Short Demo for how to Submit eCQM Data to the DDSP (duration: 6:24 minutes) click the link or copy/paste the following text in your web browser.
https://attendee.gotowebinar.com/recording/3529989106960114946

Purpose: 

The Submit Data page is available via the Submit Data menu item and provides users of The Joint Commission’s Direct Data Submission (DDSP) Platform the ability to:

•       Review the quarter(s) and eCQMs available for submission.

•       Submit the desired quarter(s) and associated eCQM patient-level data to The Joint Commission

•       Attest to having:

1. cases in the initial population, but zero cases in the denominator, or

2. not having any cases in the population of the measure, but having certified EHR software that could generate the QRDA I files if cases existed

3. Note: These two attestations are the equivalent to CMS' attestation for ‘zero denominator cases’. The Joint Commission has separated the two concepts to allow statistical analysis for those eCQMs where there are truly zero cases in the denominator.

• Invoke the ‘threshold exemption’ due to having five or fewer cases in the denominator

• Print the hospital's Submission Certificate

• Withdraw previously submitted data

Hospitals are expected to submit their data prior to the submission deadline to meet their accreditation participation requirements.

Note: If you believe you should be able to submit data for a hospital, contact an individual with Invite and Manage User permission for the hospital, as only they may modify your Workspace permissions. To be able to Upload eCQM data, you need your ‘eCQM Upload & Submit Data’ permission to be ‘Full Access’.

What can be submitted to The Joint Commission?

All eCQMs will appear in the list of measures for a given quarter.

• For eCQMs with at least one case in the Initial patient population, will be reflected on the Submit data page allowing for submission.

1. Rejected QRDA I documents (i.e., received at least one error message), even if ‘active’ (i.e., the last version of a specific document) may not be submitted. If possible, errors must be corrected before submission. 

2. Active QRDA I documents which receive only warnings are ‘accepted’ and may be submitted. However, it is encouraged the warnings are reviewed and addressed prior to submission, as they may point towards potential incorrect eCQM evaluations.

The Upload Data page may show that zip files have been uploaded to the DDSP Platform; however, this page may display the message "Results will appear after data is loaded and processed".

• Confirm that the uploaded zip file did not generate any high-level platform errors by reviewing the ‘Data Details’ on the Upload Data page.

• If no high-level errors were generated by the file, then your zip file is in the queue for processing against the schematron, edits, and eCQM logic.

1. The processing turnaround time is dependent upon how many other zip files (including from other organizations) are waiting in the queue for processing.

2. If you continue to receive this message after 24 hours, please create a DDSP Platform Support Ticket by clicking on the 'Need Help?' link in the upper right-hand corner of the page.

Production vs Trial Data:

The DDSP Platform does not utilize the concept of separate Production and Trial data upload.  Rather, when a hospital uploads their data onto the DDSP 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.

How to Use:

Note: Users with access to multiple Hospitals should always check the Header of the page to ensure they are “active” for the desired hospital.  If the correct hospital is not “active”, click on the “Switch” button in the Header and choose the appropriate hospital.  The 'Switch' button is available from all pages within the DDSP Platform.

Submit Data

• Verify that the expected data is reflected on this page. This includes the quarter(s) of data, the eCQMs, and the expected population. This data should be the same as that reflected on the Quality Improvement page.

• Select a quarter to be submitted by clicking Select Quarter button to ‘On’. The Select Quarter is on the right-hand side of the Header row for the quarter.  For this quarter:

  • Check the Submit? column for each of the eCQMs to be submitted. 

• For each 'checked' eCQM:

1. If the eCQM has zero cases in the denominator, you must attest to the Zero Den. cases by clicking the box in the Zero Den. Cases? column associated to the eCQM.

   1. The ‘Zero Den. Cases?’ checkbox can only be clicked if the eCQM has been 'checked' in the Submit? column (left-side of page). You are unable to submit any data unless this attestation has been made for those selected eCQMs with zero denominator.

2. If desired, the ‘threshold exemption’ (five or fewer cases in the denominator) may be invoked by clicking the box in the ‘Threshold Exemption’ column associated to the eCQM. The aggregate data will be submitted to The Joint Commission; however, the associated patient-level data will not.

3. If it is not possible to submit a sufficient number of eCQMs to meet your hospital’s ORYX requirements, you may attest to having certified EHR software that is capable of generating QRDA I documents should you have had cases.

   1. The ‘Zero IP Cases?’ checkbox can only be clicked if the eCQM has been 'checked' in the Submit? column (left-side of page). You are unable to submit any data unless this attestation has been made for those eCQMs with zero IP, but certified EHR software exists.

• If additional quarters are to be submitted, select the next quarter and repeat the above steps.

• Once all quarters have been selected and the appropriate eCQMs have been 'checked', click on the ‘Submit’ button on the bottom left-hand side of the page.

  • If the hospital has ≥26 Licensed beds OR ≥50,000 Outpatient visits (see ORYX  Requirements for more information):

    • If you are submitting at least four eCQMs, you will be prompted with a confirmation box asking that you verify your submission and click to complete your submission or cancel.

    • If you are submitting less than four eCQMs, you will receive a Warning message asking you to verify that you are submitting all of your data.  Click the "Cancel" button to review your submission details. If you intend to submit fewer than your selected eCQMs, click the "Submit" button.

• If the hospital has <26 Licensed beds AND <50,000 outpatient visits or if the hospital is a Critical Access Hospital (see ORYX  Requirements for more information):

  • If you are submitting at least three eCQMs, you will be prompted with a confirmation box asking that you verify your submission and click to complete your submission or cancel.

  • If you are submitting less than three eCQMs, you will receive a Warning message asking you to verify that you are submitting all of your data.  Click the "Cancel" button to review your submission details. If you intend to submit fewer than your selected eCQMs, click the "Submit" button.

• Once you have confirmed the submission, a message appears on the top of the page stating 'Your CY 2023 eCQM data has been successfully submitted to the Joint Commission’s Direct Data Submission Platform'.  This is your immediate confirmation that submission has occurred.

• To receive a formal confirmation, see below on how to print a Submission Report.

•  The eCQM Submit Data page will reflect the Date/Time of Submission and Who Submitted the data.  This is in addition to Date/Time of when the Results are generated.

DDSP Submit page:

Open

Open

 Withdraw Data

While the submission period is open, hospitals may withdraw data that has been previously submitted.  This may occur if the hospital identifies that incomplete or inaccurate data has been uploaded to the DDSP Platform. 

If you need to withdraw your data, hospitals are expected to utilize this page to resubmit their data prior to the submission deadline to meet their accreditation participation requirements.

1. Click on the ‘Withdraw Submission’ button on the bottom left-hand side of the Submission page.

2. Utilize the Upload Data page to upload and/or purge data to ensure your resubmission will be complete and accurate.

3. Review your data after upload and/or purge has been completed utilizing the Upload Summary, Data Accuracy, and Quality Improvement pages.

4. Return to the Submission page to resubmit your data and follow the instructions above on ‘How to Submit Data’.

Note:  QRDA I documents which have been replaced by being re-uploaded are not available to be submitted.  Only the last version of a given QRDA I document is ‘active’ and, if it did not receive an error, may be submitted.  For example:

• The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is uploaded on 4/1 in a zip file named ‘MJ’.

• The QRDA I document for Mary Jane (named ‘Mary Jane QRDA’) is re-uploaded on 4/2 in a zip file named ‘MJ-2’.

• Only the 4/2 version of the Mary Jane QRDA I document is ‘active’ and, presuming it did not receive an error, is available to be submitted.

Print Submission Report

Once you submitted data you can download the submission report by clicking on the “Download submission report” button on the bottom left-hand side of the Submit Data page.

Definitions for the Submit Data Page: