CMS Seeks Comments On Reporting of CQMs by Hospitals

Clinical Quality Measures - CQMsLooks to Align CQMs and EHRs

CMS is seeking public comment on hospital readiness to use EHRs in submitting reports on clinical quality measures (CQMs).  According to the notice published last week in the Federal Register, CMS is interested in increasing the efficiency associated with hospital collection and submission of patient-level data on CQMs. This includes exploring ways that hospitals might be able to report data on a subset of Hospital Inpatient Quality Reporting (IQR) Program measures using the same certified EHR technology (CEHRT) that is used for reporting under the CMS EHR Incentive Program.

The goals of aligning CQMs and reporting among  various quality reporting programs include:

  • Streamline quality reporting programs through automatic collection and reporting of data on CQMs using CEHRT.
  • Reduce the burden to hospitals by allowing them to use EHRs to submit data on CQMs that are adopted for both the Hospital IQR Program and the CMS EHR Incentive Program.
  • Develop a single set of electronic specifications for CQMs adopted under multiple quality reporting programs.
  •  Adopt data standards to facilitate hospitals’ capturing, transmitting, and formatting data elements consistently and clearly.

In the request for information (RFI) CMS is looking to address some key issues on how hospitals and EHR vendors perceive the alignment of EHR-based reporting  with hospital quality reporting programs. In seeking comments from hospitals, EHR vendors, and other interested parties CMS also wants to understand how hospitals and vendors envision being able to meet the criteria for reporting CQMs electronically for the EHR Incentive Program in the Stage 2.

Some of the topics CMS is specifically soliciting comments from hospitals on include:

  • Is the hospital planning to electronically report CQMs data under the Medicare EHR Incentive Program in FY 2014?
  •  Is the hospital already participating in or planning to participate in the 2013 Medicare EHR Incentive Program Electronic Reporting Pilot for Eligible Hospitals and Critical Access Hospitals (CAHs)?
  • Does the hospital plan to report data leveraging any state health information exchange (HIE) initiative?
  • Does the hospital plan to report data leveraging the Nationwide Health Information Network (NwHIN) Exchange, which is now the eHealth Exchange?
  • What barriers and opportunities would be created by including sampling criteria for electronically reported measures under the EHR Incentive Program?

CMS is specifically soliciting comments from EHR vendors and other interested parties in the following areas:

  • Does the vendor intend to have its EHR technology certified to the 2014 Edition EHR Certification Criteria? If so, when?
  • What are the top three operational challenges facing EHR vendors over the next 3 years (2013 through 2015)? Of those identified, does the EHR vendor have mitigation plans to overcome these challenges?

Comments are due by 5 p.m. EST on January 22, 2013. You can submit comments electronically at or by mail. Read the full RFI here.