June 10, 2025
Chris Klomp, Deputy Administrator and Director
Centers for Medicare & Medicaid Services
Department of Health and Human Services
P.O. Box 8013
Baltimore, MD 21244-8013
Attention: CMS-1833-P
Dear Deputy Administrator Chris Klomp:
The National Committee for Quality Assurance (NCQA) thanks you for the opportunity to provide feedback on the request for information Toward Digital Quality Measurement in CMS Quality Programs in the proposed rule, Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2026 Rates; Requirements for Quality Programs; and Other Policy Changes (CMS-1833-P).
NCQA is a private, 501(c)(3) not-for-profit, independent organization dedicated to improving health care quality through our Accreditation and measurement programs. We are a national leader in quality oversight and a pioneer in quality measurement. Leveraging our strengths as a trusted third party, we are committed to helping organizations navigate the challenges associated with transitioning to a digital future. Our mission to improve the quality of health for all Americans propels our daily work.
NCQA is pleased to provide the following comments on the considerations outlined for digital quality measurement.
1. FHIR eCQM Conversion Activities
US Core as an Effective Implementation Guide for CMS eCQMs
NCQA commends CMS transitioning eCQMs to FHIR. NCQA believes that as more American health care delivery systems become interoperable through FHIR-based standards, digital quality reporting will become less burdensome and lead to improvements in care delivery. NCQA is at the digital forefront, advocating for the transition to FHIR-based digital quality measures (dQM), and recognizes the importance of FHIR eCQMs as a stepstone to a modern health delivery system. While eCQMs are essential for collecting clinical data, the quality data model (QDM) and quality reporting document architecture (QRDA) may present challenges for some health care organizations during the transition to FHIR-based quality measure reporting. To lessen the burden on providers and accelerate digital reporting, NCQA supports CMS specifying US Core Data for the Interoperability (US Core) implementation guide (IG) and sunsetting QI-Core in CMS programs.
US Core provides the most amenable and low-cost approach to support providers in making their data more interoperable. Because of this, there is considerable knowledge of and familiarity with US Core in the digital health community and among health IT developers. In addition, US Core aligns with CARIN Blue Button and supports FHIR-based systems in a streamlined manner. As CMS looks toward a fully digital future, implementing eCQMs using US Core will allow better transition to dQMs, the next—and most efficient—method of quality reporting.
NCQA looks forward to the advancement of dQM reporting. Once fully operationalized, dQMs will use data from many data sources to better serve the needs of patients, practitioners and payers. To realize a fully interoperable future, it is essential that CMS and ASTP/ONC simplify and align requirements that use flexible and usable frameworks—such as US Core—to spur innovation and accelerate adoption of FHIR-based eCQMs and dQMs.
Supplementary Activities to Support the Transition to FHIR based eCQMs
Real-world pilot testing is needed to advance FHIR-based digital quality measure reporting. This work must involve community or user groups with expertise in FHIR and quality reporting.
The Digital Quality Implementers Community works with a variety of stakeholders to test real-word dQM implementation. This public/private collaboration supports organizations implementing a FHIR-based infrastructure for dQMs. NCQA welcomes the opportunity to work with CMS on testing dQMs, and to review the successes of our user groups. NCQA has been successful in the Digital Quality Implementers Community by providing technical assistance and help desk support to expedite the transition to FHIR dQMs.
2. Data Standardization for Quality Measurement and Reporting
NCQA applauds CMS’s pursuit of standardizing and optimizing tools like Data Exchange for Quality Measures (DEQM) IG and Bulk FHIR. They represent a crucial step toward enhanced efficiency and scalability in quality measurement and reporting.
DEQM is an opportunity for CMS to support the output and receipt of data for quality measurement and reporting. NCQA encourages CMS to develop DEQM’s maturity through real-world testing and standardization beyond QI-Core to US Core and CARIN Blue Button FHIR profiles. Because DEQM is a broader data model, aligning it with US Core will reduce regulatory burdens and conflicting interoperability standards, ultimately improving their adoption and usability. NCQA welcomes a partnership with CMS to facilitate real-word testing of DEQM IG using US Core.
NCQA commends CMS in realizing the importance of an efficient Bulk FHIR data framework. Through NCQA’s Bulk FHIR Quality Coalition, we have piloted §170.315(g)(10), Bulk FHIR API for patient and population services with HEDIS dQM use cases. NCQA supports the need for building a performant and scalable mechanism for this data exchange and reviewing the quality of data on output. NCQA has seen success in building a Bulk FHIR framework by leveraging a clinical data repository that caches regulated FHIR data from EHR and exposes that data through a Bulk FHIR API. This has improved the coverage of data sources used for quality measure reporting, and overcomes the barrier of scalability of Bulk FHIR for health systems.
Due to a wide variation in Bulk FHIR implementation and usability across systems, NCQA sees the value in a Bulk FHIR certification program for APIs. Meaningful improvements in Bulk FHIR data exchange can drive key use cases including digital quality measurement, value based care, and patient care.
3. The Timeline Under Consideration for FHIR-based eCQM Reporting
To support the transition to FHIR, NCQA recommends CMS partner with organizations for an early adopter program to transition to regulated FHIR standards. We believe it will be beneficial, during the early phases of requiring FHIR-based eCQM reporting, to include a dual submission or glide path for QDM and FHIR. NCQA suggests that CMS offer guidance and incentives for early adopters that use FHIR-based endpoints to meet digital reporting thresholds.
4. Measure development and reporting tools
To fully support a FHIR-based eCQM reporting model, CMS can provide or partner with organizations on mature and stable tools that leverage regulated FHIR standards. These tools will support organizations in streamlining validated digital quality measures, and will allow real-time quality improvement that organizations can rely on.
NCQA’s Data Aggregator Validation program evaluates the quality and integrity of data exchanged for organizations that undergo audit for reporting NCQA HEDIS measures. This tool helps ensure that data integrity is maintained from ingestion at the primary source to the end-point, and that output adheres to HL7 or US Core. It both builds on and improves data sharing of dQMs, parallelling the traditional NCQA HEDIS audit that is a trusted component of valid quality measure reporting.
NCQA also introduced Digital Content Services, a digital solution that provides standards-based, configurable HEDIS content in FHIR CQL format tested against NCQA specifications. This tool supports running digital HEDIS measures with patient-level results, and provides the enhanced care delivery, patient-centric approach digital quality measures provide. NCQA welcomes the opportunity to partner with CMS to ensure that precise data exchange and actionable insights are leveraged through FHIR-based tools to improve the quality of care delivery.
Thank you for the opportunity to comment. We remain committed to working with CMS to build a more efficient and digitally enabled American health care system. We welcome a discussion on our experience and our recommendations to strengthen CMS and ASTP/ONC’s goal to transition to
FHIR. If you have any questions, please contact Eric Musser, Vice President of Federal Affairs, at
(202) 955-3590 or at musser@ncqa.org.
Sincerely,
Margaret E. O’Kane
President
National Committee for Quality Assurance