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Clinical Data Elements for UDS eCQMs and their Lookback Timeframes


Useful for EHR transition planning; developed in 2023.

Year Developed: 2023

Resource Type: Toolkit.

Primary Audience: Administrative Staff Clinicians PCAs
Secondary Audience: Board of Directors C-Suite (CEOs, CFOs, CIO, COOs, CMOs, etc.) Enabling Staff Outreach Staff

Language(s): English

Developed by: HITEQ (See other resources developed by this organization).

Resource Summary: Each electronic clinical quality measure (eCQM) is composed of data elements in the EHR or health IT system that are evaluated according to the measure specifications. It is important to identify what data elements need to be transitioned to any new EHR for clinical quality measure continuity and accuracy. This resource identifies clinical data elements in eCQMs that should be considered when transitioning EHRs. These data elements are used in reporting or calculating eCQMs, so their availability or lack thereof in any new EHR system will impact reporting accuracy.

Resource Details: When selecting, upgrading, or transitioning EHRs, patient safety is of paramount importance. That is not covered in this reference; refer to the SAFER guides for best practices in ensuring patient safety. Each health center and potentially any vendor(s) involved in the transition will need to determine if these data elements, as defined in the eCQM are in their current systems, and, if so, how that data will be moved into any new system, including form and length of time. The clinical data elements resource, available for download below, may be useful in informing RFPs, discussions, or negotiations about data transition. This process of ensuring alignment with eCQMs is a key step, not only in facilitating the transition of legacy clinical quality measure data to a new system, but also as health centers prepare for the transition to patient level submission with the implementation UDS+. The UDS Data Elements table, in the second tab of the downloadable file below, lists out data elements in eCQMs reported in the annual UDS report that require historical data for accurate evaluation (e.g., a ‘lookback period’ is defined in the measure for the data element). The table on the UDS Data Elements tab includes data element, related eCQM, description, timeframe (i.e., how far back the given measure looks for data element, and therefore the length of historical data that should be available for the new EHR system to assess), relevant code sets, and CQL structure. For a full list of related codes, download value set details from the Value Set Authority Center.

Resource Topic: Clinical Issues, Health Information Technology (HIT)/Data, Workforce

Resource Subtopic: Research and Data, Electronic Health Records (EHRs), Patient Engagement, Development/Training, Data, Tools, and Dashboards.

Keywords: Business Intelligence, Care Coordination, Clinical Coding, Content Management System (CMS), Data Collection, Management, and Analytics, Education of - Staff (e.g., Competency-Based), Health Information Exchange (HIE), Health Systems, Implementation Tools, Performance Improvement, Quality Measures, Research, Uniform Data System (UDS).

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.