The CY2024 eCQM data submission deadline is March 17, 2025.

Open/close dates and deadlines are shown within the platform. Please see the timeline document available in the ORYX FAQs for additional information:

ORYX Performance Measurement Timeline

https://jointcommission-ddsp.atlassian.net/wiki/spaces/DCS/pages/71008257

Yes

Check here for the eCQM versions and HL7 standards that The Joint Commission has implemented.

The Joint Commission is in alignment with CMS and does not allow sampling for eCQMs.

The eCQI Resource Center (CMS) provides access to resources related to gaining an understanding of eCQMs, including a section under “Get Started with eCQMs” for new users:

https://ecqi.healthit.gov/

Yes - The Joint Commission’s Expert to Expert (EtoE) Webinar Series provides a deep-dive into measure intent, logic, and other clinical/technical aspects of electronic clinical quality measures (eCQMs) to assist hospitals and health systems in their efforts to improve eCQM data use for quality improvement. This series incorporates expertise from Joint Commission and other key stakeholders.

Refer to the Pioneers in Quality Expert to Expert Webinar series on The Joint Commission website:

https://www.jointcommission.org/measurement/pioneers-in-quality/pioneers-in-quality-expert-to-expert-series/

Yes

Check here for known issues with the alignment between CMS and TJC.

Yes

Check the known issues list for current known issues with the DDSP for eCQM Submission.

Aligned eCQMs: The Joint Commission is aligned with CMS regarding Certified EHR Technology (CEHRT) requirements. For more information, see ONC's Certification of Health IT webpages.

Joint Commission only eCQMs: ONC will not certify EHR Technology for eCQMs not being utilized in a CMS quality reporting program. For this reason, we acknowledge that hospital’s EHR Technology will not be certified for Joint Commission only eCQMs.

The QRDA I document file format is agnostic to the health IT software (e.g., EHR or HIE vendor) used to generate the documents. 

A hospital’s DDSP Workspace is implemented from the perspective of the hospital, not from the perspective of vendors.  While The Joint Commission allows hospitals to invite vendor staff, the DDSP does not distinguish between hospital and vendor staff or between staff from different vendors.

So, it is possible for a hospital to have multiple vendors invited at the same time or to change which vendor is invited at any given time.  This allows for the scenario of two vendors, or a vendor and hospital staff, to be submitting eCQM data for different quarters without issue.

For the question about submitting data for the same quarter, multiple DDSP Users (hospital and/or vendor staff) can upload QRDA I documents to the DDSP; however, there are some conditions that must be met by the software being used to generate the QRDA I documents for the same calendar quarter:

• Each QRDA I document must contain

  • quality data for one patient (single patient-id),

  • for all encounters that occurred during the calendar quarter being reported, and

  • all data necessary is present in the file for the reported eCQMs. 

• One QRDA I document is uploaded for each patient (patient-id) / quarter of data.

  • The Key to eCQM information uploaded to the DDSP is the Patient ID (in the PatientRole element) , CMS Program Name, HCO ID and the Quarter (in the effective date in the Reporting Parameters section).  These are the fields that determine whether or not the file will be overwritten within the hospital’s Workspace.

If two DDSP Users are uploading data for the same patient / quarter into a hospital’s Workspace, the patient-id in each of the QRDA I documents must be different to prevent overwriting the patient data and eCQMs uploaded by the other DDSP User(s).  This is because the DDSP utilizes the patient-id and quarter as the Key information to determine if existing patient data will be overwritten, regardless of which eCQMs are within the separate QRDA I documents and who performs the upload.  Therefore, if two DDSP Users upload patient data with the same keys, the second upload will overwrite the previous data.

Care must be taken to ensure that multiple DDSP Users are not creating QRDA I documents that are attempting to submit the same eCQM for the same patient and quarter.  If the same patient-id is used, the existing data will be overwritten.  If different patient-ids are used, the patient will be double counted.

In addition, please note that there is only one submission allowed per HCO on the DDSP. If two DDSP Users are submitting data for a hospital, coordination is needed between the Users (hospital/vendor staff) before the “submit” button is clicked. The DDSP does not allow additional QRDA I documents to be uploaded for the hospital once the “submit” button has been clicked. Therefore, the two DDSP Users must coordinate and submit data when all parties agree. Once both DDSP Users have completed their data upload and verification process, then the “submit” button can be clicked.

Perinatal Care Attestation (submitting eCQMs instead of chart-abstracted measures to meet the perinatal care requirement) occurs within the chart-abstracted data entry module. See the Perinatal Care Attestation on the Direct Data Submission Platform page for more information.

Organizations should attest to having “Zero IP Cases” for the required ePC measures.

The info note in the DDSP when they check ‘Zero IP Cases’ is:
"Check-mark indicates that the hospital does not have any cases in the initial population of the measure, but has certified EHR software that is capable of generating QRDA I documents for the eCQM."

No. The data contained within a QRDA-I document is associated to the Reporting Parameter section’s effective date range, which must be equal to a single calendar quarter.

For this reason, a patient being reported for multiple quarters must have separate QRDA-I documents submitted, one for each quarter.

Conformance # related to Reporting Period Effective Date:

CMS_0079

Reporting Period Effective Date Range does not match one of the Program's calendar year Discharge Quarters. 

The Reporting Parameter Section effective date range must exactly match one of the HQR allowable calendar year discharge quarters.

Yes.  You can use the left-hand menu to move between the different pages.

To move between the Upload Data and Update Data Summary pages, use the appropriate tabs near the top on the left-hand side.   

Users with access to multiple hospitals can use the ‘Switch’ button to change hospitals without having to log out.  The user will  remain on the current page, but the screen will refresh to represent the data for the selected hospital.

Yes.

The same zip file containing the QRDA I documents submitted to CMS can be uploaded to the DDSP.

Note: The zip file must not contain any folders, be password protected, or be encrypted.

No. 

The same QRDA I documents that are submitted to CMS can be uploaded to the DDS Platform.  The DDSP masks the PHI that is not required to process the eCQMs before the data is submitted to The Joint Commission.

Pre-Validation Error in Data Accuracy Page, displays “You must upload a zip file or an XML file” error in SourceViewer for the selected file. 

This error happens for many reasons. A few examples are noted below.

• If there is an empty space on top of QRDA I XML.

• If there exist an invalid and invisible character in the xml file, e.x.  in a comment in xml files triggers an invalid XML error.  

<!-- QDM Attribute: Author dateTime   the time the intervention order was signed -->

A tool such as Beyond Compare can help point to the line containing the character.

You might need to provide this information to your technical department or EHR vendor, to remove this character from affected xml files.

Yes.

• The Rule Engine on the DDSP will “ignore” data associated to CMS only measures.

Note: If the QRDA I document does not contain data for at least one Joint Commission measure, the entire document will be rejected.

Zip when uncompressed must be <= 2GB

Number of QRDA per zip must be <=15,000

A single QRDA I document must be <=10 MB (please let us know if this is truly an issue for a single patient's data for one quarter!)

For additional information about zip and QRDA I document requirements, refer to Important Information for Uploading QRDA I Documents.

Use the Upload Data page to upload the zip files containing your hospital's QRDA I documents. 

The DDSP does not utilize the concept of separate Production and Trial data upload.  Rather, when a hospital uploads their data onto the DDS Platform, the data are loaded into the hospital's individual Workspace.  Users then have the ability to evaluate the completeness and accuracy of the data prior to submitting it to The Joint Commission.

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 will continue to the Submit Data page.

No.

Submission of data is a multi-step process. Once you have uploaded data, you are encouraged to evaluate any errors or warnings that were generated and to review your measure rates.  When you are ready, go to the Submit Data page to choose the quarter(s) and eCQMs you will be submitting and click the "Submit" button.

You may purge your hospital's data from the Upload Data page.

Note: The act of purging (deleting) a hospital's data cannot be undone.  Once purged, The Joint Commission can’t restore the data.  Should you accidentally purge your hospital's data, please re-upload all necessary QRDA I documents.

Yes and No.

Aligned eCQMs: The DDSP accepts the same QRDA I documents that are submitted to CMS and has implemented the same version of the eCQM specifications as CMS.

Joint Commission only eCQMs: These eCQMs utilize the same HL7 Templates for submitting the patient-level data. So, no additional edits or schematron rules were created specifically for these measures.

We do have some additional edits that are designed to ensure the quality of the data being loaded to the Platform. Joint Commission’s edit documentation and Schematron documentation is available here.

• For the most part, these edits will generate Warning messages that are designed to identify issues that may affect measure results and highlight possible future submission corrections.  Files that generate only warning messages may still be submitted.

• There are some edits that The Joint Commission and CMS are in discussion regarding alignment; however, CMS may not have have implemented them for the current calendar year’s data.  In this case, The Joint Commission may have decided to implement earlier than CMS.

• The Joint Commission will reject QRDA I documents that if it does not contain at least one eCQM that The Joint Commission is supporting.

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.  

Joint Commission's documentation concerning errors and warnings is available under “eCQM Warning & Error Messages”.

Joint Commission’s documentation concerning Schematron errors is available under “eCQM XPath & Schematron”.

In addition, the Source Viewer allows you to view both the data and XML contained within a QRDA I document.  See above for more information concerning the Source Viewer.

You can get more information by referring to the QRDA I Implementation Guide (IG) posted on the HL7 site. 

Download the STU R5.1 with errata for eCQM data submission. 

To download the documentation, you will need to have an HL7 Login; however, you do not need to be a member and creating a login is free.

Yes.

To export a list of files that have been uploaded, hover over the Documents section of the screen and right-click.  A menu will appear, that allows you to Export the file list as either an image, PDF, or data.

Yes.  This is okay. The DDSP’s Rule Engine may evaluate to a different measure result for several reasons, including an issue with the QRDA I document format or patient data that generates a warning message.

Examples of why the EHR vendor and the DDSP could evaluate to different measure results:

• EHR vendor and DDSP Rule Engine has interpreted the eCQM logic (i.e., HQMF specification) differently.

• EHR vendor is not using the most up-to-date value sets and/or eCQM logic (as posted by CMS or The Joint Commission)

• The EHR vendor did not include data need by the measure or incorrect data was mapped into the QRDA I document

• QRDA I data does not clearly distinguish between episodes of care

If after researching your QRDA I documents for error/warnings and how they processed through the Rule Engine, you do not believe the differences can be accounted for by one of the above reasons, please submit a Support Ticket and we will assist you.

eED-1a and eED-2a are the "overall" measures which, for these measures, is represented by the eCQM logic from the Initial Population through Measure Observation. 

eED-1b and eED-2b are Stratum 1 - Not Psychiatric/Mental Health Patients 

eED-1c and eED-2c are Stratum 2 - Psychiatric/Mental Health Patients

Hospitals manage their eCQMs being submitted to The Joint Commission from within the DDSP. After the Joint Commission’s annual eCQM deadline, we will review each hospital’s submissions to ensure the appropriate number of eCQMs have been submitted.  The act of submitting automatically updates the eCQMs The Joint Commission expects from the hospital.

Yes.

The DDSP has check-boxes available on the Submit Data page.

• ‘Zero Case’ check-box: attests that the hospital had cases in the initial population of the eCQM, but zero cases in the denominator of the measure.

• ‘Zero Cases in IP’ check-box: attests that the hospital did not have any cases in the population of the eCQM, but has certified EHR software that could generate the QRDA I files if cases existed.

To assist hospitals in their usage of the screen, we implemented Warning messages to alert users that may be accidentally submitting fewer measures than they intended. ​ 

Please (1) confirm you have selected the correct quarter and appropriate eCQMs, (2) click 'Submit' at the bottom of the screen, and (3) click 'Submit' on the Warning message to confirm you are submitting the appropriate CQMs.  This will update the Joint Commission's list of expected measures for your hospital.