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Eligible Hospital / Critical Access Hospital eCQMs

Select Reporting Period:

2022 Reporting Period Eligible Hospital / Critical Access Hospital Resources
For Use eCQM Implementation Resources Published
2022 Q1-Q4 Implementation Checklist eCQM Annual Update
2022 Q1-Q4 Guide for Reading eCQMs v7.0 May 2021
2022 Q1-Q4 Hospital Quality Reporting Table of eCQMs May 2021
2022 Q1-Q4 eCQM Specifications for Hospital Quality Reporting May 2021
2022 Q1-Q4 eCQM Value Sets May 2021
2022 Q1-Q4 eCQM Direct Reference Codes List May 2021
2022 Q1-Q4 Binding Parameter Specification (BPS) May 2021
2022 Q1-Q4 Binding Parameter Specification (BPS) May 2021
2022 Q1-Q4 eCQM Logic and Implementation Guidance v5.0 May 2021
2022 Q1-Q4 Technical Release Notes May 2021
2022 Q1-Q4 Technical Release Notes May 2021
2022 Q1-Q4 Standards and tool versions used for reporting period May 2021
2022 Q1-Q4 eCQM Flows - Coming Soon
2022 Q1-Q4 2022 CMS QRDA I Implementation Guide for Hospital Quality Reporting May 2021
2022 Q1-Q4 2022 CMS QRDA I Schematrons and Sample Files May 2021
2022 Q1-Q4 eCQM Annual Update Pre-Publication Document Feb 2021
2022 Reporting Period Eligible Hospital / Critical Access Hospital eCQMs
Total number of EH/CAH eCQMs: 9
Measure Name Short Name CMS eCQM ID NQF ID Meaningful Measure Area
Anticoagulation Therapy for Atrial Fibrillation/Flutter STK-3 CMS71v11 Not Applicable Preventive Care
Antithrombotic Therapy By End of Hospital Day 2 STK-5 CMS72v10 Not Applicable Preventive Care
Discharged on Antithrombotic Therapy STK-2 CMS104v10 Not Applicable Preventive Care
Discharged on Statin Medication STK-6 CMS105v10 Not Applicable Preventive Care
Exclusive Breast Milk Feeding PC-05 CMS9v10 0480e Care is Personalized and Aligned with Patient's Goals
Intensive Care Unit Venous Thromboembolism Prophylaxis VTE-2 CMS190v10 Not Applicable Preventive Care
Median Admit Decision Time to ED Departure Time for Admitted Patients ED-2 CMS111v10 Not Applicable Admission and Readmissions to Hospitals
Safe Use of Opioids - Concurrent Prescribing Not Applicable CMS506v4 3316e Prevention and Treatment of Opioid and Substance Use Disorders
Venous Thromboembolism Prophylaxis VTE-1 CMS108v10 Not Applicable Preventive Care

Each year, CMS updates the eCQMs for potential use in CMS quality reporting programs and publishes them on the eCQI Resource Center. CMS updates the specifications annually to align with current clinical guidelines and code systems so they remain relevant and actionable within the clinical care setting. CMS requires the use of the most current version of the eCQMs for the applicable reporting periods for all quality reporting programs.

The updated eCQMs are to be used by eligible hospitals and critical access hospitals to electronically report 2022 clinical quality measure data for CMS quality reporting programs. Measures will not be eligible for 2022 reporting unless and until they are proposed and finalized through notice-and-comment rulemaking for each applicable program.

CMS has updated eCQMs for potential inclusion in these programs

  eCQM Implementation Checklist
eCQM Implementation Checklist
Use the eCQM Implementation Resources and follow the eCQM Implementation Checklist to update your electronic health record and processes for eCQM use and reporting.

Hybrid Measures

Hybrid measures are quality measures that merge electronic health record data elements with claims data to calculate measure results. Currently, the Hybrid Hospital Wide Readmission (HWR) measure is the only hybrid measure adopted for use in a program.

The electronic specifications for the Hybrid Hospital Wide Readmission (HWR) measure are updated for the voluntary reporting period from July 1, 2022 through June 30, 2023 for the Hospital Inpatient Quality Reporting (IQR) Program. Hospitals that submit data for this measure during the voluntary reporting period would receive confidential hospital-specific reports that detail submission results from the reporting period, as well as the Hybrid HWR measure results. Data will not be publicly reported during the voluntary reporting period. CMS will begin the public reporting of the Hybrid HWR measure results beginning with data collected from the July 1, 2023 through the June 30, 2024 reporting period.

Each year, CMS makes updates to the Hybrid HWR measure adopted for reporting in the Hospital Inpatient Quality Reporting (IQR) program. Hybrid measures require updates to the electronic specifications, posted below, and to claims-based specifications, available on QualityNet. CMS requires the use of updated electronic specifications for all its quality programs because they include updated codes, logic corrections, and clarifications. Reporting data for the Hybrid HWR measure to the Hospital IQR program requires that a hospital or electronic health record vendor use the most current version of the electronic measure specifications (identified below) for the applicable reporting period.

2022 Reporting Period Eligible Hospital / Critical Access Hospitals
This is a voluntary hybrid measure and does not count toward eCQM submission.
Measure Name Short Name CMS eCQM ID NQF ID Meaningful Measure Area
Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data Hybrid HWR CMS529v2 2879 Admissions and Readmissions to Hospitals
2022 Reporting Period Eligible Hospitals / Critical Access Hospital Resources
For Use Implementation Resources Published
2022 Q1-Q4
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 Feb 2021

Pre-Rulemaking Hybrid Measures

CMS pre-rulemaking hybrid measures are developed, but specifications are not finalized for use in a CMS quality reporting program. These measures will not be eligible for CMS quality reporting until they are proposed and finalized through notice-and-comment rulemaking for each applicable program.

Feedback on technical aspects of these eCQMs should be submitted to the ONC Project Tracking System (Jira) Hybrid Measure Issue Tracker.

Feedback on the potential use of these eCQMs in CMS quality programs is to be submitted during formal CMS public comment periods associated with the relevant proposed rules.

For Use Implementation Resources Published
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
2022 Q1-Q4 May 2021
Last Updated: May 05, 2021