHR data entry issue. In addition, negative values will not be utilized when calculating aggregate results. CMS will notify data submitters via several communication outlets, including ListServes, when the system has been updated.

For questions concerning the QualityNet Secure Portal, Pre-Submission Validation Application (PSVA) tool, and file-error messages, please open a ticket with the QualityNet Help Desk at

For questions on the Hospital IQR Program, please contact the Hospital Inpatient Value, Incentives, and Quality Reporting Outreach and Education Support Team at or (844) 472-4477.