Author: Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ, ACPA-C | July 20, 2026
The Centers for Medicare & Medicaid Services (CMS) is adding another electronic clinical quality measure (eCQM) to the hospital reporting portfolio, but the story doesn’t end there. The 2027 fiscal year (FY) Inpatient Prospective Payment System (IPPS) Proposed Rule signals a broader redesign of hospital quality measurement: fewer traditional process measures, greater emphasis on patient harm and outcomes, a transition from hospital-selected to mandatory reporting, and continued preparation for Fast Healthcare Interoperability Resources (FHIR)-based digital quality measures, or dQMs.
At the time of this writing, these provisions remain proposals, and may change when CMS publishes the final rule. Even so, the direction is becoming increasingly clear. CMS is building an environment in which quality results will be calculated from standardized, interoperable clinical data, rather than assembled primarily through retrospective abstraction.
A Changing Hospital IQR Measure Portfolio
For the Hospital Inpatient Quality Reporting (IQR) Program, CMS proposes adding three measures. The Excess Days in Acute Care After Hospitalization for Diabetes measure would begin with the FY 2029 payment determination. The Hospital Harm–Postoperative Venous Thromboembolism eCQM and the Advance Care Planning eCQM would begin with the FY 2030 payment determination.
The proposed postoperative venous thromboembolism measure is especially significant, because CMS also proposes removing three process-oriented eCQMs beginning with the FY 2030 payment determination:
- Venous Thromboembolism Prophylaxis, or VTE-1;
- Intensive Care Unit Venous Thromboembolism Prophylaxis, or VTE-2; and
- Discharged on Antithrombotic Therapy, or STK-02.
These measures generally center on whether an expected process occurred, such as whether appropriate prophylaxis was provided or antithrombotic therapy was prescribed at discharge. The proposed Hospital Harm–Postoperative Venous Thromboembolism eCQM instead focuses on whether a postoperative patient experienced a potentially preventable adverse event.
This does not mean that process reliability is no longer important. Hospitals still must provide appropriate prophylaxis, identify contraindications, and ensure safe discharge treatment. The difference is that quality measurement is moving beyond the question of “Did the hospital complete the expected step?” toward the more consequential question: “Did the patient experience harm, and what does the digital record show about the circumstances?”
CMS also proposes modifying five 30-day mortality measures by including Medicare Advantage (MA) patients and shortening the performance period from three years to two. The affected measures address acute myocardial infarction (MI), heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and coronary artery bypass graft surgery.
Similar modifications are proposed for the Excess Days in Acute Care measures for acute MI, heart failure, and pneumonia. Combined with the new diabetes measure, these changes broaden the quality lens across payer populations and beyond the initial hospitalization.
CMS is also requesting public comments on the potential use of the Emergency Care Access and Timeliness eCQM in the inpatient setting and the possible future use of the Adult Community-Onset Sepsis Standardized Mortality Ratio measure. These measures have not been proposed for adoption, but their inclusion indicates areas CMS is evaluating for future measurement.
Advance care planning is also part of the proposed eCQM expansion. As discussed in one of my previous articles, advance care planning becomes a quality-data issue when a meaningful clinical conversation occurs, but is not captured in the structured location or format required by the electronic measure. Its inclusion reinforces a broader principle: patient preferences must be both clinically documented and electronically retrievable.
What Does the Payment-Determination Year Mean?
Quality reporting terminology can make implementation dates appear farther away than they are. The payment-determination year is not necessarily the year in which the patient data are collected.
CMS previously finalized the following Hospital IQR reporting schedule:
- Calendar year (CY) 2026 reporting affects the FY 2028 payment determination;
- CY 2027 reporting affects the FY 2029 payment determination; and
- CY 2028 reporting affects the FY 2030 payment determination.
Therefore, when CMS proposes that an eCQM requirement begin with the FY 2030 payment determination, hospitals should understand that the applicable operational reporting year is CY 2028.
The workflows, structured data capture, measurement logic, testing, validation, and submission processes must be functioning in 2028, not 2030. The payment determination language describes when the reporting requirement affects the Medicare payment update, not when hospitals should begin preparing.
The Hospital IQR Program is a pay-for-reporting program. Hospitals that do not submit the required quality data or otherwise fail to meet all program requirements are subject to a reduction equal to one-fourth of their annual IPPS payment update.
The Most Consequential Change: From Voluntary to Mandatory
CMS proposes making the Malnutrition Care Score eCQM mandatory beginning with the FY 2030 payment determination, corresponding with the CY 2028 reporting period under the established Hospital IQR schedule.
I have discussed the Malnutrition Care Score in a previous article, including the importance of assessment, diagnosis, intervention, and follow-up. The new development is not the measure’s clinical content, but rather the proposed change in its reporting status.
CMS also proposes establishing a policy under which hospital harm eCQMs would become mandatory after two years of reporting, beginning with the FY 2030 payment determination.
This is the critical shift: a hospital harm eCQM may initially be available as a hospital-selected measure, but it would not remain optional indefinitely. As noted, under the proposed policy, hospital harm eCQMs would become mandatory after two years of reporting. The voluntary period would become an implementation runway toward mandatory reporting.
The hospital harm portfolio includes eCQMs addressing:
- Acute kidney injury;
- Falls with injury;
- Opioid-related adverse events;
- Postoperative respiratory failure;
- Pressure injury;
- Severe hyperglycemia; and
- Severe hypoglycemia.
The proposed postoperative VTE measure would join this growing portfolio if finalized.
Hospitals that have avoided a technically difficult hospital harm measure by selecting a different eCQM may therefore lose flexibility.
CMS has already finalized a progressive increase in the number of eCQMs hospitals must report: eight total eCQMs for CY 2026/FY 2028, nine for CY 2027/FY 2029, and 11 for CY 2028/FY 2030. By CY 2028, CMS will select eight measures, while only three will remain hospital-selected.
The voluntary years should not be treated as a waiting period. Hospitals need that time to test the measure logic, validate data mapping, investigate discrepancies, correct workflow defects, educate clinicians, and determine whether the electronically calculated result tells the same story as the clinical record.
From eCQMs to dQMs
At the same time, CMS is reshaping the eCQM portfolio and advancing the transition toward dQMs.
CMS defines dQMs as quality measures that use standardized digital data from one or more health information sources, captured and exchanged through interoperable systems. These measures apply standards-based specifications and code packages that can be computed in an integrated environment.
The distinction is more than a change in terminology. Traditional eCQMs have relied heavily on structured electronic health record (EHR) data and the Quality Data Model. The emerging dQM approach uses FHIR-based standards intended to support consistent capture and exchange of quality information across multiple systems.
Potential data sources for dQMs may extend beyond the traditional EHR, and can include:
- Laboratory and administrative systems;
- Case-management systems;
- Clinical registries;
- Claims information;
- Health information exchanges;
- Patient portals and applications;
- Medical devices and wearables; and
- Electronically collected, patient-reported information.
The Quality Improvement Core, or QI-Core, implementation guide defines FHIR profiles that support interoperable, quality-focused applications for dQMs, including eCQMs. QI-Core is replacing the Quality Data Model as the conceptual framework for constructing digital quality measures, while Clinical Quality Language continues to support computable measure logic.
In early 2026, CMS released draft FHIR-based dQM packages for hospital inpatient, hospital outpatient, and eligible clinician programs for public review. These documents are developmental, may change in response to public input and future rulemaking, and do not establish a final implementation date. Their release, however, demonstrates that the move toward FHIR-based quality measurement has progressed from strategic planning to technical preparation.
Why This Matters to CDI and Quality
For clinical documentation integrity (CDI) and quality teams, the health record must remain clinically understandable to people while becoming increasingly computable by electronic measure logic.
A correct diagnosis documented in a narrative note may not resolve a quality discrepancy when a measure requires a discrete laboratory result, medication administration time, procedure timestamp, structured assessment, or coded exclusion.
Conversely, structured data may trigger a quality event even when the surrounding clinical narrative explains that the condition was present on admission, clinically expected, attributable to another cause, or not representative of preventable harm.
The organizational response cannot simply be “document more.” Hospitals must understand the measure denominator, numerator, exclusions, timing windows, value sets, and risk-adjustment variables. Each required element should then be mapped to its clinical workflow, structured field, and authoritative source system.
CDI can help clarify diagnoses, timing, causation, clinical significance, and present-on-admission status. However, CDI cannot independently repair terminology mapping, interface failures, inaccurate medication timestamps, missing device information, or clinical data stored in a field the measure cannot retrieve.
This work requires collaboration among quality, CDI, health information management (HIM), informatics, analytics, coding, nursing, medical staff leadership, and EHR teams.
Measure validation should compare three elements:
- The clinical story documented in the health record;
- The structured data extracted from the organization’s source systems; and
- The electronic logic used to calculate the measure result.
Organizations should not assume that a vendor dashboard represents the final truth without validating how the result was calculated. When a result appears incorrect, the team must determine whether the issue involves clinical documentation, structured-data capture, terminology mapping, measure interpretation, system configuration, or data transmission.
The Time to Prepare Is During the Voluntary Period
The message for hospitals is clear. The measure portfolio is becoming more outcome-focused. Hospital harm reporting is moving from voluntary selection toward mandatory participation. The technical foundation is shifting from traditional eCQM reporting toward interoperable, FHIR-based dQMs.
FY 2030 may sound distant, but the operational reporting year is CY 2028. Workflow remediation, data governance, measure testing, clinician education, and interoperability preparation all require significant time.
Hospitals should use the optional years to prepare for the required years.
cannot accurately calculate may still affect payment, public reporting, regulatory compliance, and perceptions of care quality.
The transition from voluntary to mandatory reporting should therefore be treated as a call to action. Hospitals should not wait for a measure to become required before determining whether their clinical documentation, workflows, and digital infrastructure are ready to support it.
References
1. Centers for Medicare & Medicaid Services. FY 2027 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Proposed Rule Fact Sheet. April 10, 2026.
https://www.cms.gov/newsroom/fact-sheets/fy-2027-hospital-inpatient-prospective-payment-system-ipps-long-term-care-hospital-prospective
2. Centers for Medicare & Medicaid Services. FY 2025 Hospital Inpatient Prospective Payment System and Long-Term Care Hospital Prospective Payment System Final Rule Fact Sheet. August 1, 2024.
https://www.cms.gov/newsroom/fact-sheets/fy-2025-hospital-inpatient-prospective-payment-system-ipps-long-term-care-hospital-prospective-0
3. CMS Electronic Clinical Quality Improvement Resource Center. Digital Quality Measure (dQM). Updated June 9, 2026.
https://ecqi.healthit.gov/glossary/digital-quality-measure-dqm
4. CMS Electronic Clinical Quality Improvement Resource Center. QI-Core—Quality Improvement Core: About. Updated March 31, 2026.
https://ecqi.healthit.gov/qi-core/about
5. CMS Measures Management System. Now Open: Public Comment Period for Draft CMS FHIR Digital Quality Measures. February 6, 2026.
https://mmshub.cms.gov/news/2026/2026-02/now-open-public-comment-period-draft-cms-fhirr-digital-quality-measures-dqms
This article was originally published on RACmonitor.
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