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Medicare ACO eCQM Reporting Option 

Accountable Care Organizations (ACOs) participating in the Shared Savings Program are required to report via the APM Performance Pathway (APP) for the purpose of assessing their quality performance for that program. One of the reporting options that ACOs can use for APP quality submission is eCQM collection type. 


Links for the 3 quality measures included in the APP measure set (2023 Performance Year) for the eCQM collection type are listed below:


 eCQMs are Electronic Clinical Quality Measures specified in a standard electronic format (QRDA I or III) that use data electronically extracted from electronic health records (EHR) and/or health information technology (IT) systems to measure the quality of health care provided.

 eCQM Reporting Option Overview

eCQM reporting for ACOs requires the aggregation of data across all CEHRT (certified electronic health record technology) used within the ACO into a single submission. Health Endeavors is a certified qualified registry that can aggregate / deduplicate QRDA I files generate by CEHRT.  

Implementation Steps

Implementation Steps

Step 1:  Review eCQM Reporting Requirements

Step 2:  Complete eCQM Questionnaire

Step 3:  Setup Kick off Call with Health Endeavors

Step 4: Security Official Setup

Step 5: SFTP Account Setup

Step 6:  Health Endeavors Tools Training


Eligible Population

Eligible Popluation

eCQM collection type requires ACOs to report all-payer data. ACOs are reporting on behalf of eligible clinicians from all ACO participants (i.e., TINs). This means that the ACO submission should include aggregated patient data for all matched and deduplicated patients across all ACO participant TINs, for eligible patients as defined in the eCQM initial population criteria.

 Patient Creation and Deduplication

ACO must be able to capture its full eligible population through multiple EHRs using CEHRT. Aggregation, patient matching, and deduplication across the EHRs is necessary prior to submission of eCQM performance to ensure that the ACO meets the measure specification by accounting for its complete patient population. This means a patient may not be reported twice by two different facilities or TINs. Instead, patients must be matched using their demographics to avoid duplication of patients in the data set.

Data elements used by Health Endeavors for patient matching and deduplication:

  • Patient ID

  • First Name

  • Last Name

  • Gender

  • Date of Birth

  • Race 

  • Ethnicity

  • Phone Number

  • Address

  • City

  • State

  • Zip Code

Patient Creation

Data Sources

Under eCQM reporting option, data must be collected via certified electronic health record (EHR) technology (CEHRT) in a QRDA category I file format. Per regulations, EHR system should be capable of exporting eCQM data formatted to the Quality Reporting Document Architecture Category I (QRDA I) standard.

Year-Round Submissions


​​QRDA Category I Files (Single Patient Report) Individual patient-level report that contains data defined in the quality measures.  (Click here for more QRDA information in the eCQI Resource Center)

Health Endeavors will import QRDA I files on a monthly basis for calculating care gaps and performance scoring. After QRDAs are imported users will have access to EHR Import Feedback reports for a summary of the import.

Please review our File Processing Calendar for details on when imports occur.


Data Sources

Data Completeness

The ACO must meet a data completeness threshold of 70% for 2023 performance years, increasing to 75% for 2024 and 2025 performance years. Since eCQMs are specified to be calculated using all-payer data and submitted electronically without any manual manipulation such as the exclusion of certain cases, ACOs that submit eCQMs via CEHRT would generally achieve 100% data completeness by virtue of the eCQM end-to-end electronic reporting.

Data Completeness

Data Submission

Health Endeavors generates a QPP JavaScript Object Notation (JSON) file for the ACO to submit to CMS.

Data Submission

eCQM Questionnaire

eCQM Quality Questionnaire

Complete attached template and email to

Security Official Training (ACO Leadership)

Security Official

Your Security Official is the top level in the hierarchy of user roles and permissions. This person will manage user account credentials and maintain facility and provider network configuration in the solution. You may have multiple users with the Security Official role.

  • My Team is used to set-up new users or update access for current users.  



SFTP Connection

SFTP Account Setup

The participating provider will need a SFTP account to securely  transfer quality measure data. 

Please complete our online SFTP form. Once Health Endeavors has completed setup the user will receive a secure email with login and final setup details.

HE Tools

Health Endeavors Tools


  • Year-Round Gaps in Care Analysis - Proactive, year-round strategy for identifying, disease and wellness gaps in care significantly improves your quality performance. For most ACOs, the most difficult part of closing care gaps is identifying them. Our solution makes all the difference by automating the process of identifying the incompletes and complete with non-performing responses. Intuitive visuals, with the ability to drill down to patient details. Data completeness in eCQM reporting at 100%. 

  • Year-Round Performance Scoring - Track year-round performance using QRDA I files to avoid poor performance surprises at the end of the year. 





ACO will meet the Shared Savings Program quality performance standard if: 

For the 2023 performance year and subsequent performance years, an ACO achieves a quality performance score that is equivalent to or higher than the 40th percentile across all MIPS Quality performance category scores.

ACOs that meet the quality performance standard are eligible to share in savings at the maximum sharing rate, and ACOs in 2-sided models share in losses based on their quality score or at a fixed percentage based on track. ACOs that do not meet the quality performance standard are ineligible to share savings and owe the maximum amount of shared losses, if applicable. 

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The Measures Specifications is a summary of the quality measures including links to the CMS documentation.

EHR Feedback Reports are created to give you an overview of what data we are receiving in your QRDA files. Each report shows a summary of the measures and answer types we were able to find in your files. 



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