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Standards Summary

Electronic clinical quality measure (eCQM) standards are critical to data consistency, validity, and interoperability. Standards, in the context of health information technology, refer to agreed-upon methods and terminology for connecting systems such as file formats for electronic documents, messages, and related health care data elements. Standards pertain to data transport, data format and structure, and the meanings of codes and terms. See the Interoperability Standards Advisory for the recommended eCQI standards.

Key eCQM Standards

Key standards for electronic transmission of health information used to support eCQMs are



Clinical Quality Language – expression language used to communicate specific data to be retrieved and logic needed to evaluate eCQMs. The machine-readable Expression Logical Model (ELM) is a representation of the CQL.


Fast Healthcare Interoperability Resources® - a key standard under consideration for use by CMS for exchanging health care information electronically.


Health Quality Measure Format – standard format to describe eCQM metadata, such as numerator
denominator, exclusions, and exceptions, as an XML document.


Clinical Quality Language-Based Health Quality Measure Format – an implementation guide for how to use the HQMF base standard with QDM and CQL to author eCQMs.


Quality Data Model – a standard information model that describes the data to represent information necessary for electronic quality assessment.


Quality Reporting Document Architecture – standard format for reporting eCQM data in a structured, consistent representation. QRDA I is used for individual patient data and QRDA III for aggregate patient data.

The figure depicts the use and flow of the eCQM transmission standards.

Connection between standards


Health Terminology Standards

Numerous organizations develop and maintain standard terminologies. The National Library of Medicine’s (NLM) Unified Medical Language System® Metathesaursus is a large biomedical thesaurus organized by concept, or meaning, and it links synonyms to the concept from nearly 200 different terminologies. However, eCQMs use only a handful of these terminologies, e.g., SNOMED CT and RxNorm. NLM’s Value Set Authority Center (VSAC) is the official source of eCQM value sets used in eCQMs in CMS programs.

Electronic Clinical Quality Measure (eCQM) Standard Tools and Resources

The use of eCQM-friendly tools and resources provides standardization in developing eCQMs. Standardization facilitates implementation by minimizing burden.

Bonnie was sunsetted June 28, 2024. Measure developers are to use the Measure Authoring Development Integrated Environment (MADiE).

Cypress is an open-source testing tool used by health information technology (IT) vendors to certify their electronic health records (EHRs) and health IT modules (CEHRT) for calculating eCQMs. The Cypress application includes the Cypress Validation Utility + Calculation Check (CVU+). The CVU+ facilitates real-world testing, providing health IT vendors the ability to perform QRDA validation testing using their own test patients.

The Measure Authoring Development Integrated Environment (MADiE) is a web-based authoring tool required for developing and maintaining eCQMs for CMS programs. Use of the MADiE is to ensure eCQM developers are using the established health IT standards and clinical terminology code systems needed for eCQM implementation. Specifically, the MADiE enables measure developers to author eCQMs in Health Quality Measure Format (HQMF) using the Quality Data Model (QDM) data elements, Clinical Quality Language (CQL), and other standards to meet future measure authoring requirements.

United States Core Data for Interoperability (USCDI) + Quality Data Element List

Value Set Authority Center (VSAC) provides the ability to develop value sets from the Unified Medical Language System terminologies.

The figure shows the connections among eCQM standards and the tools used to help develop and test eCQMs.

Graphic shows interactions of eCQM tools

Find additional eCQI tools on the individual tools and resources tab of each standard on the main menu of the eCQI Resource Center and within the eCQI Tools & Key Resources.

Standards Update Cycle

Revisions to standards occur constantly to improve how data are captured, used, and shared. The standards update cycle figure provides an overview of the steps CMS standards contractors use to move through to support updates to standards used in CMS quality reporting and incentive programs.

Standards Update Cycle 

Last Updated: Jun 27, 2024