Short Demo for PC Attestation (duration: 6:00 minutes)
https://attendee.gotowebinar.com/recording/2525920586566070019

What’s in this section:

• General Information about Perinatal Care Attestation

• Examples

• How to Attest

General Information

For CY2023: Hospitals can attest to submitting FOUR quarters of ePC measures (eCQMs) instead of four quarters of chart-abstracted PC measures for their Perinatal Care measures via the Chart-Abstracted Submission menu.

NOTE: This is a one for one replacement:

• If an organization is uncertain the eCQM data can be submitted (e.g., ePC-06), we strongly suggest the chart-abstracted data is entered until it is certain the eCQM data can be successfully submitted.

• A PC measure submitted as a chart-abstracted measure for all 4 quarters, may also be submitted as an eCQM.

• If applicable, every ePC eCQM submitted for counts towards both an organization's PC requirement and eCQM requirement.

• May replace none, some, or all required PC measures with ePC measures.

REMINDER: In order to meet chart-abstracted measure requirements, data is submitted for four quarters. Submitting less than four quarters of an eCQM does not meet the requirement.

1. HCO submits all 4 quarters of only chart-abstracted measures on all PC measures

   1. no ePC eCQM data are used to meet the Perinatal Care requirement.
      

2. HCO submits first 1 quarter of all applicable chart-abstracted PC measures, then switches to submitting all applicable eCQMs instead

   1. The Perinatal Care requirement for CY2023 is met by submitting four quarters of ePC eCQM data on all applicable PC measures.

   2. HCO receives feedback on both chart-abstracted data submitted for the first quarter, and eCQM data submitted.
      

3. HCO does not submit chart-abstracted PC measures during 1Q

   1. The HCO is required to submit eCQM ePC data in order to meet the PC requirement.
      

4. If an organization is required to submit all PC measures, they can submit specific chart-abstracted measures for four quarters, and submit the remaining PC measures as eCQMs:

   1. ePC-01 and ePC-02 are submitted as eCQMs for four quarters

   2. PC-05 and PC-06 are submitted as chart-abstracted measures for all four quarters.

• Click on the open button for the Perinatal Care measure for which you wish to attest to submit via eCQM.

• Select the toggle on the right-hand side, “Attest to submit via eCQM”. By clicking on that toggle, you are attesting that you will be submitting this measure as eCQM data instead of aggregate chart-abstracted data. 

• This attestation begins with the currently open quarters for which aggregate data has not already been submitted, as well as applying to future quarters of the specified measure.

• Aggregate data which has already been submitted, including the open quarters, will continue to be used by The Joint Commission.

• If aggregate data has been entered into open quarters, you may delete it prior to attesting to submitting eCQM data.  However, if data was entered for closed quarters, that data may not be deleted because it was already used in Joint Commission analysis.

• After clicking the attest toggle, you will see the following message under the quarter tabs: “By clicking this link, you are agreeing that you will be submitting the required information via the eCQM Submission process. Are you sure you want to continue?”

  

• If you return to the Measure List page, this chart-abstracted measure will now be shown as complete for all open quarters.

• Note that while “Attest to submit via eCQM” is selected, you cannot change or remove already entered Chart-Abstracted data for that measure.

  

• If you previously selected “Attest to submit via eCQM” but now wish to enter chart-abstracted data instead for an open quarter, simply click on the toggle to turn the attestation selection off.  This will allow you to enter chart-abstracted data for each open quarter.

• When “Attest to Submit via eCQM” is selected, the chart-abstracted data may no longer be changed. The data are visible within the Chart-Abstracted module as a reference for what was or will be submitted. This action applies to all open and future quarters."

• If all four quarters of a measure have been entered as chart-abstracted data, attestation for that measure is not allowed. Organizations can opt to:

  • Leave the attestation button set to “Off” and submit both chart-abstracted and eCQM data for the measure; feedback on all entered/submitted data will be provided.

  • Clear all quarters of chart-abstracted data for the measure, then attest to submit the measure as an eCQM (if applicable to the organization requirements).