Electronic Clinical Quality Measure (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 (ONC) standards to capture, export, calculate, and report the measure data.

Effective CY 2016, hospitals were required to electronically report clinical quality measures (CQMs) 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 will also fulfill the Medicare Promoting Interoperability Program requirement for electronic reporting of CQMs with one submission.

There are additional program requirements for the Hospital IQR and Promoting Interoperability Programs for hospitals. For more information, refer to the Hospital IQR Program pages of QualityNet and the Promoting Interoperability pages of the Centers for Medicare & Medicaid Services (CMS) website. See Technical Specifications and Resources for the CMS Quality Reporting Document Architecture (QRDA) Category I Implementation Guide for the applicable reporting period, measure specification information, and program resources to support successful program reporting available on the eCQI Resource Center.

Note: Critical access hospitals (CAHs) are encouraged, but not required, to participate in the Hospital IQR Program. CAHs are required to participate in the Medicare Promoting Interoperability Program. Review the Medicare Promoting Interoperability Program information on the CMS.gov website for more information.


CY 2018 Reporting Period for Fiscal Year (FY) 2020 Payment Determination

For the CY 2018 reporting period, eligible hospitals (EHs) are required to report eCQMs to the Hospital IQR Program, per the FY 2018 IPPS Final Rule. This information is available on the CY 2018 eCQM Overview document. EHs and CAHs are required to electronically report to the Medicare Promoting Interoperability Program (previously known as the Medicare EHR Incentive Program). Attestation will only be permitted as a reporting option for the Medicare Promoting Interoperability Program in certain circumstances where electronic reporting is not feasible. (Review the CMS.gov website for updates regarding the attestation criteria.)

Note: The attestation option will not meet Hospital IQR Program requirements.

Hospital IQR Program Reporting Requirements for CY 2018

For the CY 2018 reporting period, hospitals participating in the Hospital IQR Program must:

  • Use Health Information Technology (IT) certified to report all 16 CQMs.
  • Self-select and successfully report a minimum of four of the available eCQMs using Health IT certified by the Office of the National Coordinator for Health IT (ONC) to the 2014 and/or 2015 Edition through the QualityNet Secure Portal, using any combination of QRDA Category I files, zero denominator declarations, and/or case threshold exemptions.
  • Report data for at least one self-selected quarter (Q) of 2018 data (Q1, Q2, Q3, or Q4) using certified Health IT.
  • Submit data via the QualityNet Secure Portal by the deadline: February 28, 2019, by 11:59 p.m. PT.

CY 2017 Reporting Period for FY 2019 Payment Determination

For the CY 2017 reporting period, EHs were required to report eCQMs to the Hospital IQR Program. EHs and CAHs were required to either electronically report or attest CQMs to the Medicare EHR Incentive Program. Beginning with the CY 2017 reporting period, the number of available eCQMs had been reduced from 29 to 16 for reporting to the Medicare EHR Incentive Program. CMS aligned 15 of the available eCQMs for the Hospital IQR Program.

Hospital IQR Program Reporting Requirements for CY 2017

For the CY 2017 reporting period, hospitals participating in the Hospital IQR Program had to:

  • Self-select and successfully report on a minimum of four of the 15 available eCQMs using Health IT certified by the ONC to the 2014 and/or 2015 Edition through the QualityNet Secure Portal, using any combination of QRDA Category I files, zero denominator declarations, and/or case threshold exemptions.
  • Report data for at least one self-selected quarter of 2017 data (Q1, Q2, Q3, or Q4) using certified Health IT.
  • Submit data via the QualityNet Secure Portal by the deadline: February 28, 2018, by 11:59 p.m. PT.
* Note: The submission deadline was extended to March 16, 2018.

CY 2016 Reporting Period for FY 2018 Payment Determination

For the CY 2016 reporting period, EHs were required to report eCQMs to the Hospital IQR Program. EHs and CAHs were required to either electronically report or attest CQMs to the Medicare EHR Incentive Program. Of the 29 eCQMs available for reporting to the Medicare EHR Incentive Program, CMS aligned 28 of the eCQMs for the Hospital IQR Program.
Hospital IQR Program Reporting Requirements for CY 2016
For the CY 2016 reporting period, hospitals participating in the Hospital IQR Program had to:

  • Successfully submit data using Health IT certified by the ONC to the 2014 or 2015 Edition for at least four of the 28 available eCQMs through the QualityNet Secure Portal, using any combination of QRDA Category I files, zero denominator declarations, and/or case threshold exemptions.
  • Submit data via the QualityNet Secure Portal by the February 28, 2017, deadline*.

* Note: The submission deadline was extended to March 13, 2017.


Paperwork Reduction Act (PRA) Disclosure Statement

The following PRA Disclosure Statement applies to forms and other information collection requirements associated with eCQM reporting for the Hospital IQR Program:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1022.The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimates(s) or suggestions for improving this form, please write to CMS, Attention: PRA Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

****CMS Disclosure**** Please do not send applications, claims, payments, medical records, or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact the Hospital Inpatient Value, Incentives, and Quality Reporting (VIQR) Outreach and Education Support Team at (844) 472-4477.

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