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Table of Contents:

  • Purpose:  

  • Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

  • Data Accuracy Messages

    • Event start date after the end date (error)

    • Event start date after the end date (warning)

    • Inpatient encounter outside of the reporting quarter (warning)

    • Inconsistent reporting of Inpatient Encounter (warning)

    • Duplicate Inpatient Encounter Detected (warning)

    • Incorrect CCN Reported (error)

    • Invalid DateTime (error/warning)

    • Invalid Patient ID (error)

    • Invalid QRDA XML file (error)

    • None of the measures supported by TJC (error)

    • Missing or Invalid Admission Date (error)

    • Missing or Invalid Discharge Date (error)

    • Missing or Invalid Header EffectiveTime (error)

    • No Discharge Date in Reporting Period (error)

    • r-validate_TZ-errors (error)

    • QDM_based_QRDA_V7-TJC-errors (error)

    • A required Medication Route is missing (warning)

    • Unacceptable Unit Reported (warning)

    • r-DOCUMENT-TJC-QDM-HEADER-warnings (warning)

    • r-DOCUMENT-TJC-QRDA-HEADER-warnings (warning)

    • r-DOCUMENT-TJC-US-HEADER-warnings (warning)

    • Reporting-Parameters-Act-TJC-errors (error)

    • r-validate_effectiveTime-TJC-warnings (warning)

Purpose:  

Below are The Joint Commission specific error and warning messages generated by the edits and Schematron rules executed against each uploaded QRDA I Document.  In addition, those CMS and Health Level Seven (HL7) Schematron rules that are frequently encountered when data is uploaded to the DDS Platform are also included below.

What is the difference between Error & Warning Messages?

QRDA I documents that generate one or more error messages have been rejected and not processed against the eCQM logic.  They are available for you to view within the Source Viewer from the Data Accuracy page.  Since they have not been processed against the eCQM logic, they are not available on the Quality Improvement page and cannot be submitted via the Submit Data page.

QRDA I documents that generated one or more warning messages AND no error messages may be submitted.  We recommend that hospitals review the warning messages to ensure they are not pointing to issues with data capture, data mapping, or QRDA I file generation that can be corrected before the submission deadline.  However, we do realize that hospitals may not have the ability to regenerate QRDA I documents from prior years and so they are unable to correct these warning messages.  If this is your situation, we suggest you continue to review the warning messages and, if needed, work to update your software for the next calendar year and for future years so as to eliminate these warning messages to ensure your measure rates are as accurate as possible.

Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

Each Data Accuracy message is associated to one or more Source Viewer descriptions.  The Data Accuracy message provides a high-level description of the issue.  Some issues such as "Missing or Invalid Admission Date" can have multiple reasons as to why the issue exists.  The specific reason(s) for the QRDA I Document are detailed within the Source Viewer.

When reviewing data edits within the Source Viewer, if appropriate, the Conformance Number of the edit is displayed.  There are three types of conformance statements with different formats for the CONF number:

  • Joint Commission CONF numbers (TJC-xxxxxx)

  • CMS CONF numbers (CMS_xxxx_xxxx-C01 or xxxx_xxxx-C01)

  • HL7 Clinical Document Architecture (CDA) QRDA Category I Errors (xxxx_xxxx). 

    • Please note that HL7 Conformance numbers are not prefixed with "HL7".  All Conformance numbers without the prefix of "TJC" or "CMS" or a suffix of "C01" are HL7 Conformance numbers.

For more information concerning CMS or HL7 Conformance numbers, see the below reference material:

  • CMS:  Visit the eCQI Resource Center CMS QRDA IG publication page for the documents associated to this year's data.

  • HL7: Visit the HL7 website to obtain the version of the HL7 CDA® R2 IG: QRDA I applicable for this year's data. 

    • The HL7 website may require a HL7 account in order to download the Implementation Guide (IG).

    • The HL7 website header states the current Release number.  Scroll to the bottom of the page to find the Release that is appropriate for this calendar years data.

  • See the eCQM Version Alignment with CMS documentation for information concerning the version of measures, CMS QRDA IG, and HL7 standards that are applicable to this year's data.

Data Accuracy Messages

...

titleEvent start date after the end date (error)

...

  • Section / Element: High@value

  • All Event End Dates (@high) used by the eCQMs must be before the associated Event Start Date (@low).

  • Apply offset before validation.

Expand
titleEvent start date after the end date (warning)
  • Source Viewer: Event End date is before the Event Start Date. (TJC-100024)

    • Section / Element: High@value

    • All Event End Dates (@high) not used by the eCQMs should be before the associated Event Start Date (@low).

    • Apply offset before validation.

Expand
titleInpatient encounter outside of the reporting quarter (warning)
  • Source Viewer: There exists an inpatient encounter with discharge datetime outside of the reporting quarter defined in the Reporting Parameter of the QRDA document. (TJC-100036)

    • Section / Element: Encounter ID

    • At least one of the inpatient encounter's discharges datetime is outside of the reporting quarter.

...

titleInconsistent reporting of Inpatient Encounter (warning)

...

  • Section / Element: Encounter ID

  • When two or more inpatient encounters exist, they are processed as the same encounter if there:

    • admit and discharge dates are the same or

    • encounter IDs and extension are the same

  • If the same inpatient encounters are reported, only the valueset may be different. Everything else should be the same. This edit is triggered if any of the below conditions exist:

    • admit or discharge date is different

    • encounter ID or extension is different

    • encounter code/codeSystem is different

...

titleDuplicate Inpatient Encounter Detected (warning)

...

Section / Element: Encounter ID

  • Admit and discharge dates, encounter code and encounter ID (root and extension) are the same among duplicates.

Expand
titleIncorrect CCN Reported (error)
  • Source Viewer: The CCN does not match with the CCN associated to the current HCO. (TJC-100032)

    • Section / Element: CCN

    • CMS' CCN in the QRDA I document does not match with the CMS CCN associated to the hospital for which the data was Uploaded.

    • The Joint Commission does not provide a 'bulk' upload function which allows QRDA I documents from multiple hospitals to be submitted within one zip file.  Instead, a zip file must be created and uploaded for each organization (based upon their CCN). 

      • Users with access to multiple hospitals may use the ‘Multi-HCO Batch Upload’ function to upload multiple zip files from one page.

      • If you need access to multiple hospitals, please contact the individual(s) for each hospital that have the "Invite & Manage User" functionality as The Joint Commission staff cannot on-board staff to a hospital's Workspace.

    • The Joint Commission processes all data submitted to the DDS Platform based upon the hospital's CMS CCN, not the hospital's Joint Commission HCO ID. The Platform crosswalks the CCN back to the HCO ID for data storage and analysis purposes.

      • You can determine the CCN which The Joint Commission has linked to your HCO ID by going into HCO Characteristics (available from the main menu).  If the CCN is incorrect, please complete the Support Ticket to inform us what the correct CCN should be and we will investigate.

Note: We have not built the functionality to receive a file containing solely our HCO ID due to our desire to reduce hospital costs and other burden.  By receiving the file using CMS' CCN, it allows hospitals to submit the same QRDA I document that they submit to CMS to The Joint Commission.

The CCN on file within the DDS Platform has been taken from your organization’s accreditation application - so it is possible it also needs to be updated there as well.

Expand
titleInvalid DateTime (error)

The 'Invalid DateTime’ error is associated to two Source Viewer messages:

  • Source Viewer: Invalid DateTime has been provided. (TJC-100008)

    • Section / Element: DateTime

    • The Joint Commission validates all the date/time fields (e.g., effectiveTime, Time, and birthTime) that may be used in measure evaluation have a valid format. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU  where

      • YYYY - year - range 1900 to 9999

      • MM - month - range 01 to 12

      • DD - day - range 01 to 31 (note: true to month and leap years)

      • HH - hour - range 0 to 23

      • MM - minutes - range 0-59

      • SS - seconds - range 0-59 x - plus or minus sign

      • UUUU - UTC time shift -1300 thru+1400

  • Source Viewer: Invalid DateTime has been provided. (TJC-100012)

    • Section / Element: DateTime

    • The Joint Commission validates all the date/time fields that may NOT be used in measure evaluation.

    • Dates are evaluated for:

      • One or more part of dateTime field is not in the YYYYMMDDHHMMSSxUUUU format

      • Year must be in the range of 1900 to 9999

      • Month cannot be 00 or greater than 12

      • Day cannot be 00 and cannot be greater than 31

      • Day cannot exceed limit for month (Leap year calculation is validated)

    • Time formats in effectiveTime, time or birthTime elements (XML tags) are evaluated for:

      • One or more part of the Time field is not in one of these formats: HH, HHMM, HHMMSS, HHMMxUUUU, or HHMMSSxUUUU

      • HH may be between 00-23

      • MM may be between 00-59

      • SS may be between 00-59

      • xUUUU represents the UTC time shift and may be between -1300 thru +1400

      • x - plus or minus sign for the UTC time shift

      • UUUU - UTC time shift

Note:  We have determined that some vendors are defaulting values into date/time fields instead of submitting a ‘null’ value or Nullflavor when something did not occur.  Please refer to the Nullflavor discussion within CMS' Implementation Guide for QRDA I documents for an understanding of how missing or null datetimes should be submitted.

Two examples which trigger this rejection:

<effectiveTime xsi:type= "IVL_TS" >
<low value= "00010101000000" />  → the start date/time is defaulted as "00010101000000-0000"
</effectiveTime>

<effectiveTime xsi:type= "IVL_TS" >
<low value= "00" />   → the start time is defaulted as "00"
<high nullFlavor= "NI" />
</effectiveTime>

Expand
titleInvalid Patient ID (error)
  • Source Viewer: Invalid Patient ID has been provided. (TJC-100029)

    • Section / Element: Invalid Patient ID has been provided. (TJC-100029)

    • The Patient ID cannot be greater than 100 characters OR there are invalid characters.

    • Please contact your IT staff or EHR vendor if assistance is needed to correct this error.

Expand
titleInvalid QRDA XML file (error)

Invalid QRDA I Documents typically cannot be displayed within the Source Viewer and it may appear as a preprocess validation error on the Data Accuracy bar chart. (TJC-100031 and TJC-100027)

There are two primary reasons for why the ‘Invalid QRDA XML file’ error is generated:

  • Section / Element: XML File format issue

    • File does not confirm to being a valid HL7 QRDA I XML file.  Please review the file that you submitted using tools available within your organization or supplied by your vendor.

    • Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

  • Section / Element: Patient ID

    • Only English alphabet characters, numeric characters, and the following special characters are allowed in the Patient ID:
       ~  !  @  #  $  %  ^  *  (  )  _  +  {  }  |  :  ?  `  -  =  [  ]  \  ;  ‘  .  ,  / and space

      • All other characters will trigger this error, including &, <, >,  and foreign numbers and characters.

    • If this file does not open within Source Viewer, please review it using tools available within your organization or supplied by your vendor. 

      • Especially look for '<' and '>' being before and after the Patient ID.  We have been informed by some EHR vendors that this may occur when a 'temporary' Patient ID has been assigned to the record within the EHR. 

      • Please contact your IT staff, EHR vendor, or vendor that supplied the software being used to generate the QRDA I documents if assistance is needed to correct this error.

Expand
titleNone of the measures supported by TJC (error)
  • Source Viewer: None of the Measures reported in the file are from the TJC supported eMeasure list. (TJC-100003)

    • Section / Element: Measure Version Specific ID 

    • The software used to generate the QRDA I document has identified only measures not utilized by The Joint Commission. 

      • Inpatient QRDA I documents rejected by this message need to be evaluated and, if necessary, corrected by having at least one eCQM utilized by The Joint Commission identified within the document.  If corrected, the QRDA I document will need to be re-uploaded to the DDS Platform.

      • Outpatient QRDA I documents will only be identified as belonging to the Initial Patient Population of CMS' ED-3 eCQM. 

      • Given that we have asked for the same zip files which were submitted to CMS to be submit to the DDS Platform, it is appropriate for these outpatient cases to be submitted since CMS will evaluate them against their ED-3 eCQM.

      • At the same time, it is correct for the DDS Platform to reject the outpatient cases since we do not utilize this measure.  You can ignore the outpatient cases when submitting your hospital’s data.

      • When using the Submit Data page, you are only submitting the QRDA I documents associated to the measures that you select to submit. Since ED-3 is not an option, the outpatient cases will remain solely within your hospital’s DDSP Workspace and will not be submitted to The Joint Commission.

  • The ‘Missing or Invalid Admission Date’ error is associated to four Source Viewer messages:

    • Source Viewer: Invalid Inpatient encounter admission date has been provided or it's before 1900. (TJC-100006)

    • Source Viewer: Inpatient encounter admission date is required. (TJC-100007)

    • Source Viewer: Inpatient encounter admission date value must be precise to the minute. (TJC-100009)

    • Source Viewer: Inpatient encounter admission date cannot be greater than current date (TJC-100010)

  • Section / Element for all four Source Viewer messages: Encounter Inpatient Admit Date

  • The Encounter Inpatient Admit Date is either missing or not properly formatted.  Inpatient QRDA I document rejected by this message need to be corrected by adding or updating the Admit Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform. The Inpatient Encounter Template effective-time 'low' field:

    • cannot be missing or

    • after today's date, and

    • must be reported up to minutes.

  • The Joint Commission requires up to minutes. Seconds may either be present or missing; however, if present the time must be of a valid format. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU  
    Expand
    titleMissing or Invalid Admission Date (error)
    Info

    TIP: Use a keyboard shortcut key to find eCQM Warning & Error Messages help content by number.

    “Control” + “F” for Windows
    ”Command-F” for Mac

    Table of Contents:

    • Purpose:  

    • Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

    • Data Accuracy Messages

    Purpose:  

    Below are The Joint Commission specific error and warning messages generated by the edits and Schematron rules executed against each uploaded QRDA I Document.  In addition, those CMS and Health Level Seven (HL7) Schematron rules that are frequently encountered when data is uploaded to the DDS Platform are also included below.

    What is the difference between Error & Warning Messages?

    QRDA I documents that generate one or more error messages have been rejected and not processed against the eCQM logic.  They are available for you to view within the Source Viewer from the Data Accuracy page.  Since they have not been processed against the eCQM logic, they are not available on the Quality Improvement page and cannot be submitted via the Submit Data page.

    QRDA I documents that generated one or more warning messages AND no error messages may be submitted.  We recommend that hospitals review the warning messages to ensure they are not pointing to issues with data capture, data mapping, or QRDA I file generation that can be corrected before the submission deadline.  However, we do realize that hospitals may not have the ability to regenerate QRDA I documents from prior years and so they are unable to correct these warning messages.  If this is your situation, we suggest you continue to review the warning messages and, if needed, work to update your software for the next calendar year and for future years so as to eliminate these warning messages to ensure your measure rates are as accurate as possible.

    Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

    Each Data Accuracy message is associated to one or more Source Viewer descriptions.  The Data Accuracy message provides a high-level description of the issue.  Some issues such as "Missing or Invalid Admission Date" can have multiple reasons as to why the issue exists.  The specific reason(s) for the QRDA I Document are detailed within the Source Viewer.

    When reviewing data edits within the Source Viewer, if appropriate, the Conformance Number of the edit is displayed.  There are three types of conformance statements with different formats for the CONF number:

    • Joint Commission CONF numbers (TJC-xxxxxx)

    • CMS CONF numbers (CMS_xxxx_xxxx-C01 or xxxx_xxxx-C01)

    • HL7 Clinical Document Architecture (CDA) QRDA Category I Errors (xxxx_xxxx). 

      • Please note that HL7 Conformance numbers are not prefixed with "HL7".  All Conformance numbers without the prefix of "TJC" or "CMS" or a suffix of "C01" are HL7 Conformance numbers.

    For more information concerning CMS or HL7 Conformance numbers, see the below reference material:

    • CMS:  Visit the eCQI Resource Center CMS QRDA IG publication page for the documents associated to this year's data.

    • HL7: Visit the HL7 website to obtain the version of the HL7 CDA® R2 IG: QRDA I applicable for this year's data. 

      • The HL7 website may require a HL7 account in order to download the Implementation Guide (IG).

      • The HL7 website header states the current Release number.  Scroll to the bottom of the page to find the Release that is appropriate for this calendar years data.

    • See the eCQM Version Alignment with CMS documentation for information concerning the version of measures, CMS QRDA IG, and HL7 standards that are applicable to this year's data.

    Error Messages

    Message #
    Section/ Element
    Status
    Data Accuracy Label
    (Short Description)
    Source Viewer Description
    (Long Description)
    Expected Behavior in Source Viewer Upon Clicking Error
     Additional Information
    100001
    Discharge Date
    Critical
    Missing Encounter Performed Relevant Period High Date
    Encounter Performed Relevant Period High Date (effectiveTime/ high) is missing (TJC-100001)
    Highlight the encounter performed section, which is missing the 'high' time field, in the source viewer
    Validate effective-time 'high' field of all Encounter Performed which includes Inpatient encounter, ED, Observation.
    100002
    Discharge Date
    Critical
    Invalid Encounter Performed Relevant Period High Date
    Invalid Encounter Performed Relevant Period High Date (effectiveTime/ high) has been provided or it's before 1900. (TJC-100002)
    Highlight the encounter performed section which has invalid 'high' time  in the source viewer
    Apply all date validation
    Do not apply offset, but validate offset format
    Valid Date/Time Format:
    YYYYMMDDHHMMSSxUUUU
    where
    YYYY - year Range 1900 to 9999
    MM - month - range 01 to 12
    DD - day - range 01 to 31 (note: true to month and leap years)
    HH - hour - range 0 to 23
    MM - minutes - range 0-59
    SS - seconds - range 0-59 x - plus or minus sign
    UUUU - UTC time shift -1200 thru+1400
    100004
    Discharge Date
    Critical
    Invalid Encounter Performed Relevant Period High Date
    Encounter Performed Relevant Period High Date (effectiveTime/ high) must be precise to the minute. (TJC-100004)
    Highlight the encounter performed section which has invalid 'high' time  in the source viewer
    Validate effective-time 'high' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
    100005
    Discharge Date
    Critical
    Encounter Performed Relevant Period High Date is out of range
    Encounter Performed Relevant Period High Date  effectiveTime/ high) cannot be greater than current date. (TJC-100005)
    Highlight the encounter performed section which has invalid 'high' time  in the source viewer
    Validate effective-time 'high' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
    100006
    Admit Date
    Critical
    Invalid Encounter Performed Relevant Period Low Date
    Invalid Encounter Performed Relevant Period Low Date  effectiveTime/ low) has been provided or it's before 1900. (TJC-100006)
    Highlight the encounter performed section, which has invalid the 'low' time field, in the source viewer
    Apply all date validation
    Do not apply offset, but validate offset format
    Valid Date/Time Format:
    YYYYMMDDHHMMSSxUUUU
    where
    YYYY - year Range 1900 to 9999
    MM - month - range 01 to 12
    DD - day - range 01 to 31 (note: true to month and leap years)
    HH - hour - range 0 to 23
    MM - minutes - range 0-59
    SS - seconds - range 0-59 x - plus or minus sign
    UUUU - UTC time shift -1200 thru+1400
    100007
    Admit Date
    Critical
    Missing Encounter Performed Relevant Period Low Date
    Encounter Performed Relevant Period Low Date  effectiveTime/ low) is required. (TJC-100007)
    Highlight the encounter performed section, which is missing the 'low' time field, in the source viewer
    Validate effective-time 'low' field of all Encounter Performed which includes Inpatient encounter, ED, Observation.
    100008
    DateTime
    Critical
    Invalid DateTime
    Invalid DateTime has been provided. (TJC-100008)
    Highlight the template/EffectiveTime with incorrect date
    Only validate effectiveTime, Time, and birthTime in QRDA that are listed in TJC xPath Document required by current eCQMs and other than Inpatient Encounter Performed Admit and discharge date.
    Check effectiveTime/Time/birthTime's provided values for  accurate format.
    For 2021, add validation: Assessment Performed Result as DateTime.
    XPATH location: {AssessmentPerformed}/value @xsi:type="TS": @value
    Valid Date/Time Format:
    YYYYMMDDHHMMSSxUUUU
    where
    YYYY - year - range 1900 to 9999
    MM - month - range 01 to 12
    DD - day - range 01 to 31 (note: true to month and leap years)
    HH - hour - range 0 to 23
    MM - minutes - range 0-59
    SS - seconds - range 0-59 x - plus or minus sign
    UUUU - UTC time shift -1200 thru+1400
    Do not apply offset- but validate the offset format
    100009
    Admit Date
    Critical
    Invalid Encounter Performed Relevant Period Low Date
    Encounter Performed Relevant Period Low Date  effectiveTime/ low) value must be precise to the minute. (TJC-100009)
    Highlight the encounter performed   section, which has invalid the 'low' time field, in the source viewer
    Validate effective-time 'low' value of Encounter Performed which includes Inpatient encounter, ED, Observation.
    100010
    Admit Date
    Critical
    Encounter Performed Relevant Period Low Date is out of range
    Encounter Performed Relevant Period Low Date  effectiveTime/ low) cannot be greater than current date (TJC-100010)
    Highlight the encounter performed  section, which has invalid the 'low' time field, in the source viewer
    Validate effective-time 'low' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
    100012
    DateTime
    Warning
    Invalid DateTime
    Invalid DateTime has been provided. (TJC-100012)
    Highlight the template/EffectiveTime with incorrect date
    Only validate effectiveTime, Time, and birthTime in QRDA that are listed in TJC xPath Document but NOT used by current eCQMs.  
    Check effectiveTime/Time/birthTime's provided values for  accurate format.
    Valid Date/Time Format:
    YYYYMMDDHHMMSSxUUUU
    where
    YYYY - year - range 1900 to 9999
    MM - month - range 01 to 12
    DD - day - range 01 to 31 (note: true to month and leap years)
    HH - hour - range 0 to 23
    MM - minutes - range 0-59
    SS - seconds - range 0-59 x - plus or minus sign
    UUUU - UTC time shift -

    ...

    1200 thru+1400

    ...

    Expand
    titleMissing Encounter Performed Relevant Period High Date (error)
    • The ‘Missing or Invalid Discharge Date’ error is associated to four Source Viewer messages:

      • Source Viewer: Inpatient encounter discharge date is missing. (TJC-100001)

      • Source Viewer: Invalid Inpatient encounter discharge date has been provided or it's before 1900. (TJC-100002)

      • Source Viewer: Inpatient encounter discharge date must be precise to the minute. (TJC-100004)

      • Source Viewer: Inpatient encounter discharge date cannot be greater than current date. (TJC-100005)

    • Section / Element: Encounter Inpatient Discharge Date

    • The Encounter Inpatient Discharge Date is either missing or improperly formatted.  Inpatient QRDA I document rejected by this message need to be corrected by adding or updating the Discharge Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform.

    • The Inpatient Encounter Template effective-time 'high' field:

      • cannot be missing or

      • after today's date, and

      • must be reported up to minutes.

    • The Joint Commission requires up to minutes. Seconds may either be present or missing; however, if present the time must be of a valid format. Valid Date/Time Format: 

      •  YYYYMMDDHHMMSSxUUUU  where

        • YYYY - year - range 1900 to 9999

        • MM - month - range 01 to 12

        • DD - day - range 01 to 31 (note: true to month and leap years)

        • HH - hour - range 0 to 23

        • MM - minutes - range 0-59

        • SS - seconds - range 0-59 x - plus or minus sign

        • UUUU - UTC time shift -1300 thru+1400

    Note: At this time, The Joint Commission only utilizes inpatient measures.  Therefore, all QRDA I Documents are expected to contain a valid Inpatient Encounter with a valid Discharge Date.  Outpatient data (e.g., ED-3) will be rejected.

    Expand
    titleMissing or Invalid Header EffectiveTime (error)
    • Source Viewer: Invalid or null US Realm Date and Time is provided. (TJC-100035)

      • Section / Element: Header Effective Time

      • The US Realm Date and Time under <header> as given in the XPath is null or invalid.  This Date/Time is required to make the QRDA I document a valid document. Valid Date/Time Format:  YYYYMMDDHHMMSSxUUUU   where

        • YYYY - year - range 1900 to 9999

        • MM - month - range 01 to 12

        • DD - day - range 01 to 31 (note: true to month and leap years)

        • HH - hour - range 0 to 23

        • MM - minutes - range 0-59

        • SS - seconds - range 0-59 x - plus or minus sign

        • UUUU - UTC time shift -1300 thru+1400 

    Expand
    titleNo Discharge Date in Reporting Period (error)

    ·         Source Viewer: There is no Inpatient Discharge Date within the reporting period in the QRDA file. (TJC-100022)

    o    Section / Element: Discharge Date

    o    This error is stating that the QRDA I document does not contain a Discharge Date or that the Discharge Date is not within the Reporting Period stated within the QRDA I document (i.e., calendar quarter).  Discharge Date must be equal to or before 23:59:59 local time on the final day of the calendar quarter (reporting period).

    §  Inpatient QRDA I documents rejected by this message need to be corrected by adding or updating the Discharge Date.  Once corrected, the QRDA I document needs to be re-uploaded to the DDS Platform.

    §  Outpatient QRDA I documents will not contain an inpatient Discharge Date.  

    §  Given that we have asked for the same zip files which were submitted to CMS to be submit to the DDS Platform, it is appropriate for these outpatient cases to be submitted since CMS will evaluate them against their ED-3 eCQM.

    §  At the same time, it is correct for the DDS Platform to reject the outpatient cases since we do not utilize this measure.  You can ignore the outpatient cases when submitting your hospital’s data.

    §  When using the Submit Data page, you are only submitting the QRDA I document associated to the measures that you select to submit. Since ED-3 is not an option, the outpatient cases will remain solely within your hospital’s DDSP Workspace and will not be submitted to The Joint Commission.

    Expand
    titler-validate_TZ-errors (error)

    ·         Source Viewer: Inconsistent usage of time zone is found in the file.  Time zone must be used (OR not used) consistently throughout the file in all Datetime fields which contain time part. (TJC-0043)

    o    Section / Element: Time zone

    o    Time Zone must be consistently either be included or not be included for all Date elements that include a time stamp  (HH, HHMM, or HHMMSS).

    Expand
    titleQDM_based_QRDA_V7-TJC-errors (error)

    ·         Source Viewer: CCN (Facility CMS Certification Number), SHALL be six to ten characters in length (CONF:TJC-0011)

    o    Section / Element: CCN

    o    The hospital's Facility CMS Certification Number SHALL be six to ten characters in length.

    o    The Joint Commission processes all data submitted to the DDS Platform based upon the hospital's CMS CCN, not the hospital's Joint Commission HCO ID. The Platform crosswalks the CCN back to the HCO ID for data storage and analysis purposes.

    §  You can determine the CCN which The Joint Commission has linked to your HCO ID by going into HCO Characteristics (available from the main menu).  If the CCN is incorrect, please complete the Support Ticket to inform us what the correct CCN should be and we will investigate.

    §  Note: We have not built the functionality to receive a file containing solely our HCO ID due to our desire to reduce hospital costs and other burden.  By receiving the file using CMS' CCN, it allows hospitals to submit the same QRDA I documents that they submit to CMS to The Joint Commission.

    The CCN on file within the DDS Platform has been taken from your organization’s accreditation application - so it is possible it also needs to be updated there as well.

    ...

    titleA required Medication Route is missing (warning)

    ...

    Do not apply offset- but validate the offset format
    100022
    Discharge Date
    Critical
    No Discharge Date in Reporting Period
    CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR) and there is NO Inpatient Discharge Date within the reporting period defined in the Reporting Parameters section in the QRDA file. (TJC-100022)
    Highlight the first Inpatient Encounter
    When CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
    Anything on or before 23:59:59 local time on the final day of the reporting period is valid.
    Do not apply offset before validation
    100023
    High@value
    Critical
     Event start date after the end date
    Event End date is before the Event Start Date. (TJC-100023)
    Highlight the template/EffectiveTime with incorrect date
    Rejection  for all dates in TJC xPath Document required by current eCQMs.  
    apply offset before validation
    100024
    High@value
    Warning
     Event start date after the end date
    Event End date is before the Event Start Date. (TJC-100024)
    Highlight the template/EffectiveTime with incorrect date
    Warning for all dates in TJC xPath Document but not used by current eCQMs.  
    apply offset before validation
    100025
    Encounter ID
    Warning
    Inconsistent reporting of Inpatient Encounter
    CMS Program Name is an Inpatient Program and
    there exists inconsistent encounter id, code/codeSystem or effectiveTime in the Inpatient Encounter templates for the same episode, there is a possibility of increased number of EOCs. (TJC-100025)
    Highlight the first instance of Inpatient Encounter template for the same episode
    For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
    When two inpatient encounters exist, if below condition, we consider they are the same encounter:
    • admit and discharge dates are the same

    Or
    • encounter IDs and extension are the same

    If the same inpatient encounters are reported, we only allow for valueset to be different, everything else should be the same.  If any below condition, we trigger this edit:
    1. Admit, discharge date or their offsets are different

    2. Encounter ID or extension is different

    3. encounter code/codeSystem is different

    Apply offset before comparison
    100026
    Encounter ID
    Warning
    Duplicate Inpatient Encounter Detected
    CMS Program Name is an Inpatient Program and two instances of inpatient encounter template are exactly the same. The last instance in the QRDA file will be used for measure evaluation. Remove duplicate encounter template/s to avoid unexpected outcome. (TJC-100026)
    Highlight the first instance of Inpatient Encounter template for the same episode
    For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
    Admit and discharge dates, encounter code and encounter ID (root and extension) are the same among duplicates.
    Apply offset
    100027
    Patient id
    Critical
    Invalid QRDA XML file
     
    Source Viewer stays blank with no data
    Any character which engine is not able to process will trigger this error
    (& and foreign numbers and characters are invalid chars).
    Following characters are valid for patient_id:
    English alphabet and numeric characters, and following special characters:
     ~  !  @  #  $  %  ^  *  (  )  _  +  {  }  |  :  ?  `  -  =  [  ]  \  ;  ‘  .  ,  /  < > and space 
    100029
    Patient id
    Critical
    Invalid Patient ID
    Invalid Patient ID has been provided. (TJC-100029)
    Expectation: Highlight the Patient ID
    The patient-id fields cannot be greater than 100 characters OR there are invalid characters.
    100031
    XML File
    Critical
    Invalid QRDA XML file
     
    Source Viewer stays blank with no data
    File is not a valid QRDA XML file
    100032
    CCN
    Critical
    Incorrect CCN Reported
    The CCN does not match with the CCN associated to the current HCO. (TJC-100032)
    Highlight the CCN Number
    The CCN is provided. However, the CCN in the document does not match with the CCN associated to the current user.
    100035
    Header Effective Time
    Critical
    Missing or invalid Header EffectiveTime
    Invalid or null US Realm Date and Time is provided. (TJC-100035)
    Highlight the header effectiveTime
    US Realm Date and Time under <header> as given in the XPath is null or invalid. 
    Valid Date/Time Format:
    YYYYMMDDHHMMSSxUUUU
    where
    YYYY - year - range 1900-9999
    MM - month - range 01 to 12
    DD - day - range 01 to 31 (note: true to month and leap years)
    HH - hour - range 0 to 23
    MM - minutes - range 0-59
    SS - seconds - range 0-59 x - plus or minus sign
    UUUU - UTC time shift -1200 thru+1400
    Note: Do not use the template id to find the date, Following the  XPath should be sufficient to find the effective time
    Do not apply offset before validation
    100036
    Encounter ID
    Warning
    Inpatient encounter outside of the reporting quarter
    CMS Program Name is an inpatient Program and there exists an inpatient encounter with discharge datetime outside of the reporting quarter defined in the Reporting Parameter of the QRDA document.  (TJC-100036)
    Highlight the Encounter ID
    For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
    This warning will only trigger when at least one of the inpatient encounter's discharge datetime is outside of the reporting quarter.  
    Do not apply offset
    100037
    Route Code
    Warning
    A required Medication Route is missing
    Route code is missing for an administered medication, and is required by a reported eCQM. (

    ...

    o    Section / Element: Route Code

    o    This warning indicates that a Medication Template in the QRDA file should have the medication Route information because:

    §  the QRDA I document denotes that it should be processed against VTE-1 or VTE-2

    §  the medication belongs to one of the below value sets used by VTE-1 or VTE-2

    §  the Route Code has not been negated with negationID=true.

    o    The two Medication value sets for eVTE-1 and eVTE-2 require the Route Code:

    ...

    TJC-100037)
    Highlight the Medication Template, which is missing the route, AND has negationInd=false or it's negationInd missing AND the code belongs to the value set required by eCQM
    Only trigger the warning for those Medications that belong to the value set that eCQM asks for, AND do not have the route and are not negated with negationID=true. (e.g. VTE-1 and VTE-2)
    Below listed are Value sets and Codes that need Route code
    1. Unfractionated Heparin value set (2.16.840.1.113883.3.117.1.7.1.218) contains the following codes:

     (1361607, 1658717, 1659195, 1659197)
    1. Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.

    ...

    1. 113762.

    ...

    1. 1.

    ...

    1. 4.

    ...

    1. 1045.

    ...

    1. 39 ) value set contains the following codes :

     (1361226, 1361568, 1361574, 1361577, 1361615, 1361853, 1362831, 1658634, 1658637, 1658647, 1658659, 1659260, 1659263, 1798389, 2121591)
    RouteCode ValueSets and codes
    A) ["Medication, Administered": "*Low Dose Unfractionated Heparin for VTE Prophylaxis

    ...

    *"] VTEMedication
    where VTEMedication.route in "Subcutaneous route":
    "Subcutaneous route" valueset 2.16.840.1.113883.3.

    ...

    117.1.

    ...

    7.

    ...

    1.223 and code in this value set- 34206005
    B) Medication, Administered": "Unfractionated Heparin"] UnfractionatedHeparin
     where UnfractionatedHeparin.route in "Intravenous route"
    "Intravenous route"  valueset 2.16.840.1.113883.3

    ...

    o    If you have not received the expected measure results for eVTE-1 or eVTE-2, you may update the QRDA I documents by adding the Route information, if available within the patient’s EHR, and regenerating the QRDA I documents (see below for more info). We then recommend that you Purge your data and upload the new zip file(s). To find the missing Route information:

    §  In Data Accuracy tab, click on the magnifier next to the file name and it opens the Source Viewer.

    §  Click on this message in the Source Viewer and the tool will take you to the correct template that is missing the <route>.

    §  Compare your template with the example template from QRDA I Guide provided below.

    o    Following is an example provided in HL7’s QRDA I Implementation Guide and you can see how the route is provided. Also, as given in the message description, if the <route> tag is provided, the code MUST be from value set OID=2.16.840.113883.3.88.12.3221.8.7, otherwise the document will receive an error message and will be rejected.

    ...

    .117.1.7.1.222and codes in this value set- 418114005, 419993007, 47625008
    100039
    Result Unit
    Warning
    Unacceptable Unit Reported
    There exists an unacceptable unit in the QRDA document. Enter the correct unit as definied in the eCQM logic to avoid an unexpected outcome. (TJC-100039)
    Highlight the incorrect/invalid unit
    Validate this edit only when below conditions are met-
    1. When below specified measures are reported

    2. When code is in the below listed Value Sets

    3. When result value is provided

    Note: DO NOT trigger warning if code is provided from below listed Value Sets but reported measure is not from below specified measures.
    List of measures,  required units and data element/Value Sets:
    1. For eSTK-6 - unit 'mg/dL' for Laboratory Test Performed

    • "Laboratory Test, Performed: LDL-c" using "LDL-c (2.16.840.1.113883.3.117.1.7.1.215)"

    1. for eHH-1 and eHH-2- "Laboratory Test, Performed: Glucose Lab Test Mass Per Volume" using "Glucose Lab Test Mass Per Volume (2.16.840.1.113762.1.4.1248.34)"

    1. ePC-01, ePC-02, ePC-05, ePC-06, ePC-07 - unit- 'wk', 'week' or 'weeks' for Assessment Performed Gestational Age calculation.

    • For ePC-01, ePC-02, and ePC-07"- Assessment, Performed: Estimated Gestational Age at Delivery" using "Estimated Gestational Age at Delivery (2.16.840.1.

    ...

    • 113762.

    ...

    • 1.

    ...

    • 4.

    ...

    titleUnacceptable Unit Reported (warning)

    ...

    o    Section / Element: Result Unit

    ·         This warning will only trigger when incorrect/invalid unit is provided for eCQM measure logic evaluation.

    ·         Below are required unit as per CY2021 eCQM-

    ·         1) eSTK-6 - 'mg/dL' for Laboratory Test Performed

    ·         2) ePC-01, ePC-02, ePC-05, ePC-06 - 'wk', 'week' or 'weeks' for Assessment Performed Gestational Age calculation.

    ·         3) ePC-05, ePC-06 - 'g' for Assessment Performed Birth Weight calculation.

    Expand
    titler-DOCUMENT-TJC-QDM-HEADER-warnings (warning)

    ·         Source Viewer: This document SHALL contain exactly one [1..1] QDM-based QRDA document level templateId @root="2.16.840.1.113883.10.20.24.1.2" @extension="2019-12-01". QDM data elements will not be validated properly (TJC-050).

    o    Section / Element: Document Level templateID

    o    All valid HL7 QRDA I documents must contain one [1..1] QDM-based QRDA document level templateId @root="2.16.840.1.113883.10.20.24.1.2" @extension="2019-12-01".

    o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

    Expand
    titler-DOCUMENT-TJC-QRDA-HEADER-warnings (warning)

    ·         Source Viewer: This document SHALL contain exactly one [1..1] QRDA Category I Framework document level templateId @root="2.16.840.1.113883.10.20.24.1.1" @extension="2017-08-01". QRDA-I data elements will not be validated properly (TJC-0049).

    o    Section / Element: Document Level templateID

    o    All valid HL7 QRDA I documents must contain one [1..1] QRDA Category I Framework document level templateId @root="2.16.840.1.113883.10.20.24.1.1" @extension="2017-08-01".

    o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

    Expand
    titler-DOCUMENT-TJC-US-HEADER-warnings (warning)

    ·         Source Viewer: This document SHALL contain exactly one [1..1] US Realm document level templateId @root="2.16.840.1.113883.10.20.22.1.1" @extension="2015-08-01". CDA data elements will not be validated properly (TJC-0048).

    o    Section / Element: Document Level templateID

    o    All valid HL7 QRDA I documents must contain one [1..1] US Realm document level templateId @root="2.16.840.1.113883.10.20.22.1.1" @extension="2015-08-01".

    o    Please contact your IT staff or vendor that supplied the software being used to generate the QRDA I documents to correct this error.

    Expand
    titleReporting-Parameters-Act-TJC-errors (error)

    ·         Source Viewer: This effectiveTime SHALL contain exactly one [1..1] low and exactly one [1..1] high for reporting period start date and end date respectively. Reporting Period must only represent one calendar quarter with valid start and end dates within the reporting year (TJC-0007). 

    o    Section / Element: Reporting Parameter

    o    The Reporting Period start date must be the first day of a calendar quarter. Valid quarter start dates are: January 1, April 1, July 1 and October 1.

    o    For hospital QRDA I documents, the Reporting Period end date must be the last day of the calendar quarter associated to the start date. Valid quarter end dates are: March 31, June 30, September 30 and December 31.

    ...

    titler-validate_effectiveTime-TJC-warnings (warning)

    ·         Source Viewer: effectiveTime or time SHALL have either @value or low and high but SHALL NOT have @value and low and high. (TJC-0036)

    o    Section / Element: effectiveTime and time

    ...

    • 1045.26)"

    • For  ePC-05 and ePC-06- code "Gestational age--at birth" ("LOINC Code (76516-4)")

    1. For ePC-05, ePC-06 - 'g' for Assessment Performed Birth Weight calculation

    • valueset "Birth Weight" (2.16.840.1.113762.1.4.1029.194)

    100041
    Header intendedRecipient
    Critical
    No outpatient measure reported
    In the QRDA document, reported CMS program name is 'HQR_OQR'. QRDA file did not report any TJC supported outpatient measure. (TJC-100041)
    Highlight the CMS program name
    This edit triggers when QRDA file contains CMS program name as 'HQR_OQR' but no TJC supported outpatient measures are reported.
    100042
    Header intendedRecipient
    Critical
    No inpatient measure reported
    In the QRDA document, reported CMS program name is  'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR'. QRDA file did not report any TJC supported inpatient measure. (TJC-100042)
    Highlight the CMS program name
    This edit triggers when QRDA file contains CMS program name as 'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR  but no TJC supported inpatient measures are reported.
    100043
    Header intendedRecipient
    Warning
    Inpatient measure reported for outpatient CMS program name
    TJC supported Inpatient measures will not be evaluated when reported CMS program name is 'HQR_OQR' . (TJC- 100043)
    Highlight the CMS program name
    This warning will only trigger when
    • CMS program name as 'HQR_OQR '

    • QRDA file contains TJC supported outpatient measures

    • And at least one of the TJC supported inpatient  measures

    100044
    Header intendedRecipient
    Warning
    Outpatient measure reported for inpatient CMS program name
    TJC supported outpatient measures will not be evaluated when reported CMS program name as ' HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR ' . (TJC- 100044)
    Highlight the CMS program name
    This warning will only trigger when
    • CMS program name as 'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR '

    • QRDA file contains TJC supported Inpatient measures

    • And at least one of the TJC supported outpatient  measures

    100045
    Departure Date
    Critical
    No ED Relevant Period High Date in Reporting Period
    CMS Program Name is 'HQR_OQR' and there is NO ED Relevant Period High Date (effectiveTime/ high) within the reporting period defined in the Reporting Parameters section in the QRDA file. (TJC-100045)
    Highlight the first Departure Encounter 
    When CMS Program Name is an outpatient Program (HQR_OQR)
    Anything on or bef
    Anything on or before 23:59:59 local time on the final day of the reporting period is valid.
    Do not apply offset before validation
    100046
    Encounter ID
    Warning
    Inconsistent reporting of Outpatient Encounter
    CMS Program Name is an Outpatient Program and
    there exists inconsistent encounter id, code/codeSystem or effectiveTime in the Outpatient Encounter templates for the same episode, there is a possibility of increased number of EOCs. (TJC-100046)
    Highlight the first instance of Outpatient Encounter template for the same episode
    For CMS Program Name is an Outpatient Program (HQR_OQR)
    When two outpatient encounters exist, if below condition, we consider they are the same encounter:
    • Relevant Period Low Date and Relevant Period High Dates are the same

    Or
    • encounter IDs and extension are the same

    If the same outpatient encounters are reported, we only allow for valueset to be different, everything else should be the same.  If any below condition, we trigger this edit:
    1. Relevant Period Low Date and Relevant Period High Date or their offsets are different

    2. Encounter ID or extension is different

    3. encounter code/codeSystem is different

    Apply offset before comparison
    100047
    Encounter ID
    Warning
    Duplicate Outpatient Encounter Detected
    CMS Program Name is an Outpatient Program and two instances of outpatient encounter template are exactly the same. The last instance in the QRDA file will be used for measure evaluation. Remove duplicate encounter template/s to avoid unexpected outcome. (TJC-100047)
    Highlight the first instance of Outpatient Encounter template for the same episode
    For CMS Program Name is an Outpatient Program (HQR_OQR)
    Relevant Period Low Date and Relevant Period High Date, encounter code and encounter ID (root and extension) are the same among duplicates.
    Apply offset
    100048
    Encounter ID
    Warning
    Outpatient encounter outside of the reporting quarter
    CMS Program Name is an Outpatient Program and there exists an outpatient encounter Relevant Period High Date outside of the reporting quarter defined in the Reporting Parameter of the QRDA document.  (TJC-100048)
    Highlight the Outpatient Encounter ID
    For CMS Program Name is an Outpatient Program (HQR_OQR)
    This warning will only trigger when at least one of the outpatient encounter Relevant Period High Date is outside of the reporting quarter.  
    Do not apply offset