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Cheat Sheet

Hospital eCQM reporting

10 Minute Read

Key Takeaways
  • CMS requires hospitals to report electronic clinical quality measures (eCQM), which track quality data generated by certified electronic health record technology (CEHRT).
  • Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs) must report eCQM data year-over-year as one component of participation in the Promoting Interoperability (PI) program.
  • Successful eCQM reporting for the hospital PI program also counts toward the eCQM reporting component of the Inpatient Quality Reporting (IQR) program.
  • If hospitals fail to satisfy annual PI or IQR reporting requirements, they may face hefty Medicare penalties.

What is it?

"eCQMs are tools that help measure and track the quality of health care services…as generated by a provider’s EHR."
-Center for Medicare and Medicaid Services website

The Promoting Interoperability (PI) program requires Medicare hospitals to submit electronic clinical quality measure (eCQM) data. CMS sets the annual eCQM requirements for eligible hospitals (EHs) and critical access hospitals (CAHs).

Technology to support eCQM reporting

Hospitals must use certified EHR technology (CEHRT) to generate eCQM data for submission. CMS works with the Office of the National Coordinator for Health IT (ONC) to establish CEHRT requirements. Since 2019, CMS has required hospitals to use 2015 Edition CEHRT.

eCQM reporting is one part of PI program participation

Successful PI program participation requires more than eCQM reporting alone. Hospitals must also meet reporting requirements for measures that assess whether a hospital is a “meaningful user” of CEHRT.

Alignment across CMS programs

The eCQM reporting requirement is aligned between the hospital PI program and the Inpatient Quality Reporting (IQR) program. Hospitals can submit eCQM data to the CMS QualityNet secure portal to simultaneously satisfy the eCQM reporting component under both programs. CMS has required electronic submission of eCQM data since 2018 for the PI program and 2016 for the IQR program. 


Why does it matter?

Hospitals must submit eCQMs each year as part of PI program participation. Otherwise, they could face hefty Medicare penalties—CMS applies a 75% percent reduction to the annual IPPS1 market basket update for hospitals that fail to meet PI requirements. The eCQM data submission is pay-for-reporting, which means hospitals meet the requirement by reporting data to CMS and there is no financial impact for poor performance.

Public reporting of eCQM data

Beginning with data reported for the 2021 program year, CMS will make eCQM data publicly available on Hospital Compare. This is part of CMS’s effort to increase data transparency. To maintain a competitive position in the market, hospital must address:

  • Accuracy. Hospitals must validate that eCQM data generated by CEHRT accurately reflects the quality of care being delivered. Each data element that is used to generate eCQM performance data must be collected in discrete coded format and mapped according to the appropriate electronic specifications.
  • Performance. Low performance on eCQM data can damage a hospital’s reputation among patients and payers. Hospitals should proactively identify improvement opportunities, as it can take significant time and resources to implement the necessary steps to boost performance.

While eCQM performance doesn’t currently factor into hospital reimbursement, it’s only a matter of time. In future years we expect CMS will seek to tie eCQM data to incentives and/or penalties in one or more hospital reporting programs, as they continue to prioritize electronic reporting and value based care initiatives.

1. IPPS: Inpatient Prospective Payment System. Each year the IPPS final rule establishes the annual market basket update, a percentage update to Medicare hospital reimbursement that reflects inflation in costs of goods and services used by hospitals in treating Medicare patients.


How does it work?

CMS publishes eCQM reporting requirements in each year’s IPPS final rule. Hospitals must keep up-to-date with the available eCQMs, how many eCQMs they must report, reporting period, and required electronic specifications.

Available eCQMs

Hospitals must report four eCQMs selected from a list of nine set by CMS. The available eCQMs cover several clinical areas – for example, preventive care for patients who are treated for stroke, or prophylaxis for venous thromboembolism. Beginning 2022, hospitals must report an eCQM that measures safe use of opioids as of as one of their four self-selected measures.

Reporting period

In previous years, hospitals were required to report one self-selected calendar quarter of eCQM data. For the 2021 program year, hospitals must report their four eCQMs from two self-selected calendar quarters. CMS will continue to increase the number of required calendar quarters each year until 2023, when hospitals must begin reporting all four calendar quarters.

Electronic specifications

CMS issues annual updates to the electronic specifications for eCQM reporting. Hospitals must implement the most recent specifications in CEHRT to generate eCQM data files1 that are reported to CMS. Those files are then submitted via the QualityNet secure portal, either directly by the hospital or through a third- party intermediary.

Conversations you should be having
  1. Identify who is accountable for eCQM reporting, data validation, and performance improvement efforts.

  2. Determine which eCQMs you plan to report based on your hospital’s broader quality goals.

  3. Communicate with your vendors about CEHRT updates and devote resources to implement annual changes.

Successful eCQM reporting involves IT and quality departments working closely together in order to implement both the technology and clinical workflows necessary for capturing quality performance. Hospitals must continue to monitor  CMS rulemaking to prepare for future updates, and adjust their eCQM reporting plans each year to meet increasing reporting requirements

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