The electronic Clinical Quality Measures (eCQM) were created as part of Meaningful Use; at the time, they held the promise of automatically extracting the discrete data elements required to capture a clinical quality measure, without human intervention. The intent of the initial set of eCQMs were based on capturing processes of care provided to patients to determine if a patient received quality care based on evidence based practices. But 10 years after eCQMs were first proposed, EHR vendors and healthcare providers still struggle with extracting the existing eCQMs in an accurate way that reflects the quality of care. Throughout the years of trial and error, many lessons have been learned. This presentation examines these challenges and how they can be avoided in future eCQM development. Participants will benefit from learning why the discrete data that resides in a clinical data warehouse, might not reflect what is actually happening at the point of care when it is provided to a patient.