Implementing New eCQMs: A Strategic Guide for Hospital Quality Directors

The landscape of Electronic Clinical Quality Measures (eCQMs) is rapidly evolving, and hospitals must prepare for significant changes ahead. After years of relatively stable requirements, where hospitals could comfortably manage with four self-selected eCQMs alongside familiar measures like VTE and Stroke (STK), the regulatory environment is shifting dramatically. 

What does this mean to you? Simply put, you’re not in Kansas anymore. If the past few years were the calm before the storm, consider this your first clap of thunder. Grab your coffee, your IT bestie, and a few brave clinical champions, because we’re headed into uncharted territory. 

The New eCQM Reality: What's Coming 

The transition began gradually with CMS introducing the Safe Use of Opioids Concurrent Prescribing measure (CMS506) as a requirement in 2022, followed by maternal care measures PC-02 (Cesarean Birth) and PC-07 (Severe Obstetric Complications) in 2024. These were just the warmup laps for what is now a three-year marathon of changes. 

By 2028, CMS will require all hospitals to submit five new Hospital Harm (Safety) eCQMs in addition to existing requirements (three self-selected measures, CMS506, PC-02, and PC-07). For hospitals participating in the TEAM model, two additional measures (HH-RF and HH-FI) will be evaluated, creating an even more complex reporting landscape. 

Implementation Timeline for Hospital Harm Measures 

The Implementation Journey…down the Yellow Brick Road 

We thought it would be a good time to revisit the process of implementing a brand-new eCQM such as the hospital harm measures above. Successfully implementing new eCQMs requires a structured, collaborative approach that typically spans six months or more. The process involves multiple stakeholders and requires careful attention to both technical and clinical considerations. 

Phase 1: Specification Review and Population Mapping (this might be a good time to refill your coffee) 

The foundation of successful eCQM implementation begins with a thorough understanding of how patients flow through the measure's different populations. Once you understand the measure requirements, the Quality and IT teams must collaborate closely to conduct a comprehensive current-state assessment, identifying gaps in data elements that need mapping or adjustment and clinical workflows that require updates or creation. 

For instance, Stages 2, 3, 4 and Deep Tissue Pressure Injury found on the exam are required documentation for CMS826: Hospital Harm – Pressure Injury (HH-PI). To understand your current state, you’ll need to determine: 

• Where the staging of pressure injuries found on exam is documented. Staging may be documented in multiple places; make sure you identify wherever it’s captured.  

• How documentation is captured – is it on paper, a note, discrete fields? 
• Is your current documentation in alignment with the measure requirements. You may be documenting PI staging, but maybe you don’t differentiate whether the PI was found on exam or present on admission, which is a key part of the measure logic.
• Is the PI staging mapped? You'll need to check all documentation to see if it's mapped to the required codes.

This phase involves detailed review of the specification logic and data elements, ensuring a complete understanding of how patients qualify for the initial population, denominator, exclusions, and numerator. The team must map out these population flows with precision, as any gaps will compromise the measure's accuracy. 

Phase 2: Value Set Decisions and EHR Mapping 

Each data element within an eCQM specification comes with associated value sets that are available on the Value Set Authority Center (VSAC) website. Each value set includes the codes that need to be mapped for each specific data element. Quality and IT teams, and other clinical stakeholders must carefully evaluate each value set and determine which codes and terminologies align best with their current documentation practices and system capabilities. 

Here are the steps you’d need to take to do this for the HH-PI pressure injury staging example above. 

1. Find the full list of data elements at the bottom of the specification. 
2. Copy the long number (the OID) after the data element “Pressure Injury Stage…”
   
3. Open VSAC and search for the value set codes using the OID number. 
4. Review the codes and the descriptions and determine which align with your documentation. These will be the codes you need to map to that documentation in your EHR.
5. Repeat for every defined data element in the specification.

The mapping requirement is absolute. Every data element must be mapped for the eCQM to calculate correctly. This comprehensive mapping process often reveals documentation gaps that must be addressed through workflow modifications or system enhancements. 

Phase 3: Clinical Workflow Assessment and Design 

Current clinical workflows must be thoroughly reviewed to identify where required data elements are being captured. Any gaps discovered during this assessment need to be addressed through new workflow creation or updates to existing processes. You’ll want to work with your team to determine if and how to update the data capture workflow. Be sure to document along the way. You’ll need to keep track of how you set up the measure as a reference for future updates and audit planning.

This phase is critical because it determines whether clinicians will be able to seamlessly provide the necessary data or if new documentation requirements will disrupt established practices. Engaging clinical stakeholders early in this process helps ensure that workflow changes are practical and sustainable.  

These stakeholders serve as valuable advisors and can become eCQM champions when new documentation requirements or workflow changes need to be communicated to staff. 

Ok, you’re almost there…the Emerald City of eCQMs is in sight! 

Phase 4: Stakeholder Education and Change Management 

Once workflows are designed, comprehensive education becomes essential. Clinicians and staff need training on new documentation requirements and any changes to established processes. This phase requires strong change management principles, as resistance to new documentation requirements can undermine the entire implementation. 

Your champions play a crucial role during this phase, helping to communicate the importance of accurate documentation and addressing concerns from their colleagues. Clear communication about the measure's purpose and impact on patient care helps build buy-in for necessary changes. 

Phase 5: Validation and Testing  

Rigorous validation ensures that all data elements are being captured correctly and that codes are accurate. This phase involves implementing the new measure processes in your EHR, activating your eCQM reports and reviewing results for accuracy and completeness. 

Use validation tools within your eCQM reports to confirm the mapped codes are being captured. The example below, from Medisolv’s ENCOR for Electronic Hospital Measures application, shows that no codes are “coming in” to the eCQM report for the value set we’ve been using as our example. This is an indication that something may be wrong with the mapping.

The validation process often reveals unexpected issues, such as edge cases in patient populations or documentation patterns that don't align with the measure specifications. These discoveries require refinement of both system configurations and clinical workflows.

Phase 6: Clinical Engagement and Continuous Improvement 

The implementation doesn't end when the measure goes live. Ongoing engagement with clinicians involves presenting results and identifying opportunities for process improvements. Share information on good performance and implement solutions for areas of improvement. Including stakeholders in this feedback loop is essential for maintaining data quality and driving meaningful quality improvement. 

Regular monitoring of eCQM data helps identify trends, patterns, and potential issues that require attention. The goal extends beyond accurate reporting to using eCQM data for genuine quality improvement initiatives. 

Building Effective Leadership Dashboards 

For high-priority measures with financial impact or brand implications, a well-designed dashboard is essential for leadership oversight and strategic action. It should serve as both a monitoring tool and a driver for improvement. Here's an example of an eCQM dashboard for the Safe Use of Opioids eCQM.

Essential Dashboard Components 

Executive Summary and Measure Context 
Start with a clear explanation of the measure’s purpose, regulatory requirements, and organizational impact. Note which programs require the measure, potential financial risks, and how performance affects reimbursement or accreditation. This context helps leaders prioritize appropriately. 

Performance Visualization with Trending 
Display current performance alongside historical trends to show progress or decline. Use easy-to-read visuals with goal rates and benchmarks, such as national, state, regional, or peer-based data, to frame performance. 

Benchmark Comparisons and Goals 
Incorporate multiple benchmarks, including CMS averages, peer performance, and internal targets, with clear indicators showing where performance stands relative to each. 

Detailed Performance Analytics 
Enable data slicing by hospital, unit, timeframe, disposition, or physician to identify specific gaps and opportunities for targeted action. 

Service Line and Provider Analysis 
Break down performance by service line or specialty, showing both volume and rate. This prioritizes interventions in areas where they will have the most impact. 

Improvement Initiative Tracking 
Include a timeline of initiatives, implementation dates, and performance shifts. This shows what is working and promotes accountability. 

Actionable Insights and Opportunities 
Call out specific improvement areas such as prescribing patterns, documentation issues, or workflow inefficiencies identified through analysis. 

Dashboard Implementation Best Practices 

• Start with Leadership Needs: Engage leaders early to tailor the dashboard to their questions and decision-making style. 

• Ensure Timely Data: Use real-time or near-real-time data to support responsive action. 

• Design for Multiple Users: Provide executive summaries for leadership, analytics for quality teams, and operational detail for front-line managers. 

• Always Provide Context: Define good performance, show goal comparisons, and explain influencing factors. 
• Build for Scalability: Ensure your dashboard infrastructure can expand with new measures without needing a full rebuild. 

The Ongoing Challenge: Annual Maintenance 

Unfortunately, the story doesn’t end with three clicks of your ruby slippers. CMS regularly updates measure specifications, requiring hospitals to repeat significant portions of the implementation cycle annually. These updates may involve changes to value sets, population definitions, or calculation logic that necessitate reviewing workflows, identifying new gaps, adjusting system configurations, and remapping data elements. 

Also read: The eCQM Annual Cycle: Two Processes for your Organization  

This annual cycle requires dedicated resources and systematic processes to ensure continued compliance and accuracy. Organizations that treat this as routine maintenance rather than urgent crisis management tend to be more successful in maintaining high-quality eCQM programs. 

Preparing for Success 

The upcoming wave of eCQM requirements represents both a challenge and an opportunity for hospital quality programs. Organizations that invest in robust implementation processes, comprehensive stakeholder engagement, and effective monitoring systems will be well-positioned to meet these requirements while driving genuine quality improvement. 

The key to success lies in treating eCQM implementation as a strategic initiative rather than a technical project. When quality teams, IT departments, clinical leaders, and executive leadership work together with clear processes and shared goals, hospitals can transform regulatory requirements into powerful tools for improving patient care. 

As the eCQM landscape continues to evolve, hospitals that master these implementation principles will find themselves better prepared for future requirements and better positioned to leverage quality data for meaningful improvement initiatives. The investment in robust processes and systems pays dividends not just in regulatory compliance, but in the ultimate goal of delivering better care to patients. 

Ready to Master Your eCQM Implementation Journey? 

The wave of new Hospital Harm measures is coming whether you're ready or not. By 2028, your organization will need to successfully implement and report on multiple complex eCQMs while maintaining accuracy across your existing portfolio. The question isn't whether you'll need to tackle this challenge; it's whether you'll have the expertise and support to do it right the first time. 

Don't Let eCQM Implementation Become a Crisis 

Medisolv's eCQM Optimization & Validation Advisory Services provide the strategic guidance and hands-on support that transforms regulatory requirements into quality improvement opportunities. Our experienced advisors work alongside your teams to identify data quality gaps, streamline workflows, and build sustainable processes that keep you audit-ready year after year. 

What you'll gain: 

• Deep-dive data quality assessment to uncover hidden mapping errors and documentation gaps before they impact your scores 

• Targeted workflow optimization recommendations that reduce inefficiencies without overwhelming your clinical staff 

• CMS validation readiness with a reliable action plan that eliminates surprises during audit season 

• Customized improvement roadmap aligned to your specific EHR systems, resources, and organizational goals 

Your quality directors shouldn't have to navigate these complex implementations alone. Partner with advisors who bring 20+ years of healthcare experience and proven expertise in helping hospitals successfully implement new eCQMs while driving meaningful quality improvement. 

Start with a free eCQM review. We'll identify your biggest risks and opportunities, no strings attached. 

Get Your Free eCQM Assessment → 

"Our Medisolv Clinical Quality Advisor has been a blessing. I don't have to worry about knowing if I'm going to meet all the measures. I know I will."- Pat Stubbs, IT Director, Mile Bluff Medical Center