CMS Quality Measures are designed to ensure that high-quality healthcare and best practices are adhered to across participating healthcare systems. As discussed by CMS (2020), “Data on quality measures are collected or reported in a variety of ways, such as claims, assessment instruments, chart abstraction and registries” (para. 1). In hospital systems, electronic specifications gather information from the Electronic Health Record systems. E-specifications are a relatively easy method of obtaining information once proper coding systems are in place. More difficult measures to obtain are gathering information from patients and families related to their outcomes and patient satisfaction. As discussed by (Deshpande & Schellhase (2015):

To make patient safety metrics and their presentation more meaningful, cross-sector input from patients, families, providers, and payers should be actively sought. Patient-reported outcome measures may prove better metrics for patient safety and quality than any currently in use. (p. 295)
Measures related to outcomes and patient satisfaction are likely more difficult to attain due to stakeholders’ information regarding these measures is not captured within the EHR system.