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Tuesday 4:10 CST, September 26, 2017

Joint Commission FAQ Page

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eCQM- Submit a Question

What is a value set?

Why are eCQM rates different from chart-abstracted measure rates?

Where can I find eCQM specifications?

Are the eCQMs used by The Joint Commission and by CMS for 2016 reporting the same?

What is an eMeasure package and what does it include?

What is an eCQM?

What is HQMF?

How do I report an issue with an eCQM?

How do eCQMs differ from chart-abstracted measures?

What are standard terminologies?


eCQM

Q: What is a value set?
A:

Value sets are lists of values to define clinical concepts (e.g. patients with diabetes, statin medications used for stroke treatment). A value set consists of the numerical values (codes) and human-readable names (terms), drawn from standard vocabularies such as SNOMED CT®, RxNorm, LOINC® or ICD-10-CM.


Value sets are a critical part of eCQM specifications because they are used to define eCQM data elements. Value sets are referenced in eCQMs by their unique identifier, the object identifier (or OID). The Value Set Authority Center (VSAC) houses all value sets used in eCQMs.
 

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Q: Why are eCQM rates different from chart-abstracted measure rates?
A:

Due to the distinct nature of eCQMs and chart-abstracted measures, differences in rates are expected to some extent. There are several reasons why eCQM rates are different from chart-abstracted measure rates:

  • eCQM specifications and chart-abstracted specifications are different: representation of data elements and inclusions and exclusions is constrained by the standards used to represent eCQMs, as well as the information that is captured in a structured and encoded fashion in an EHR system. For example, a chart-abstracted data element may be represented by multiple data elements in the eCQM.

  • eCQM data sources are more limited than data sources used for chart-abstracted measures: eCQMs rely solely on data that is captured in a structured and encoded fashion in the EHR. In addition, eCQMs typically rely on a single structured data field in the EHR for a given data element. Discrepancies in rates often happen when data is not consistently captured in the field selected for data extraction.

  • eCQM specifications and chart-abstracted specifications release schedules and updates are not always aligned: while there are continued efforts to keep eCQMs and chart-abstracted measure specifications as closely aligned as possible, eCQM specifications updates are released on a different schedule than the chart-abstracted measures manual. eCQMs updates are published once a year in early Spring, whereas the chart-abstracted measures manual is released twice a year, in January and July.

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Q: Where can I find eCQM specifications?
A:

Complete eCQM specifications include eCQM packages and value sets, which are published in separate locations:

eCQM Packages

The Centers for Medicare and Medicaid Services provide official releases of eCQM packages used in CMS programs in the eCQM library. The eCQM library includes all eCQMs in a single downloadable zip file (one file for eligible hospitals and one file for eligible providers). CMS also publishes technical release notes and an implementation guidance document along with the eCQM packages for each annual update release.

The eCQI Resource Center provides the same content as the eCQM library, in addition to the ability to navigate the most recent specifications for each individual eCQM.

Value Sets

The Value Set Authority Center (VSAC) is the authoritative source for value sets used in eCQMs. VSAC allows you to search for, navigate and download individual value sets. VSAC also provides a comprehensive download of value set content for eCQMs used in CMS programs, known as the Data Element Catalog. In order to access VSAC content, you will need to obtain a free Unified Medical Language System® Metathesaurus License.

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Q: Are the eCQMs used by The Joint Commission and by CMS for 2016 reporting the same?
A:

The specifications used by The Joint Commission and by CMS are the same. For submission of 2016 discharge data, both The Joint Commission and CMS will only accept data consistent with the June 2015 annual update eCQM specifications posted on the CMS website for the 2016 Reporting Year.

However, there are four (4) key differences between The Joint Commission and CMS programs: 

  • For many organizations, reporting to CMS is required and reporting to The Joint Commission is optional. 

    Organizations participating in the CMS Hospital Inpatient Quality Reporting program for FY 2018 payment determination must report on 4 of 28 available inpatient eCQMs for either Q3 or Q4 of 2016 by 2/28/17. 

    For purposes of the 2016 ORYX flexible reporting options, Joint Commission accredited hospitals have the option to select and report on eCQM sets and/or chart-abstracted measure sets. For hospitals reporting on eCQM sets with multiple measures, they may report on as few as one measure in an eCQM set for either or both Q3 or Q4 of 2016 by 3/5/17. 

  • Organizations can report to CMS without a vendor and must use a vendor to report to The Joint Commission.

    Hospitals submit eCQMs to CMS via the QualityNet Secure Portal, using either a vendor or direct submission. Hospitals submit eCQMs to The Joint Commission via an ORYX Vendor. The Joint Commission is evaluating the technical requirements to support hospitals’ direct submissions.

  • For 2016 reporting, The Joint Commission accepts 23 of the 28 eCQMs used by CMS. The 5 measures The Joint Commission does not support are: 

    • AMI-2

    • AMI-10

    • HTN

    • PN-6

    • SCIP-Inf-2a

  • The Joint Commission refers to the measure abbreviations slightly differently than CMS. 

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Q: What is an eMeasure package and what does it include?
A:

An eMeasure created in the Measure Authoring Tool is exported as a package. Each measure package contains two files and an XML Stylesheet Language for Transformations (XLST) subfolder.  The eMeasure package includes:

  • eMeasure human-readable: A HyperText Markup Language (HTML) file that displays the eMeasure content in a human-readable format directly in a web browser.
  • eMeasure XML: An XML document based on the HQMF standard. IT applications that can “read” the HQMF XML can be used to import the measure and generate measure results automatically.
  • eMeasure style sheet: This allows the eMeasure XML file to be opened directly in a web browser.

For more information on the eMeasure package and how to use it, please refer to the CMS Guide For Reading Eligible Professional (EP) and Eligible Hospital (EH) eMeasures, Version 4.

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Q: What is an eCQM?
A:

An electronic clinical quality measure (eCQM) is a clinical quality measure that is specified in a standard electronic format and is designed to use structured, encoded data present in the electronic health record.

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Q: What is HQMF?
A:

The Health Quality Measure Format (HQMF) is an HL7 standard format for representing a health quality measure as an electronic document. It is an XML document format based on the HL7 Reference Information Model (RIM). The HQMF standard describes how to compute a quality measure. A measure encoded in HQMF is referred to as an “eMeasure” or “eCQM.”

For more information on HQMF, including the standard and implementation guides, please visit the HL7 Product Brief page, Representation for the Health Quality Measure Format (eMeasure) DSTU, Release 2.

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Q: How do I report an issue with an eCQM?
A:

Issues with eCQMs are reported via JIRA. JIRA is the Office of the National Coordinator’s (ONC) tracking system that is a collaboration platform that supports the implementation of health information technology by providing a space in which internal and external users can transparently log, prioritize, and discuss issues with appropriate subject matter experts on a host of topics.  In order to submit an issue, you will select the CQM Issue Tracker project.  Visit the main issue tracking webpage. Navigate to this webpage to create a log in if not already a registered user. This must be done in order to Create Issues.

Click here for the CQM Issue Tracker.

Click Create Issue, ensure you select the correct project which is CQM Issue Tracker:

 


Complete the rest of the fields to the best of your abilities, and submit the issue.
View additional information on how to use Jira to Track eCQM issues.
 

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Q: How do eCQMs differ from chart-abstracted measures?
A:

Chart-abstracted measures require manual chart review by abstraction staff. The data is manually extracted from the medical record and calculated for reporting. For eCQMs, data must be codified and/or captured as structured data and entered in the electronic health record by the clinician. The data is then available for electronic extraction forcalculation and reporting.

At a more granular level, chart abstracted CQMs utilize a human-readable narrative definition for how to collect the data. Chart-abstracted CQMs allows data collection from any documentation in the medical record. Inconsistent provider documentation can be mediated by abstraction staff trained to interpret clinical process of care from patient records. The data does not require codification of data elements to be captured at the point of care.

eCQMs utilize eMeasure specifications and value sets. For CMS programs, EHR certification requirements demand specific data coding in software. Only structured and encoded documentation is acceptable. Data is typically extracted from a single field. When conflicting data exists, typically only one value is accepted. There is no opportunity for mediation.

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Q: What are standard terminologies?
A:

Specific vocabularies or terminologies are used to identify clinical concepts identified by the data elements within an eCQM.  These vocabularies are what are used to build value sets, and are based on ONC Health Information Technology Standards Committee (HITSC) recommendations for standard and transition vocabularies. 

eCQMs include both standard and transition vocabularies to convey the intended clinical intent:

  • Standard- are primarily clinical vocabularies (as opposed to billing) and can serve more needs and for a longer period of time; however are not widely used.

    • LOINC®-  used for laboratory tests or observations; generally the "question"

    • SNOMED CT®- used for observations or procedures; generally the "answer"

    • RxNorm- used for medications

  • Transition- allow for immediate use and least burdensome for eCQM reporting purposes while standard vocabulary use is not yet widespread.

    • ICD-9-CM- coded diagnosis, procedures, encounters

    • ICD-10-CM- coded diagnosis

    • ICD-10-PCS- coded procedures, encounters, interventions

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