The Electronic Clinical Quality Measures Expansion: An American Data Network Guide to Preparing for 2027 and 2028

A hospital that reported six electronic clinical quality measures (eCQMs) without trouble in 2024 and 2025 now has to report eight, and both additions measure patient harm. Picture its quality director reviewing the first quarter of Hospital Harm – Severe Hyperglycemia results and finding more harm days than the diabetes care team can account for. Alongside the clinical review of those cases, the quality team has to answer a narrower question: did the right data reach the measure?

For hospital quality teams, the practical response is to test eCQM reporting against the chart now: compare the medical record with the data each eCQM receives, starting with the two glycemic measures every hospital now reports, assign an owner to each measure, and fix documentation and data-flow gaps before Falls with Injury and Postoperative Respiratory Failure count as mandatory. The rest of this American Data Network (ADN) guide explains what each measure depends on, how to run the review, and how to interpret the results.

For the calendar year (CY) 2026 reporting period, hospitals in the Hospital Inpatient Quality Reporting (IQR) Program must report eight eCQMs: five selected by the Centers for Medicare & Medicaid Services (CMS) and three self-selected by the hospital. The fiscal year (FY) 2025 Inpatient Prospective Payment System (IPPS) final rule established that requirement, raised it to nine for CY 2027, and originally set 11 for CY 2028. The same rule added Hospital Harm – Falls with Injury and Hospital Harm – Postoperative Respiratory Failure as new self-selected options in 2026 and expanded the Malnutrition Care Score to adults ages 18 through 64.

The five CMS-selected measures for 2026, listed in the FY 2028 Hospital IQR Program Guide, are Safe Use of Opioids, Cesarean Birth, Severe Obstetric Complications, and the two newly mandatory glycemic measures: Hospital Harm – Severe Hypoglycemia and Hospital Harm – Severe Hyperglycemia. In CY 2027, Hospital Harm – Opioid-Related Adverse Events becomes the sixth CMS-selected measure, according to CMS’s FY 2025 final rule overview for hospital quality programs.

The FY 2027 IPPS final rule, released July 31, 2026, subsequently changed the CY 2028 measure set, resulting in 14 required eCQMs: 11 CMS-selected measures and three self-selected measures. As the rule text published in the Federal Register specifies, Falls with Injury, Postoperative Respiratory Failure, and the Malnutrition Care Score become mandatory beginning with the CY 2028 reporting period (FY 2030 payment determination), under a new policy that moves Hospital Harm eCQMs to mandatory reporting after two years of self-selected reporting. A hospital that does not select these measures in 2026 or 2027 will report them for the first time in the year they become required.

Accuracy carries payment weight as well. For the FY 2028 payment determination, CMS validates CY 2025 data from selected hospitals and calculates two separate confidence intervals, one for chart-abstracted measures and one for eCQMs. The upper bound of each must be 75% or higher to pass, according to the FY 2028 Hospital IQR Program Guide, and hospitals that fail to meet IQR requirements are subject to a one-fourth reduction of the applicable percentage increase in their annual payment update (APU).

Key Takeaways

• Eight now, nine in 2027, 14 in 2028: CY 2026 requires eight eCQMs, including the newly mandatory Severe Hypoglycemia and Severe Hyperglycemia measures. CY 2027 requires nine, adding Hospital Harm – Opioid-Related Adverse Events, and CY 2028 requires 14. Falls with Injury, Postoperative Respiratory Failure, and the Malnutrition Care Score become mandatory beginning in CY 2028.
• Validation affects payment: For FY 2028, the upper bound of the eCQM validation confidence interval must reach 75% or higher, separately from chart-abstracted measures, and hospitals that fail IQR requirements are subject to a one-fourth reduction of the applicable percentage increase in their APU.
• Check the data alongside the care: An unexpected Hospital Harm result can reflect clinical data quality problems such as missing glucose results, mismatched timestamps, or inconsistent unit documentation, so teams should verify the underlying data as part of investigating the result.
• The comparison shows the source: An incomplete chart points to unit documentation, a correct chart with different eCQM data points to data flow or EHR configuration, and matching data with a still-unexpected result points to the specification.
• Start with a sample review: Compare a sample of glycemic cases now, and Falls with Injury and Postoperative Respiratory Failure cases before 2028, against the data each eCQM received, and confirm an owner and backup for every measure.

What Does the Electronic Clinical Quality Measures Expansion Require From Your Team?

Electronic clinical quality measures each bring their own data elements, timing requirements, exclusions, and dependencies on how clinical information is captured in the electronic health record (EHR). A chart-abstracted measure passes through an abstractor who reads the record; an eCQM calculates from structured data electronically extracted from the EHR and other health information technology systems, so gaps in how information is captured can affect the calculated result.

Hospital Harm – Severe Hypoglycemia counts a severe event when a glucose result below 40 mg/dL follows a hypoglycemic medication given within the previous 24 hours, with no repeat result above 80 mg/dL within five minutes. The measure depends on glucose results, medication administration records, and accurate timestamps for both. If a confirming repeat test is performed but its result does not reach the measure, the original low reading can count as harm.

Hospital Harm – Severe Hyperglycemia counts harm days rather than events. After the first 24 hours, a day can count when a glucose result exceeds 300 mg/dL or when no glucose result is found after two consecutive days that each had at least one result of 200 mg/dL or higher. Days are 24-hour periods measured from the time of admission, including emergency department and observation time, so the result depends on accurate admission timestamps and on every glucose result, including bedside point-of-care tests, reaching the data the measure uses.

Both measures often draw on data from every inpatient unit.

The measures that become mandatory in 2028 add their own dependencies. The Hospital Harm – Falls with Injury eCQM counts inpatient hospitalizations with a fall that results in moderate or major injury, and the injury diagnosis must not be present on admission, so the record has to capture the fall, the injury, and its present-on-admission status in a form the measure can identify.

Hospital Harm – Postoperative Respiratory Failure applies to elective surgical hospitalizations and uses detailed criteria for mechanical ventilation, intubation and extubation, and procedure timing. It excludes patients based on factors such as acute respiratory failure present on admission, certain head, neck, and thoracic surgeries, degenerative neurological or neuromuscular disorders, and abnormal blood gas results before surgery, which means perioperative care, respiratory therapy, laboratory testing, and physician documentation all feed the result.

Is Your eCQM Reporting Process Ready for Nine Measures in 2027 and 14 in 2028?

Start with current accuracy performance: repeated corrections, unexpected swings in results, submission problems, or measures that routinely need extra review show where eCQM reporting is already strained. Then sample cases and compare the medical record with the data the eCQM received. The same chart-to-measure comparison works for any eCQM a hospital reports; the questions below cover the four Hospital Harm measures described above:

• Severe Hypoglycemia: Do low glucose results, repeat tests, and hypoglycemic medication administration times match the medical record?
• Severe Hyperglycemia: Are all glucose results, including point-of-care tests, reaching the measure, and does the admission time used to set the 24-hour periods match the record?
• Falls with Injury: Does the measure reflect the documented fall and injury, and is the injury’s present-on-admission status captured correctly?
• Postoperative Respiratory Failure: Do ventilation, intubation, extubation, and procedure times match the medical record, and are exclusion diagnoses and preoperative blood gas results reaching the measure?

The same review tests internal capacity. A process that worked for six eCQMs may be harder to maintain at nine measures in 2027 and 14 in 2028, so leaders should confirm who owns each measure, whether there is backup coverage, and whether the team has the time and expertise to review specification changes and investigate unexpected results.

Finding these problems before submission matters because validation now scores eCQM accuracy on its own confidence interval. When a hospital does fall short, ADN’s guide to what happens after a failed CMS data validation audit outlines the remediation path, including internal sampling of eCQM data.

Where Do eCQM Accuracy Problems Come From?

When the sample review turns up a discrepancy, three common clinical data quality problems are the first places to look: inconsistent documentation, data that do not flow correctly from the chart to the measure, and an outdated reading of the specification.

The chart-to-measure comparison points to which problem is at work. If the chart itself is incomplete, the problem is documentation. If the chart is correct but the eCQM data differ, the problem is data flow or EHR configuration. If the chart and the eCQM data match but the result still looks wrong, check the specification.

That data check runs alongside the clinical review, since a data problem and a real change in care can both be present. The same principle runs through ADN’s article, Why Inter-Rater Reliability Is the Hidden Risk Control in Hospital Quality: hospitals need confidence in the data before they use it to guide improvement.

Check Documentation Consistency Across Units

If information in the EHR is missing, inconsistent, or entered in the wrong place, the measure may not reflect what actually happened.

For Severe Hyperglycemia, one unit may record bedside glucose checks in a way that reaches the measure while another documents them somewhere the measure does not read. For Falls with Injury, one unit may document injury details in structured fields while another relies on free-text notes. Differences like these can make performance look different between units even when the care itself is similar.

Remediation belongs with the units involved: standardize where and how the information is documented, reinforce the change with the staff who document it, and re-sample the same measure afterward to confirm the gap closed.

Trace Data From the Chart to the Measure

Correct clinical documentation can still produce a wrong result. A lab value may be in the chart but not flow into the measure. Dates or times may not match between systems. A diagnosis or procedure may be coded in a way the measure does not recognize.

Quality teams need a way to compare the medical record with the data used by the eCQM. When the chart contains the correct information and the measure does not, the team can document the specific records, the data element involved, and the value in the chart compared with the value the measure received, then bring that discrepancy to IT or the appropriate EHR team.

After a fix, re-running the comparison on a new sample confirms it held. Because several measures can share the same data element, it is worth checking the other eCQMs that use it.

Confirm You Are Using the Current eCQM Specifications

CMS updates its eCQM specifications every year, and program-specific reporting requirements and resources are posted on QualityNet’s eCQM page. Updates can change which patients a measure includes or excludes and what information it uses.

The Malnutrition Care Score, formerly the Global Malnutrition Composite Score, is one example. Beginning in 2026, the measure includes adults ages 18 through 64, so a hospital working from older assumptions could miss patients who now belong in the measure.

The remediation is an annual review with a named owner: read the updated eCQM specifications and technical release notes for each reported measure, compare the changes against current documentation workflows, and confirm with the EHR vendor that the current measure version is in place before the reporting period begins.

What Changes in the eCQM Measure Set After 2026?

CMS is moving the electronic clinical quality measures program toward harm and outcome measures that draw on documentation from many parts of the hospital. The FY 2027 IPPS final rule continues that shift for the CY 2028 reporting period: CMS adds the Hospital Harm – Postoperative Venous Thromboembolism and Advance Care Planning eCQMs to the measure set for self-selection and removes three process measures from the self-selection list: Venous Thromboembolism Prophylaxis (VTE-1), Intensive Care Unit Venous Thromboembolism Prophylaxis (VTE-2), and Discharged on Antithrombotic Therapy (STK-02).

The same rule sets how mandatory Hospital Harm results become public. For the first year of mandatory reporting, CMS will post the data on the Provider Data Catalog, then report them on the Care Compare tool, including Hospital Star Ratings, beginning with the second year.

How Can Hospitals Build an eCQM Process That Holds as CMS Adds Measures?

The glycemic measures show what the expansion of electronic clinical quality measures demands this year, and Falls with Injury and Postoperative Respiratory Failure show what comes next: each new eCQM depends on different parts of the clinical record and different workflows across the hospital. Building one shared process for tracing the record to the measure data lets the effort carry forward to every measure CMS adds.

For Falls with Injury reviews specifically, ADN’s Patient Safety Event Reporting Application gives quality teams a second source to check against: its Fall Dashboard breaks down reported falls by types of injury and risk factors, so fall events can be compared with the cases the eCQM counted.

As the measure set grows, ADN’s Healthcare Data Analytics Services can analyze clinical and quality data to identify patterns, trends, and priorities across it.

eCQM review competes for the same quality staff who manage chart-abstracted reporting. Because IQR validation scores chart-abstracted measures such as Severe Sepsis and Septic Shock: Management Bundle (SEP-1) separately from eCQMs, and both must pass, protecting abstraction accuracy while freeing internal time for eCQM review matters on both sides of the score.

To free that time, hospitals can outsource to ADN’s Clinical Data Abstraction Outsourcing Services, which offer full, partial, or as-needed (PRN) support for core measures and registries, backed by a rigorous inter-rater reliability (IRR) policy that includes routine IRR on a sample of cases for every measure and maintains an overall accuracy score of 98% or higher.

Go back to the quality director from the opening and move the calendar to 2028. This time, the result that does not add up is Falls with Injury: the eCQM counts fewer falls with injury than the event reporting system shows. The measure is now mandatory, that year’s results are headed to the Provider Data Catalog, the next year’s will reach Care Compare and the hospital’s Star Rating, and eCQM validation still counts toward the annual payment update.

Finding that gap in 2026 or 2027, while the measure is still self-selected, is an internal fix. Finding it in 2028 is a public result.

Start the first sample review this quarter, with one owner for each measure.