For Inpatient eCQMs used by both The Joint Commission and The Centers for Medicare & Medicaid Services (CMS)

The Joint Commission aligns with CMS on the eCQM version for each annual reporting period and associated data capture and submission standards.  The standards listed below were used by CMS to create and/or support the implementation of the eCQM specification updates. These versions are currently used for the applicable reporting periods and there may be newer versions or updates available. 

• Hospital and critical access hospital’s eCQM Specifications, Technical Release Notes, and Measure Logic Guidance. Note: Select the Reporting Year and click Apply.  

• The Value Set Authority Center (VSAC) houses all official versions of vocabulary value sets contained in the electronic Clinical Quality Measures (eCQMs) published by CMS. The value sets are downloadable and each value set consists of the numerical values (codes) and human-readable names (terms), drawn from standard vocabularies such as SNOMED CT®, RxNorm, LOINC and ICD-10-CM, which are used to define clinical concepts used in clinical quality measures (e.g., patients with diabetes, clinical visit).

For information on CMS' Hospital Inpatient Quality Reporting (IQR) Program Electronic Clinical Quality (eCQM) requirements, policy, and alignment questions contact the QualityNet Service Center for assistance or (866) 288-8912.

Note:  The QRDA III document is being used by CMS for the submission of provider level aggregate data used in the Merit-based Incentive Payment System (MIPS) programs.

For Inpatient eCQMs used only by The Joint Commission

The Joint Commission continues its commitment to actively developing and testing additional eCQMs. See the Reporting year specifications and additional information regarding eCQMs that have been developed by The Joint Commission or will be maintained by The Joint Commission following removal by CMS. The Joint Commission uses the same data capture and submission standards for these eCQMS as those used by the aligned eCQMs.

Based on HL7 standards, CMS should accept QRDA I documents containing data related to Joint Commission only eCQMs. Therefore, it is still a requirement that a patient’s data for the quarter is submitted in a single QRDA I document. If a patient's data is submitted in multiple QRDA I documents, the last one processed will replace the previous submitted documents within the DDSP.

Certified EHR Technology (CEHRT)

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.

Data Capture and Submission Standards

Visit the CMS/ONC eCQI Resource Center  for more information about the eCQM Annual Update and to access guides to the standards and tools used to support electronic clinical quality improvement. Resources include:

• The Quality Data Model (QDM) information model that defines relationships between patients and clinical concepts in a standardized format to enable electronic quality performance measurement. The model is the current structure for representing quality measure concepts for stakeholders involved in electronic quality measurement development and reporting.

Visit the HL7 website to obtain the version of the HL7 CDA® R2 IG: QRDA I applicable for this year's data. 

• The HL7 website may require a HL7 account in order to download the Implementation Guide (IG).

• The HL7 website header states the current Release number.  Scroll to the bottom of the page to find the Release that is appropriate for this calendar years data.