April 23, 2019 Pioneers in Quality™ 2019 eCQM Direct Data Submission for All Hospitals: Transitioning to the Direct Data Submission Platform 11:00 a.m. – 12:00 p.m. (PT) 12:00 p.m. – 01:00 p.m. (MT) 01:00 p.m. – 02:00 p.m. (CT) 02:00 p.m. – 03:00 p.m. (ET)
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Pioneers in Quality™ - Joint Commission...Chief Quality Officer Contact − Primary Accreditation Contact −Via the online form, HCOs provide information to assist with onboarding,
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April 23, 2019
Pioneers in Quality™
2019 eCQM Direct Data Submission for All Hospitals: Transitioning to the Direct Data Submission Platform
The Joint Commission recognizes that accredited hospitals are at the forefront of a new era in health care quality reporting, in which:− information is collected through electronic health
records for the quality of care that patients receive, and
− data is transmitted to The Joint Commission electronically.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
File Format for DDS Platform− The DDS Platform accepts the same QRDA-I documents that are submitted to
CMS. The Joint Commission implements the same version of the QRDA-I specifications as CMS.
− For more information concerning the submission standards being used to generate the QRDA-I documents, please visit CMS/ONC’s eCQI Resource Center at https://ecqi.healthit.gov/. − Choose the “eCQMs – Electronic Clinical Quality Measures” option from the top of the page− Select “Eligible Hospital / Critical Access Hospital eCQMs” link.− On the web page, make sure that the reporting period is set to “2019” and click “Apply”
− Direct Data Submission Process ensures all the required security, including HIPAA requirements around the receipt and storage of Protected Health Information (PHI) is in place.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
− Question: When uploading zip file containing QRDA-I documents, do I upload the exact zip file used when I uploaded to CMS? Is there scrubbing of PHI prior to upload?
− Answer:− Yes, the same zip files containing QRDA-I documents and
submitted to CMS are uploaded to the platform.− The DDS Platform scrubs the PHI before the data is
submitted to The Joint Commission.
Note: The zip file must not contain any folders and must not be encrypted.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
− The Business Associate Agreement (BAA), Terms of Service (ToS), and End User License Agreement (EULA) remain in effect with no changes. Returning users do not need to sign legal documents.
− New users are invited by the existing Designated Contact, and the "Invite and Manage Users" process remains the same in the CY 2019 Platform.− New users sign the ToS during the registration process.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
New HCOs – Email Filtering− If HCOs use email filtering, following domains and email
addresses must be “whitelisted” to ensure all DDS Platform communications are received.
− The Apervita Domain: @apervita.com− The Apervita email address: [email protected]− The Joint Commission Domain: @jointcommission.org− The email address from which Direct Data Submission
⎻ 2 Factor Authentication is an extra layer of security requiring not only a password and username but also something, the user has on them (i.e. a piece of information only they know or have immediately at hand).
⎻ The piece of information is a code sent to user’s cell phone.
⎻ Once the code is received via text, it is entered into the appropriate field on the registration form.
⎻ Registration can then proceed with the completion of key fields.
Note: Upon the first login to the platform, and periodically (every 90 days), the user is prompted to enter a new security code received via text as part of continued two factor authentication process.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
Upload vs Submit Data− Question: What is the difference between “uploading data to the DDS Platform”
vs. “submitting data to The Joint Commission”
− Answer:
− Uploading is the process of bringing your QRDA I documents onto the DDS Platform. Once uploaded you can:− view the Data Accuracy page to evaluate errors and warnings− view the Quality Improvement page to evaluate measure rates
− Submission is the final process following the uploading and evaluation of your QRDA I documents and is required to complete your CY2019 eCQM data submission to The Joint Commission. Once submitted:− print your “proof of submission” from your home page
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
User Management− The users granted permission by a HCO to access the Direct Data
Submission Platform can include anyone needed to assist in a successful submission of data for the HCO, such as other HCO staff, a consultant or EHR/HIE vendor.
− The HCO: − is responsible for authorizing and managing the users, protecting and
managing the content (including, but not limited to data and analytics) and the use of web services; HCOs must exercise caution and only invite and provide appropriate permissions for users needed to assist in successful submission of data.
− is responsible for user’s compliance with the Terms of Service− should review the list of “current users” frequently to ensure only those
who are authorized access the content and have the appropriate privileges.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
Other Users on the Platform− Question: May a hospital invite an external user (e.g., vendor or
consultant) to assist them on the DDS Platform?
− Answer: Hospital staff using the Joint Commission’s DDS Platform can grant external user permissions to assist with functionality such as uploading QRDA I documents or the data verification process (e.g., correct QRDA I generation based on error/warnings, review measure results and rates to assist with data mapping issues).
− Hospital staff using the Joint Commission’s DDS Platform are responsible for the data submission process and the relationships with users on the DDS Platform.
− If a vendor/consultant has a question, they must submit a ticket via the platform.
Note: The Joint Commission no longer has any contracts with ORYX eCQM vendors.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
Background – Alignment with CMSCMS maintained its CY 2018 eCQM reporting requirements and currently available eCQMs for CY 2019.− Hospitals are required to report on four of 15 available
eCQMs for one self-selected calendar quarter. − CMS has two additional eCQMs available: eSTK-8 Stroke
Education and eSTK-10 Assessed for Rehabilitation. − These measures were previously retired by The Joint
Commission effective 1/1/2017
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
eCQMs Available for The Joint Commission CY2019 Reporting
− eAMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival − eCAC-3 Home Management Plan of Care Document Given to Patient/Caregiver − eED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients − eED-2 Admit Decision Time to ED Departure Time for Admitted Patients − eEHDI-1a Hearing Screening Prior to Hospital Discharge − ePC-01 Elective Delivery − ePC-05 Exclusive Breast Milk Feeding − eSTK-2 Discharged on Antithrombotic Therapy − eSTK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter − eSTK-5 Antithrombotic Therapy by End of Hospital Day Two − eSTK-6 Discharged on Statin Medication − eVTE-1 Venous Thromboembolism Prophylaxis − eVTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019
Changing ORYX Measure Selections− Question: How can I change my measure selections using the Direct Data Submission Platform?
− Answer:
− As the data submitter, you directly manage the eCQMs being submitted to The Joint Commission.
− To update The Joint Commission’s list of expected measures for the hospital: Use the checkbox for the eCQMs for the appropriate quarter on the “Submit Data” Screen and complete the submission steps.
− After the Joint Commission’s CY2019 eCQM deadline (3/16/2020), we review each hospital’s data to ensure the appropriate number of eCQMs are submitted.
− To assist hospitals for data submission, there is a Warning message to alert users when fewer measures or different measures than intended are submitted.
Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019