Hospital Reporting of Electronic Clinical Quality Measures (eCQMs) and Hybrid Measures

CRISP and Medisolv are working in partnership to support the HSCRC in collecting hospital-reported digital quality measures, with initial effort focused first on Electronic Clinical Quality Measures (eCQMs) and subsequently on hybrid quality measures. A few hospitals started optional submission of the 2021 eCQM measures in Spring of 2022. In calendar year (CY) 2022, HSCRC required Maryland hospitals to submit on a quarterly basis 4 eCQMs. For CY 2023, hospitals are required to submit 6 eCQMs. All eCQM data is being submitted in the Quality Reporting Document Architecture (QRDA) I format to Medisolv ENCOR portal via CRISP Portal. While these measures align with federal IQR measures, it does not replace IQR Reporting requirements for Maryland hospitals.

eCQM Reporting Schedule for MD Hospitals CY 2023

Calendar Year 2023 Required Data Submission

• At this time, the HSCRC will require submission of QRDA-1 files for the following measures:
  • ED-2: Median Admit Decision Time to ED Departure Time
  • eOPI-1: Safe Use of Opioids – Concurrent Prescribing
  • PC-02: Cesarean Birth
  • PC-07: Severe Obstetric Complications (risk adjusted)
  • HH-01: Hospital Harm- Severe Hypoglycemia
  • HH-02: Hospital Harm- Severe Hyperglycemia
• Please read this important announcement from HSCRC about new requirements to include facility MRN in your QRDA 1 submissions as well as information on locking annual data submissions 90 days following the last quarter of the previous year.
• For hospitals that do not qualify for the PC-02 and PC-07 measures, you must submit QRDA-1 files for two of the other CMS 2023 specified eCQMs to CRISP (see Appendix A). Data submissions will generally be due quarterly within approximately 90 days of the end of the quarter. The first two quarters are combined and due following the second quarter for eCQMs in order to allow for hospitals to update their EHR data specifications.

Hybrid Measures Submission Requirements

• Beginning in July 2023, to enhance future risk-adjustment, HSCRC will require submission of the Core Clinical Data Elements (CCDE) for the CMS-specified hybrid measures below, with quarters three and four combined and due within 90 days after the fourth quarter; HSCRC’s goal is to extend these measures to data for all payers.
  • Hybrid HWR: Hospital-Wide 30-day Readmission
  • Hybrid HWM: Hospital-Wide 30-day All-Cause Risk Standardized Mortality Measure
  • 2023 Hybrid Measure eCQM Specifications

Performance Period Submission Windows

Hospital eCQM Project: 2023 List of Measures

What if our hospital needs an Extension?

If your organization needs to request an extension or exemption from eCQM reporting, please see additional information about the Maryland Extraordinary Circumstances Exemption policy and request form here: Maryland Hospital Extraordinary Circumstances Quality Reporting Exceptions (MECE) Policy

Documentation

CY 2023 eCQM Digital Measures Memo