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eCQMs

As with the chart-abstracted measures, selections should be based on populations and services provided. If a hospital does not provide a service(s) addressed by certain eCQMs such that the hospital is unable to identify four applicable eCQMs, then the hospital would report on only those eCQMs for which it has the relevant patient population/service. Hospitals should not select eCQMs for which it has no patient population and would be reporting zero values.

Important Note: Effective CY2022, hospitals unable to meet the eCQM requirement and are granted an extenuating circumstance (see “General ORYX Information: Basics” question 2.8 regarding ECRs) by The Joint Commission must substitute chart-abstracted measure(s) and submit those chart-abstracted measures for all four quarters of the calendar year.

Additional information will be provided on our website regarding eligibility for recognition. See the “Pioneers in Quality” section of our website for additional information: https://www.jointcommission.org/measurement/pioneers-in-quality/

Joint Commission requires reporting for at least three self-selected quarters (Q) of 2022 data (1Q, 2Q, 3Q, or 4Q). The same eCQMs must be submitted for whichever quarters are submitted. The Joint Commission and CMS do not share data and there is no requirement to submit the same measures/quarters to each entity. For eCQMs, the quarters being submitted are at the discretion of the hospital but must reflect patient population/services offered. The same measure(s) must be submitted for a minimum of three quarters, but the selected quarters may vary.

Example:

ePC-01 submitted 1Q, 2Q, 4Q
ePC-02 submitted 2Q, 3Q, 4Q
ePC-05 submitted 1Q, 2Q, 3Q
PC-06 submitted as a chart-abstracted measure for all four quarters
eOPI-1 submitted 2Q, 3Q, 4Q

The DDSP is set up to be a “rolling” platform, where once the data submission deadline for the preceding calendar year passes, the next year shortly becomes available for upload/submission. QRDA I documents for eCQM data may be submitted as soon as The Joint Commission makes the platform available for submission of that calendar year’s eCQMs. To submit data, the entire calendar quarter must be available. eCQM data is submitted retroactively:

CY2022 eCQM data deadline is March 15, 2023 after which CY2023 data can begin.
CY2023 eCQM data deadline is March 15, 2024 after which CY2024 data can begin.
CY2024 eCQM data deadline is March 17*, 2025 after which CY2025 data can begin.

*3/15/2025 falls on a weekend

A minimum of three calendar quarters of data based on the hospital’s selection of four eCQMs are due at The Joint Commission no later than the annual deadline date. Hospitals may submit their eCQM data on a quarterly basis; however, the submission deadline is the same for all quarters of eCQM data submitted.