2025 Quality Dashboard
2025 Performance Score
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CQM Import Chart
Diabetes: Glycemic Status Assessment Greater than 9%
Controlling High Blood Pressure
Screening for Depression and Follow-up Plan
Breast Cancer Screening
Colorectal Cancer Screening
FAQs
MIPS CQM
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Medicare Claims
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QRDA Category I Files
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Flat File Imports
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Manual Key (Auditing only)
MIPS eCQM
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QRDA Category I Files
Medicare CQM
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Medicare Claims
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QRDA CCAtegory I Files
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Flat File Imports
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Manual Key (auditing only)
CQM
MIPS CQMs use a variety of data sources including claims, manual key, flat files and quality reporting document architecture files (QRDAs).
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CQM data does NOT need to be generated using CEHRT.
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Manual intervention is allowed.
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eCQM
eCQMs require structured data to be captured electronically in the EHR using ONC-cerified technology.
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The data for these measures is collected through CMS published value sets (lists of codes and corresponding terms( that capture patient data.
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No manual intervention is allowed.
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QRDA I - Quality Reporting Document Architecture (QRDA) Category I file is an individual patient-level report. It contains quality data for one patient for one or more eCQMs.
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QRDA III - Quality Reporting Document Architecture (QRDA) Category III file is an aggregate quality report that contains quality data for a set of patients for one or more eCQMs.​​​
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CQM - Merit-Based Incentive Payment System Clinical Quality Measures. Use a variety of data sources including claims, manual key, flat files, and Quality Reporting Document Architecture files (QRDAs). Does NOT need to be generated using CEHRT.
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eCQM - Electronic Clinical Quality Measures. Require structured data to be captured electronically in the EHR using ONC-certified technology. The data for these measures is collected through CMS published value sets (lists of codes and corresponding terms) that capture patient data.
Q. Will Health Endeavors provide any 1:1 practice level support to assist practices on getting the QRDA Files?
A. Health Endeavors offers training to assist practices with submitting files to us through an SFTP connection. However, practices will need to reach out to their EHR directly to download their QRDA I files.
Q. How often does a practice need to provide files to Health Endeavors?
A. We recommend sending files 1x per month to keep your data current. QRDA I files are imported on the first and third Monday of each month and BRD/Flat Files are imported on the first and third Thursday of each month. We recommend bookmarking our File Processing Calendar for the most accurate import dates.
Q. Is there a way to automate the process of downloading from from certified EHRs?
A. Practice would need to reach out to their EHR and see if they have an automated process to download and send files to Health Endeavors.
Q. Does Health Endeavors have any experience working with paper charts when it comes to eCQM/CQM reporting?
A. When submitting eCQMs the only option is sending QRDA I files. No other files are acceptable for answering measures.
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When submitting CQMs Health Endeavors will import your CMS CCLF files and Commercial claims files if available. You may also use our BRD/Flat files to import measure answers along with QRDA I files.
Q. Can we submit 75% of practices with certified EHRs to meet the 75% requirement?
A. No. 100% of patients from all payers must be included in the denominator. Choosing practices is the same as cherry-picking patients to report, which is prohibited.
Q. Are eCQMs required in 2025?
A. An ACO may report using Medicare CQM, MIPS CQM or eCQM measures in 2025.
Q. Are duplicate patients in an eCQM file acceptable to Medicare?
A. Duplicated patients are specifically prohibited by Medicare. Your submission file must be deduplicated before submitting. Health Endeavors will deduplicate patients during the file import process.
Q. Colorectal cancer is listed in Health Endeavors, but it is not required for 2025. Are we supposed to collect it anyway?
A. The Colorectal Cancer measure is not a required measure for 2025. Health Endeavors has added this measure for review purposes only. Any data submitted to Health Endeavors will not be submitted to CMS in 2025. Health Endeavors recommends starting to work on this measure as it is expected to be a quality measure in 2026.
Q. The Medicare CQM roster we get quarterly for from CMS is it attributed patients only or all FFS patients seen by our TINS that will be included in the Medicare CQM reporting?
A. The quarterly Medicare CQM roster will include all FFS patients that had an encounter with your ACO during the previous period. (Q1 roster includes all patients with an encounter in Q1, Q2 includes all patients that had an encounter in Q1 and Q2, Q3 includes all patients with an encounter in Q1, Q2, and Q3 and the Q4 roster includes patients with an encounter in Q1, Q2, Q3 and Q4.)
Q. How is data completeness calculated?
A. For data completeness your denominator is 100% of eligible patients for each quality measure and your numerator is patients that have a performance met or performance not met answer.
Q. How is Performance Rate calculated?
A. Performance Rate denominator is the data completeness numerator (performance met + performance not met ) and the numerator is your performance met answers. Incomplete patients are not included in the performance rate.