eCQM Overview

Beginning in Calendar Year (CY) 2013, hospitals were provided the opportunity to voluntarily submit data for eCQMs. These quality measures were developed specifically to allow an electronic health record (EHR) system, certified to the Office of the National Coordinator for Health Information Technology (ONC) standards, to capture, export, calculate, and report the measure data.

Since CY 2016, hospitals have been required to report eCQM data as a portion of the Hospital Inpatient Quality Reporting (IQR) Program and the Medicare Promoting Interoperability Program (previously known as the Medicare EHR Incentive Program). Hospitals that successfully submit eCQM data to meet Hospital IQR Program requirements also fulfill the Medicare Promoting Interoperability Program requirement for reporting of eCQMs with one submission.

Electronic clinical quality measures (eCQMs) are tools that help measure and track the quality of health care services that eligible hospitals and critical access hospitals (CAHs) provide, as generated by a provider's electronic health record (EHR). Measuring and reporting eCQMs helps to ensure that our health care system is delivering effective, safe, efficient, patient-centered, equitable, and timely care. CMS’ eCQMs measure many aspects of patient care, including:

• Patient and Family Engagement
• Patient Safety
• Care Coordination
• Population/Public Health
• Efficient Use of Healthcare Resources
• Clinical Process/Effectiveness

Health care providers are required to electronically report eCQMs, which use data from EHRs and/or health information technology systems to measure health care quality. To report eCQMs successfully, health care providers must adhere to the requirements identified by the CMS quality program in which they intend to participate.

Each year, CMS makes updates to the eCQMs approved for CMS programs to reflect changes in:

• Evidence-based Medicine
• Code Sets
• Measure Logic

The ACDIS Regulatory Committee thanks Wendy Haney, BSN, RN, CCDS, for serving as lead author for this work.