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 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.

Refer to the 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 eCQM reporting 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 2019 Reporting Period for Fiscal Year (FY) 2021 Payment Determination

For the CY 2019 reporting period, eligible hospitals are required to electronically report eCQMs to the Hospital IQR Program, per the FY 2019 IPPS/LTCH PPS Final Rule. This information is available on the CY 2019 Submission Overview document. Eligible hospitals and CAHs are required to electronically report eCQMs to the Medicare Promoting Interoperability Program. Attestation will only be permitted as a reporting option to 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 2019

For the CY 2019 reporting period, hospitals participating in the Hospital IQR Program must:

  • Self-select and successfully report a minimum of four of the 15 available eCQMs 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 2019 data (Q1, Q2, Q3, or Q4).
  • Use Health Information Technology (IT) certified to the 2015 Edition of the ONC certification standards and certified to report all 15 eCQMs.
  • Submit data via the QualityNet Secure Portal by the deadline: March 2, 2020, by 11:59 p.m. Pacific Time (PT). (Deadline extended due to original deadline falling on a weekend and/or holiday.)

Hospital IQR Program Reporting Requirements for CY 2018

For the CY 2018 reporting period, hospitals participating in the Hospital IQR Program were required to:

  • Self-select and successfully report a minimum of four of the 15 available eCQMs 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 2018 data (Q1, Q2, Q3, or Q4).
  • Use Health IT certified to the 2014 and/or 2015 Edition of the ONC certification standards and certified to report all 15 eCQMs.
  • Submit data via the QualityNet Secure Portal by the deadline*: February 28, 2019, by 11:59 p.m. PT.
  • *Note: The submission deadline was extended to March 14, 2019.

Hospital IQR Program Reporting Requirements for CY 2017

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

  • Self-select and successfully report on a minimum of four of the 15 available eCQMs 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).
  • Use Health IT certified to the 2014 and/or 2015 Edition of the ONC certification standards and certified to report all 15 eCQMs.
  • 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.

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 (expires 01-31-2022). 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 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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