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  • REMINDER: New eCQM Requirements for IQR Reporting Year 2016 for PPS Hospitals

REMINDER: New eCQM Requirements for IQR Reporting Year 2016 for PPS Hospitals

For calendar year 2016, electronically specified clinical quality measure (eCQM) data submission is required for the Hospital Inpatient Quality Reporting (IQR) program. The following steps may assist Prospective Payment System (PPS) hospitals with meeting this requirement. For further information on this topic, please visit the QualityNet eCQM page.

To meet the new eCQM requirements, hospitals must:

  1. Select 4 of the 28 available eCQMS for CY 2016 reporting
    Note:  Hospitals must also abstract required measures from chart review, even if those measures are submitted via eCQMs
  2. Report one quarter of eCQM data from Quarter 3 or Quarter 4 of 2016
  3. Report using either the 2014 or 2015 edition of certified electronic health record technology
  4. Submit data in QRDA Cat 1 format through the QualityNet Secure Portal by February 28, 2017 (regardless of the reporting quarter selected for submission)
  5. Complete other remaining IQR Program requirements
    Note: Submitting eCQMs only meets a portion of the IQR Program requirements. Hospitals must also submit data for all required chart-abstracted, Web-based, structural and claims-based measures.

More Information on Hospital IQR Program

eCQM for IQR and Meaningful Use (MU):
Hospitals that successfully submit eCQM data as required by the IQR Program will also get credit for all CQM reporting requirements for the EHR Incentive Program (Meaningful Use). Be mindful that submitting eCQMs via the IQR Program only meets the CQM portion of Meaningful Use requirements.  Hospitals must also meet all other reporting requirements.

Steps for IQR and MU eCQM Reporting for Hospitals:

  1. Decide if your hospital will submit your eCQM data or if a certified EHR vendor will submit on the hospital’s behalf.
  2. If your hospital will submit data directly: create (or update) your QualityNet login account, requesting “EHR data Upload” role from the QualityNet helpdesk.
    If a certified EHR Vendor will submit data for your hospital: create (or update) your QualityNet login account and authorize your vendor on the QualityNet Secure Portal by measure set, data transmission start/end date, or discharge quarter start/end date. Authorized EHR vendors must register for a QualityNet account and request the “EHR Data Upload” role
  3. Verify what eCQMs are available for reporting
  4. Confirm existing functionality for needed eCQMs or implement eCQM functionality in your system
  5. Check EHR configuration and workflows and confirm correct tracking and collection of data for eCQMs
  6. Validate eCQM data and troubleshoot/correct any issues
  7. Create QRDA Category 1 files for needed eCQMs
  8. Download Pre-Submission Validation Application (software) (PSVA)  (resides on your system/network) from QualityNet (you must have “EHR data Upload” role)
  9. Use PSVA to test QRDA files to validate for correct formatting and to troubleshoot exported data
  10. Test PSVA validated QRDA files via the Hospital Quality Reporting System, to be available from QualityNet in Fall 2016
  11. Submit HQR validated QRDA files via QualityNet by February 28, 2017


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