Comment on CMS-2026-2344-0001

We appreciate CMS's ongoing efforts to improve confidence in eCQM validation and support complete medical record submission. However, we have concerns regarding the proposal to treat all missing medical records as validation mismatches. The proposal would classify missing records as mismatches for eCQM validation beginning with CY 2027 data affecting the CY 2030 payment determination. While we support timely submission of requested records, a missing record does not necessarily indicate an inaccurate eCQM submission. Large health systems frequently manage records across multiple facilities, EHR platforms, archival systems, and acquired entities, creating operational challenges that may affect record retrieval despite substantial good-faith efforts. In addition, some components of the medical record originate from external entities that are not under the hospital's direct control. For example, EMS and ambulance records are often incorporated into the patient's medical record and may be required to support quality measure validation. However, these records are frequently maintained by independent EMS agencies utilizing separate documentation systems and varying levels of interoperability. Delays or challenges in obtaining EMS documentation may occur despite a hospital's best efforts to retrieve the complete record. In these situations, the inability to produce an EMS record within the validation timeframe does not necessarily indicate that the hospital's eCQM result is inaccurate. We are concerned that automatically categorizing missing records as mismatches may disproportionately impact integrated delivery systems and may penalize circumstances unrelated to actual measure accuracy. Hospitals serving large geographic regions, trauma centers, stroke centers, and other facilities that routinely rely on documentation from multiple EMS providers may be particularly affected. In many cases, the electronically calculated measure result may be accurate even if all supporting documentation cannot be produced within the requested timeframe. We encourage CMS to consider alternative approaches, including a grace period, an exception process for circumstances outside a hospital's control, or a separate classification for unavailable records that does not automatically equate record unavailability with measure inaccuracy. Such an approach would preserve program integrity while avoiding unintended consequences for hospitals that maintain accurate eCQM reporting processes but encounter operational barriers to record retrieval, including obtaining documentation from external care partners such as EMS agencies.