Assignment 8: Electronic Clinical Quality Measures

Assignment 8: Electronic Clinical Quality Measures

Assignment 8: Electronic Clinical Quality Measures 150 150 Peter

Assignment 8: Electronic Clinical Quality Measures: Building an Infrastructure for Success

A group of family practice physicians are having issues meeting stage 2 of meaningful use because the staff forget to provide patients with information on accessing the portal. The staff complain that they don’t have enough time to go over the process with the patients and the printed information is stacked in the utility room. Which quality improvement process should the nurse leader use to analyze this issue?
Access the web site: and

Read about the Quality Payment Programs and EHR Incentives.
Then select up-to-date information available for CQM Reporting options and answer the following questions:
1. What information is the eCQM Library?
2. Using the educational resources available, how can the nurse leader use these resources when participating in the design of the eCQM program?
Include both topics in a 1200-1500 word APA 7 essay, using a minimum of 4 scholarly sources to support your perspective. Be sure to cite your source. Include a conclusion and reference page.

Sample Paper

Electronic Clinical Quality Measures: Building an Infrastructure for Success

Metrics are essential in healthcare. If a health care institution wants to be effective, it must constantly compare its goals to its outcomes. Patients and their families are engaged in the healthcare process, as well as patient safety, care coordination, population and public health, efficient use of healthcare resources, and the efficacy of the clinical process, all of which can be measured and tracked using electronic clinical quality measures (eCQMs) (Schreiber et al., 2021). When it comes to evaluating the quality of medical care, electronic clinical quality measures rely on data from electronic medical records or health information technology systems. Monitoring and reporting on eCQMs help ensure that treatment is provided in an efficient and effective manner that is also fair to all patients. E-quality measures are used in quality incentive programs by the Centers for Medicare & Medicaid Services (CMS) to publicly provide statistics on the quality of treatment (Schreiber et al., 2021). The CMS Meaningful Measures Initiative emphasizes critical areas for quality assessment and improvement as a high priority for the agency’s workforce.  Its goal is to benefit patients, their loved ones, and healthcare practitioners while also easing the load on those who are being assessed. As a link between CMS’s strategic objectives and specific metrics and actions, the meaningful measure areas are essential (Schreiber et al., 2021). The success of eCQM reporting depends on several things (HER, 2010). Identifying clinical quality indicators that match with an organization’s aims is the first step in the process. There should be a seamless integration of clinical quality measurements into clinical workflow. EHRs or health information technology systems are used to monitor health care quality in eCQMs, which must be electronically reported by health care providers (Schreiber et al., 2021). This paper discusses a quality improvement process of an eCQM challenge as well as up-to-date information in the eCQM library and their application in designing the eCQM program.

Quality Improvement Process

Patient portals were created with an eye toward streamlining and improving access to care for patients. As with many new technological advancements, portals were hit hard by poor product rollouts and user error from a populace that was not completely sold on the notion at the time of their introduction. There are many doctors who find it unfair that they must rely on patients to register into their patient portal and transmit encrypted messages to satisfy regulatory obligations. Physicians have little influence over whether or not a patient utilizes the gateway once they have left the room. Before the Centers for Medicare & Medicaid Services (CMS) announced the end of meaningful use as it exists now, it has been a significant impediment for practices to achieve the stage two standards of the Meaningful Use program. Use of the Master Patient Index (MPI) is the best quality improvement process for analyzing this issue. Patients’ demographic information is stored in a computerized database that may be accessed at any time. Individuals are individually identified as part of the MPI in order to ensure correct data matching and linkage (Thorell et al., 2019). This is accomplished by keeping track of personal data like name, date of birth, gender, and so on, and then allocating a numerical identity to each individual. Analyzing the present situation is the first step towards making improvements. The evaluation helps identify problems that need to be solved, identifies stakeholders, explains what success looks like in a specific setting and indicates challenges/barriers to overcome (Thorell et al., 2019). This procedure will establish the basis for the development of MPIs.

The second phase will focus on creating leadership and ownership. In order to develop and execute the MPI, a group of influential stakeholders’ leaders (SLG) should be assembled. The third step will involve documenting the specifications and the requirements. This step makes the MPI be sensitive to the demands of the users. The fourth phase in the quality improvement process will be to implement the requirements to remedy the problem. Software and hardware requirements will be determined in this phase; patient matching algorithms (for specific use cases) will be defined, and validation and testing will follow (Thorell et al., 2019). Finally, a supporting strategy for the process will be created. There should be procedures in place to prioritize requests from users, whether they be for data or system upgrades or integrations. They might also be for operational assistance or troubleshooting.

Information in the eCQM library

In order to define each CMS quality measure definition, the eCQM library is utilized. There are yearly changes to eCQM requirements in the eCQM library. A new set of electronic clinical quality measures for CMS quality reporting programs is released by the Medicare & Medicaid Services Centers each year. Updates to CMS contain new codes, logical adjustments, and clarifications, all of which must be implemented and used. CMS, for example, finalized adjustments to the Medicare Promoting Interoperability Program for eligible hospitals, critical access hospitals (CAHs), and dual-eligible hospitals in the final rule for the 2021 program requirements. These regulations will help CEHRT use progress, lessen administrative burdens, and improve interoperability and patient access to their health information in the long term. Any continuous, self-selected, 90-day period is required for new and returning participants who are reporting to CMS (, 2020). Successful attestation by eligible hospitals and CAHs are required in order to prevent a reduction in Medicare payments. There were four objectives for hospitals that were obliged to report to CMS, which included health information exchange, provider-to-patient exchange, electronic prescriptions, and the interchange of public health and clinical data across hospitals (, 2020). Two self-selected calendar quarters of eCQM data on four self-selected eCQMs were needed of participants in 2021.

Ways in Which a Nurse leader can Use these Resources

Health care performance data collection and reporting have traditionally been a time-consuming, highly regimented procedure. However, eCQM programs may be designed by nurse leaders to address this issue. Data from EHRs and other electronic clinical data repositories is queried as part of the creation of eCQM queries, which are then used to create quality data reports. In order to get the information they need, nurse leaders will utilize the educational materials available. In addition, the nurse leader can use the educational resources to assist the institution to find ways to improve patient/client care and strengthen the eCQM program. In addition, these educational resources can be utilized by the nurse leader for thorough analysis, such as through routine audits of patient data used in reporting to minimize the possible, unexpected implications of picking seldom or inconsistently obtained data pieces. The available education resources provide crucial information on the schedule for Medicare physician fees for each year. Therefore, the nurse leader who is designing an eCQM program can use these educational resources to understand the trend for several years. This analysis will help the nurse leader design an effective program that is eligible and congruent. Materials such as the final rule provide information on the fiscal year objectives and measures outcome. Therefore, nurse leaders can use the available educational resources to know precisely which objectives and measures they should use in their eCQM program.


Hospitals in the United States have invested a great deal of time and money in the adoption of eCQM programs in order to enhance clinical treatment and patient outcomes. Clinical quality reporting and local quality improvement programs will be aided by hospitals implementing this technology, according to the hospitals’ rationale. Healthcare facilities can use eCQM data as a starting point for continuous improvement in the delivery of high-quality care. But as hospital quality measures and payments become more linked, the need for quality measure reporting solutions that strike a balance between the importance of reporting and quality measurement and the complexity of meeting various reporting requirements is growing exponentially. To simplify reporting burdens and provide access to real-time information to assist quality improvement in patient care, eCQM automated quality measure reporting may be performed successfully if implemented appropriately. It is essential for nurse leaders to seek help from colleagues, the hospital’s quality department, and leadership while developing eCQM initiatives. In order to better comprehend, map, and adapt the current clinical process, they need to assemble a multidisciplinary team. Interprofessional teams can help adopt or enhance quality improvement initiatives and utilize the eCQMs to monitor improvements in the clinical workflow. As leaders, they should always strive towards achieving the best for their clients. They should ensure continued growth and advancement through programs such as quality improvement initiatives.



Schreiber, M., Krauss, D., Blake, B., Boone, E., & Almonte, R. (2021). Balancing value and burden: the Centers for Medicare & Medicaid Services electronic Clinical Quality Measure (eCQM) Strategy Project. Journal of the American Medical Informatics Association28(11), 2475-2482.

EHR. (2010). Medicare & Medicaid EHR Incentive Program. Centers for Medicare & Medicaid Services | CMS.

Thorell, L., Dal Molin, J., Fyfe, J., Hone, S., & Lwin, S. M. (2019). Working towards a master patient index and unique identifiers to improve health systems: the example of Myanmar. WHO South-East Asia Journal of Public Health8(2), 83.;year=2019;volume=8;issue=2;spage=83;epage=86;aulast=Thorell (2020, December 21). 2021 program requirements. Centers for Medicare & Medicaid Services | CMS.