What is the Difference Between Manual Attestation and Electronic File Submission?

Over the course of several years, hospitals became familiar with the process of Meaningful Use attestation. Now CMS is requiring a new method of reporting eCQM quality data and hospitals must familiarize themselves with this process. This year, hospitals must submit four eCQMs as a part of the Inpatient Quality Reporting (IQR) Program.

Here is the main difference between attestation and submission.

What is Meaningful Use eCQM Attestation?

Attestation is your way of saying to CMS that you can electronically capture patient-level eCQM detail in your hospital. It is a part of the EHR Incentive Program (Meaningful Use) which, if successfully completed, will award your hospital with Meaningful Use Incentive funds.

Think of it as a signing a legal document stating that everything you filled out during the attestation process is accurate.

What is eCQM Submission?

Submission is your way of demonstrating to CMS that you can electronically capture patient-level data in your hospital. It is a part of the CMS IQR program and by successfully submitting your eCQM data, your hospital can avoid the risk of penalty adjustments.

What are we reporting on?

In both attestation and submission we are reporting on how many patients passed or failed the measure. For example, if your hospital has a stroke patient, they must be assessed for rehab before they leave the hospital. Clinicians note whether this was completed or not. In the simplest terms, if the answer is yes, that patient passes the measure. If not – and the patient does not have any applicable exceptions – the patient fails the measure. This data is what is reported to CMS in both attestation and submission.

What is the eCQM Attestation Process?

Attestation is completed on the CMS Registration and Attestation System online. To complete attestation, hospitals must login to the CMS attestation portal and manually enters the values of their eCQM data.

What is the eCQM Submission Process?

Submission is completed on the CMS QualityNet website. As noted above, with attestation you login to your portal and punch in the values. With submission, the electronic measure data is exported in the form of a QRDA I file format. (Quality Reporting Data Architecture) The QRDA file is then uploaded to QualityNet.

What are the requirements for each program in 2016?

Meaningful Use Attestation

  • Report on one year’s worth of data (some exclusions apply for those who have never attested before.)
  • Input values for the 9 objective measures
  • Input values for 16 eCQMs


eCQM Submission

  • Report data from either Q3 (July 1 – September 30) or Q4 (October 1 – December 31) of 2016
  • Submit data for four eCQMs
  • Submit a patient-level QRDA I File

*This is a requirement for the CMS IQR Program. Hospitals could lose up to 2 percent of their Medicare reimbursements.

Do the programs overlap?

Yes. When you electronically submit your four eCQMs it will automatically fulfill your eCQM requirements for the Meaningful Use program. You do not need to attest for your eCQMs. You still need to complete the attestation process for the MU objective measures.

Are there thresholds for the eCQMs with attestation or submission?

No. As of 2016, there are no thresholds that hospitals must meet for successful attestation or submission. Additionally, hospital eCQM submission data will not be posted on the Hospital Compare website.

What should I do now to prepare?

Your hospital should organize a team made up of representatives from the quality, IT and executive departments. If you have not already assessed where your hospital’s capabilities stand, do so now.

Start by examining your hospital’s ability to implement, validate and submit eCQMs. In the past, the Meaningful Use attestation primarily relied on IT and your hospital’s abstractors to manually enter the data. With eCQM submission, the process is more complicated and will require collaboration across multiple departments.

If you are unsure of your hospital’s capability for submission, talk with a quality reporting vendor like Medisolv who can assist you with eCQM implementation, provide a software platform to view your eCQM data and will submit eCQMs on your behalf.



ECQMS 101: Getting Started With Electronic Clinical Quality Measures

You Will Leave With An Understanding Of The Following:

  • Understand the purpose of eCQMs
  • Identify the differences between Electronic measures and Abstracted measures
  • Define common quality reporting terms and vernacular
  • Recognize the process of implementing an eMeasure
  • Identify the main quality reporting programs and their basic requirements

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Michele Riviere