Electronic Clinical Quality Measures (eCQMs) For the Orthopedic Surgeries

Tien Thai, BS
Department of Medicine
Division of General Internal Medicine and Primary Care
Poster Overview

The MOOR project focuses on making the care safer through measure development. We developed eCQMs to assess the treatment after surgery. The measures focus on adult patients who had a total hip or knee surgery since these are common and painful surgeries. We examined the complication rate and opioid management from the report.  This approach showed how effective the treatments are. Experts reviewed our data and agreed. Next, we will test the eCQMs with Cerner EHR system. This test is to ensure the eCQMs will also work in different EHR systems.

Scientific Abstract


Hip and knee replacements are the most common implant surgeries in the United States. As part of the Measuring Orthopedic Outcomes Routinely (MOOR) Project, we developed several electronic clinical quality measures (eCQMs) that primarily focus on improving the healthcare quality in the domain of orthopedic surgery. These eCQMs include:

  1. Risk Standardized Complication Rate
  2. Opioid Extended Use Rate
  3. High-Dose Opioid Prescribing Practices After Surgical Discharge in Previously Opioid Naïve Patients.
  4. Inpatient Opioid-Induced Respiratory Depression Rate
  5. Risk Standardized Major Bleeding/VTE Rate


We conducted an environmental scan to identify any similar or competing measures and then drafted the business cases for each of the measures. As part of the eCQM development, we iteratively conducted an in-depth analysis on the data from our database to identify measurement gaps and data elements for measure components. We used the Quality Data Model (QDM), Clinical Quality Language (CQL) and value sets to develop eCQMs in the Measure Authoring Tool (MAT) and tested eCQMs logic using the Bonnie tool. We tested eCQMs on different EHR systems including Epic and Cerner.


All eCQMs have been developed and are currently being reviewed by the CMS for future endorsement.


Clinical Implications
These eCQMs will be used to assess the outcomes of treatment following THA/TKA surgeries by healthcare providers and organizations. Once implemented in the EHR system, the regulatory administrators can start generating performance reports for these eCQMs.
Research Areas
Tien Thai
Principal Investigator
Dykes, Patricia C.

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