Are You Ready for eCQM Reporting in 2016?

Quality Reporting for Hospitals Quality reporting is a complicated and, in some cases, a mandatory requirement for hospitals and providers.

In this week’s blog we break down the 2016 requirements for reporting eCQMs to the following programs:

1. CMS’ Inpatient Quality Reporting program
2. PQRS program for Eligible Professionals
3. The Joint Commission Hospital accreditation program

Here’s what you need to know.

For the past two years, CMS has offered hospitals the option to submit Electronic Clinical Quality Measures (eCQMs) to meet part of their Inpatient Quality Reporting (IQR) program requirements. Few hospitals have taken advantage of eCQM reporting, preferring instead to continue manual abstraction.

Electronic submission of data for four eCQMs is now required for Calendar Year (CY) 2016 reporting. The good news is that this submission will also fulfill the eCQM reporting requirements in the Meaningful Use program. Failure to submit 2016 data may result in an up to 2 percent payment penalty applied in FY 2018.

But you’re in luck! We’ve done the homework for you and compiled a list of the requirements for each of the quality reporting programs.
Note: Attestation of Meaningful Use Objective measures is still required.


  • Select four out of the 28 available eCQMs to report electronically as patient level QRDA I files.
  • Use 2014 or 2015 edition Certified EHR Technology (CEHRT) with the June 2015 eCQM specifications update.
  • Report data for one of the following CY 2016 quarters: Q3 (July 1 – Sept. 30) or Q4 (Oct. 1 – Dec. 31) before the submission deadline of Feb. 28, 2017.
  • CMS will begin accepting test files in May, 2016, affording hospitals an opportunity to: a) confirm files are formatted properly and will pass validation checks, b) have measure calculations completed, c) view reports, and d) fix any errors prior to submission.
  • Hospitals may choose to generate QRDA I files and submit data on their own or select a Data Submission Vendor, like Medisolv, to submit data on their behalf, using the vendor’s CEHRT Quality Module.



  1. Vendor submission of quarterly data on six of nine sets of chart-abstracted measures (four sets for Critical Access Hospitals). Data must be reported on all measures in the chart-abstracted measure sets.
  2. Vendor submission of data on six of the eight sets of electronic clinical quality measures (eCQMs) (four sets for Critical Access Hospitals).
  3. Vendor submission of data on six sets of measures using a combination of chart-abstracted measure sets and eCQM sets (four sets for Critical Access Hospitals).


Note: The current ORYX Requirement by TJC is reporting on six of nine measure sets of chart-abstracted measures. Critical Access Hospitals are not required to report data to the TJC, but may do so voluntarily, and need only submit four measure sets.


  • Nine eCQMs across three NQS Domains (unless reporting CAHPS for PQRS, in which case only six eCQMs across two NQS Domains).
  • Submit data for the entire calendar year 2016 during the submission window from Jan. 1st, 2017 through Feb. 28th, 2017.
  • Submit as individual Eligible Provider (EP) at the NPI level or choose Group Practice Reporting Option (GPRO) at the TIN level.
  • Groups planning to submit as GPRO must make that election with CMS no later than June 30th, 2016.
  • Individual EPs will be required to submit patient-level QRDA I files. GPRO submission will require aggregate QRDA III files.



Lessons from the First Year of Quality Reporting

ecqm reporting

1 Inpatient Quality Reporting (IQR) Program 2016 CMS QRDA Implementation Guide Changes for Eligible Hospitals/Critical Access Hospitals.
2 The CY 2016 Final Rule on Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Policy Changes by the Centers for Medicare & Medicaid Services.
3 The Joint Commission’s Frequently Asked Questions About 2016 ORYX® Performance Measure Reporting Requirements and Options.
4 The CY 2016 Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Medicare Part B.
Erin Heilman