DDSP GENERAL TECHNICAL INFORMATION

Hospital’s will be provided with additional information on how to use the new DDSP mid-CY2022.

When a hospital uploads their data onto the DDSP, the data are loaded into their individual workspace.  Users can then use additional features of the DDSP to evaluate the completeness and accuracy of their data. Once an organization is satisfied that the data within their workspace is ready to be submitted as Production data to The Joint Commission, the hospital utilizes functionality within the DDSP to submit their data. Data that is uploaded but not submitted is not received by The Joint Commission and does not count towards completion of ORYX requirements.

DDSP QRDA-1 FILES

The Quality Reporting Data Architecture (QRDA) is the data submission standard used for a variety of quality measurement and reporting initiatives. QRDA creates a standard method to report quality measures results in a structured, consistent format and can be used to exchange eCQM data between systems. QRDA Category I is an individual-patient-level report. It contains quality data for one patient for one or more eCQMs. The DDSP uses the QRDA I file format.

Additional information concerning QRDA I is available on the eCQI Resource Center at:
https://ecqi.healthit.gov/qrda

The DDSP will accept the same QRDA I documents that are submitted to CMS (with the exception of measures not currently supported by CMS).

For CY2022 ORYX purposes, ePC-01 (Elective Delivery) has been retained and ePC-02 (Cesarean Birth) has been adopted as ORYX measures.

Links to the eCQM specifications, measure flows, value sets, and technical release notes for both measures are available at: https://www.jointcommission.org/measurement/specification-manuals/electronic-clinical-quality-measures/

As a reminder, the specifications and supporting information for eCQMs used by both The Joint Commission and the Centers for Medicare & Medicaid Services (CMS), are available from the eCQI Resource Center or by clicking copying and pasting the web address into your internet browser: https://ecqi.healthit.gov/qrda  (Make sure to select the appropriate Reporting Period).

Hospital staff using the Joint Commission’s DDSP may grant external user permissions to assist with the eCQM upload process, e.g., uploading QRDA I documents or the data verification process (correct QRDA I document generation based on error/warnings, review measure results and rates to assist with addressing data mapping issues). The Joint Commission does not provide a separate Workspace to any vendor or consultant.  Instead, all vendors/consultants should work with their clients to test changes to their QRDA I document generation software.  Hospital staff using the Joint Commission’s DDSP are responsible for the data submission process and the relationships with users on the DDSP. The Joint Commission no longer has any contracts with ORYX vendors. Vendor/consultant staff with access to an organizations workspace and wish to submit a question must utilize the platform Support Ticket functionality from within the hospital’s workspace that is being used for “testing” purposes to ensure that the responses to their questions are the same as what would be provided to the hospital should they submit the same question.

The DDSP provides tools to assist hospitals in both identifying QRDA I document errors and in drilling down into the QRDA I XML structure to identify how to correct the issue.  There is no need to run QRDA I documents through the CMS PSVA tool first.

We encourage hospitals to submit all their eCQM data, even if they have concerns about rejected data. This facilitates the hospital’s learning about the DDSP’s tools to assist in researching and correcting QRDA I issues and the Joint Commission’s learning about the types of issues still occurring in the field as it relates to eCQMs. We encourage hospitals to UPLOAD all their eCQM data even if they have concerns.

QRDA I documents that are rejected have not been processed against the eCQM logic. Hospitals may resubmit a zip file containing only those QRDA I documents that were rejected. If only one document needs to be resubmitted, it must still be zipped. Hospitals may Purge all their data and completely re-upload if desired.

The QRDA III document is only being used by CMS for the submission of provider level aggregate data used in the Merit-based Incentive Payment System (MIPS) program.  Both CMS and The Joint Commission are utilizing the QRDA I document for submission of hospital patient-level eCQM data for our respective uses.

The DDSP does not utilize the concept of separate Production and Trial data upload.  Rather, when a hospital uploads their data onto the DDSP, the data are loaded into their individual workspace.  Hospital staff can then use additional features of the DDSP to evaluate the completeness and accuracy of their data. Once a hospital is satisfied that the data within their workspace is ready to be submitted as Production data to The Joint Commission, the hospital utilizes functionality within the DDSP to submit their data. Note that up until the submission deadline, a hospital can choose to purge and re-upload data as many times as needed.

The Joint Commission aligns with CMS on the eCQM version for each annual reporting period.  Refer to the eCQI Resource Center for more information.

As a measure developer, The Joint Commission works closely with CMS to develop the eCQM specifications utilizing not only HL7’s HQMF (V3) normative standard, but also HL7’s CQL standard and associated CQL-based HQMF Implementation Guide.

The DDSP’s Rule Engine implements the eCQM specifications based on CQL, as published by CMS on the eCQI Resource Center. In addition, all Joint Commission only eCQMs (e.g., ePC-01, ePC-02, ePC-06) are implemented using CQL.

The Joint Commission will be accepting the same QRDA I documents as CMS.  These are the files that EHR/HIT vendors are certified by ONC for quality measurement purposes.

QRDA I documents are not de-identified.

The Joint Commission's process is to anonymize the data being stored within our database.  This means that only the PHI data which is required to calculate the eCQMs (e.g., Admission and Discharge Dates).is stored.

VOLUME/CASE THRESHOLD

Hospitals should select those chart-abstracted and/or eCQMs applicable to their patient population and services offered in order to derive a quality improvement benefit. Hospitals should not select measures for which zero patients are expected.

Joint Commission's requirements state hospitals should only select measures applicable to the services provided and patient populations served. A hospital can still meet the intent of the ORYX requirement if at least one patient is in the initial population for each measure submitted.

For eCQMs: The Joint Commission is aligned with CMS with allowing attestation for zero denominators in a measure or, if desired, invoking the case threshold exemption (five or fewer cases in the denominator).

When submitting eCQM data via the DDSP:

• Zero Cases: a checkmark indicates a HCO's attestation of having zero patients/cases that fit the denominator criteria for the calendar quarter.

• Threshold Exemption: a checkmark indicates the hospital is submitting this measure to The Joint Commission; however, they are invoking the exemption to not submit the associated patient-level data because they have five or fewer cases that fit the denominator criteria for the calendar quarter.

• Zero Cases in IP: a checkmark indicates "No cases are in the Initial Population (IP) of the measure; however, my hospital has certified EHR software capable of generating QRDA I documents for the measure."

NOTE: For submission of eCQMs to The Joint Commission, it is appropriate if the "self-selected calendar quarters" to be submitted is by measure; meaning that the HCO submits eCQMs, but not necessarily all eCQMs are submitted for the same quarter.

For chart-abstracted measures: The Joint Commission is aligned with CMS with allowing attestation for zero denominators in a measure.

When submitting chart-abstracted data via the DDSP:

• Zero Cases Initial Population: if a zero (0) is entered into the Initial Population field for a month, the user is prompted to attest that the HCO had zero patients/cases that fit the Initial Population of the measure for the month. This attestation is to support hospitals which may not have a patient in the initial population every month and psychiatric hospitals which only provide services to children or adults.

• Zero Cases: if a zero (0) is entered into the Denominator (proportion/ratio measures) or Population (continuous variable measures) field, the user is prompted to attest that the HCO had zero patients/cases that fit the denominator criteria for the month.

NOTE: The exemption for not submitting patient-level data when the hospital has five or fewer discharges that fit the denominator criteria for the calendar quarter is no longer applicable for Joint Commission chart-abstracted measures as hospitals are only submitting aggregate data. There is no exemption for chart-abstracted measures as it relates to certified EHR software.