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.
CY 2022 Inpatient eCQM ID and Specification Versions of eCQMs Being Utilized by The Joint Commission | ||
Measure Short Name | Measure Name | eCQM ID and Version |
eED-2 | (Median) Admit Decision Time to ED Departure Time for Admitted Patients | CMS111v8 |
eOPI-1 (added with 2021) | Safe Use of Opioids | |
ePC-01 (retained) | Elective Delivery | PC01v8 |
ePC-02 (added with 2020) | Cesarean Birth | PC02v1 |
ePC-05 | Exclusive Breast Milk Feeding | CMS9v8 |
ePC-06 (added with 2021) | Unexpected Complications in Term Newborns | |
ePC-07 (added with 2022) | Severe Obstetric Complications | |
eSTK-2 | Discharged on Antithrombotic Therapy | CMS104v8 |
eSTK-3 | Anticoagulation Therapy for Atrial Fibrillation/Flutter | CMS71v9 |
eSTK-5 | Antithrombotic Therapy By End of Hospital Day 2 | CMS72v8 |
eSTK-6 | Discharged on Statin Medication | CMS105v8 |
eVTE-1 | Venous Thromboembolism Prophylaxis | CMS108v8 |
eVTE-2 | Intensive Care Unit Venous Thromboembolism Prophylaxis | CMS190v8 |
CY 2023 Inpatient eCQM ID and Specification Versions of eCQMs Being Utilized by The Joint Commission | ||
Measure Short Name | Measure Name | eCQM ID and Version |
eED-2 | (Median) Admit Decision Time to ED Departure Time for Admitted Patients | CMS111v8 |
eOPI-1 (added with 2021) | Safe Use of Opioids | |
ePC-01 (retained) | Elective Delivery | PC01v8 |
ePC-02 (added with 2020) | Cesarean Birth | PC02v1 |
ePC-05 | Exclusive Breast Milk Feeding | CMS9v8 |
ePC-06 (added with 2021) | Unexpected Complications in Term Newborns | |
ePC-07 (added with 2022) | Severe Obstetric Complications | |
eSTK-2 | Discharged on Antithrombotic Therapy | CMS104v8 |
eSTK-3 | Anticoagulation Therapy for Atrial Fibrillation/Flutter | CMS71v9 |
eSTK-5 | Antithrombotic Therapy By End of Hospital Day 2 | CMS72v8 |
eSTK-6 | Discharged on Statin Medication | CMS105v8 |
eVTE-1 | Venous Thromboembolism Prophylaxis | CMS108v8 |
eVTE-2 | Intensive Care Unit Venous Thromboembolism Prophylaxis | CMS190v8 |
eHH-01 (added with 2023) | Hospital Harm-Severe Hypoglycemia Measure | |
eHH-02 (added with 2023) | Hospital Harm-Severe Hyperglycemia Measure | |
eOP-40 (added with 2023) Outpatient measure | ST-Segment Elevation Myocardial Infarction (STEMI) | |
Note: .
For CY2022 data, outpatient eCQMs will be rejected by the DDSP as at least one inpatient encounter is expected in all QRDA I documents.
Starting with CY2023 data, The Joint Commission will align with CMS on utilizing the outpatient STEMI eCQM.
Reporting Period |
eCQM Annual Update | Data Capture and Submission Standards and Versions | |||
CMS QDM | HL7 eCQM Standards | HL7 Data Submission Standard | CMS QRDA Implementation Guide (IG) * | ||
CY 2024 | Waiting for publication | V5.6 | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 4.1 CQL: R1 v1.5 | QRDA I: R1 STU R5.3 with errata | 2024 QRDA I IG for HQR Waiting for publication |
CY 2023 | Aligned eCQMs: Inpatient EH/CAH: Nov 2022 Outpatient (OQR): Aug 2022 Addendums: any future addendums released by CMS Addendums: any future addendums released by The Joint Commission | V5.6 | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 4.1 CQL: R1 v1.5 | QRDA I: R1 STU R5.3 | 2023 QRDA I IG for HQR (published Jan 2023) |
CY 2022 | Aligned eCQMs: EH/CAH May 2021 Addendums: any future addendums released by CMS Addendums: any future addendums released by The Joint Commission | V5.5 Updated May 2020 | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 4 CQL: R1 STU 4 | QRDA I: R1 STU R5.2 with errata | 2022 QRDA I IG for HQR (published Nov 2021) |
CY 2021 | Aligned eCQMs: EH/CAH May 2020 Addendums: any future addendums released by CMS Addendums: any future addendums released by The Joint Commission | V5.5 | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 4 CQL: R1 STU 4 | QRDA I: R1 STU R5.2 | 2021 QRDA I IG for HQR (published May 2020) |
CY 2020 | Aligned eCQMs: EH/CAH May 2019 Addendums: any future addendums released by CMS Joint Commission only eCQMs: May 2019 Addendums: any future addendums released by The Joint Commission | V5.4 | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 3 CQL: R1 STU 3.1 | QRDA I: R1 STU R5.1 | 2020 QRDA I IG for HQR (published Dec 2019) |
CY 2019 | EH/CAH May 2018 Addendums: -Sept and Nov 2018 code system updates | V5.3 Annotated | HQMF: V3 Normative R1 CQL-based HQMF: V3 R1 STU 2.1 CQL: R1 STU 2 | QRDA-I: R1 STU R5 | 2019 QRDA I IG for HQR |
CY 2018 | EH/CAH May 2017 Addendums: -September 2017 (1Q-4Q 2018) -future addendums released by CMS | V4.3 | HQMF: V3 Normative R1 QDM-based HQMF: R1.4 | QRDA-I: STU R4 | 2018 QRDA I IG for HQR |
CY 2017 | EH/CAH April 2016 Addendums: -January 2017 (1Q-3Q 2017) -September 2017 (4Q 2017 only) | V4.2 | HQMF: R2.1 QDM-based HQMF: R1.3 | QRDA-I: DSTU R3.1 | 2017 QRDA I IG for HQR |
Note: CMS’ QRDA I file format for data submission for their quality programs is different than the format which ONC currently utilizes for EHR Vendor certification purposes. To ensure hospitals can submit the same QRDA I file to both CMS and The Joint Commission, we have aligned with CMS and are utilizing their QRDA I file format.