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Clinical Quality Measures Basics

Electronic clinical quality measures (CQMs) are tools that help measure and track the quality of health care services that eligible professionals (EPs), 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. 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

To successfully participate in the Medicare and Medicaid Promoting Interoperability Programs, CMS requires EPs, eligible hospitals, CAHs, and dual-eligible hospitals to report on eCQMs. These eCQMs are determined by CMS and require the use of 2015 Edition of certified electronic health record technology (CEHRT). For more information on 2015 Edition CEHRT, review this fact sheet.

Medicare Promoting Interoperability Program Requirements for 2019 and 2020

For first-time and returning participants, the 2019 and 2020 reporting period for eligible hospitals and CAHs who report electronically is one self-selected quarter of calendar year (CY) data. The submission period will be the two months following the close of the each CY. If they submit electronically for 2020, they must submit 4 eCQMs from the list of 8 available eCQMs. If they submit electronically for 2019, they must submit 4 eCQMs from the list of 16 available eCQMs.

In 2019, if electronic reporting is not feasible, an eligible hospital or CAH may report via attestation. This reporting period would require data from the full CY 2019 (consisting of four quarterly data reporting periods). If an eligible hospital, CAH, or dual-eligible hospital reports via attestation, they are required to report on all 16 eCQMs.

Specific details for both 2019 and 2020 are listed below:

  • 2019 Electronic Reporting Requirements
    • Electronic reporting requires eligible hospitals and CAHs to report on four self-selected eCQMs from the set of 16 available
    • Submission period deadline: February 29, 2020
  • 2020 Electronic Reporting Requirements
    • Required to report on four self-selected eCQMs from the set of 8 available
    • Submission period deadline: February 28, 2021

Medicaid Promoting Interoperability Program Requirements for 2019

The 2019 eCQM reporting period for EPs is the full 2019 CY, except for first time meaningful users, for whom the reporting period is any continuous 90-day period within CY 2019. All participating EPs are required to report on any 6 eCQMs relevant to their scope of practice from the set of 50 available. In addition, EPs must report on at least one outcome measure. If no outcome measure is relevant to his or her scope of practice, the EP must report on one high priority measure. If no high priority measures are relevant to their scope of practice, they may report on any six relevant measures. The list of available eCQMs, including which qualify as outcome or high-priority can be found here. More information on each eCQM can be found on the eCQI Resource Center.

For first-time hospitals who submit eCQMs electronically, the reporting period is any continuous 90-day period, these participants are required to report on four measures. For first-time hospitals who submit eCQMs via attestation, the reporting period is the full 2019 CY data. These participants are required to report on all 16 eCQMs. 

For returning hospitals who submit eCQMs via attestation, the reporting period is any continuous 90-day period and requires reporting on all 16 eCQMs is required. The reporting period is the same for those who submit electronically, but this form of submission only requires reporting on four eCQMs.

Note: Under the Medicaid Promoting Interoperability Program, states have the flexibility to determine the method of reporting eCQMs and submission period, subject to prior approval by CMS. States also have the flexibility to determine the specifications that may be used to electronically report eCQMs under the Medicaid Promoting Interoperability Program.

eCQM Reporting Requirement Tables

Additional Resources