Hospitals must decide if they are submitting PC (chart-abstracted) or ePC (eCQM) measure data for a given measure prior to the submission deadline. Hospitals may elect to submit all chart-abstracted measures quarterly, all eCQMs for the required number of quarters annually per the reporting requirements, or combination of both. For example, an organization may elect to submit PC-01 and PC-02 as eCQMs, but still submit PC-05 and PC-06 as chart-abstracted measures.  To notify The Joint Commission that a measure will be submit as an eCQM, the HCO will Attest via the Chart-Abstracted Data Submission module.  Each measure must be Attested to individually.

NOTE: If the Attestation is made too early and the hospital discovers they are unable to submit their eCQM data by the annual deadline, they will not have met their ORYX Requirements for the year because the aggregate data was not submitted.  For this reason, The Joint Commission strongly suggests the chart-abstracted data is submitted until the hospital is certain the eCQM data can be successfully submitted.

Hospitals that do not provide obstetrical services have no chart abstracted measure requirements. Additionally:  

• They may elect to submit optional chart abstracted measures if they choose.

• Hospitals that do not provide obstetrical services are not required or expected to submit "substitute" measures.

• Hospitals that do not provide obstetrical services should not enter zeros for PC/ePC measures.

There are currently no specified required eCQMs. Hospitals self-select eCQMs based on their patient population/services offered.

For the PC measures:

• CY2021: 2 quarters of eCQM data = 4 quarters of chart-abstracted measure data

• CY2022: 3 quarters of eCQM data = 4 quarters of chart-abstracted measure data

• CY2023: 4 quarters of eCQM data = 4 quarters of chart-abstracted measure data

• Submission of annual eCQM ePC data exempts the hospitals from submitting any chart-abstracted data for the associated PC measures, e.g. if an HCO submits all required PC measures as eCQMs, no additional eCQMs are required.

No - additional eCQMs are not required if all four required PC measures are submitted as eCQMs, (although they may submit additional eCQMs if they choose).

Large acute care hospitals providing obstetrical services are required to submit PC data and can meet both their eCQM AND PC requirement by submitting ePC-01, ePC-02, ePC-05, ePC-06.

Also note submission of annual eCQM ePC data exempts the hospitals from submitting any chart-abstracted data for the associated PC measures, e.g. if an HCO submits all required PC measures as eCQMs, no chart-abstracted measures are required.

Organizations are strongly encouraged to “attest” to submitting perinatal care eCQMs instead of chart-abstracted perinatal care measures within the chart-abstracted measure module.

TIP: Be certain you are able to submit eCQM PC data before the first chart-abstracted measure deadline.