Pioneers in Quality™ - Joint Commission...Chief Quality Officer Contact − Primary Accreditation Contact −Via the online form, HCOs provide information to assist with onboarding,

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)

2© 2019 The Joint Commission. All Rights Reserved.

− Background of DDS Platform− Onboarding Process

− Existing HCOs− New HCOs

− User Management− Platform Education/Help− Important Resources

Pioneers in Quality™: 2019 eCQM Direct Data Submission for All Hospitals Webinar – April 23, 2019

Webinar Agenda


Background of Direct Data Submission (DDS) Platform


Changing Measure Environment

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.



eCQM Reporting

Hospitals (with an ADC > 10) meet their CY2019 eCQM reporting requirement

by Direct submission through the Joint Commission

Direct Data Submission (DDS) Platform

Note: This platform uses the QRDA-I file format



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.


https://ecqi.healthit.gov/


Data Flow

Verification

Upload Data

Data Accuracy

Quality Improvement

Deidentification

Submit Data

DataData

(Stripped of unwanted PHI)

ANALYTICS

RESULTS

ANALYTICS

DASH-BOARDS



Platform Close Date

− Direct Data Submission Platform is open for submission of CY2019 eCQM data until March 16, 2020, 8 pm CST.

− Upload and Submit data after the organization is onboarded to the Platform.

− Organizations are encouraged to plan ahead and onboard to the platform in order to:

− Address any questions with the upload and submit processes. − Resolve any issue(s) which impacts the ability to upload and

submit eCQM data and requires engagement with your IT staff.− Address any technical issues using the Platform.



QRDA-I File Format

− 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.



Onboarding ProcessExisting HCOs


Existing vs. New HCOs

− Existing HCOs− Have used the Direct Data Submission Platform

for CY2018 eCQM Data Submission

− New HCOs− Will start using the Direct Data Submission for

CY2019 eCQM Data Submission



Existing HCOs – DDS Platform Access

To access the CY2019 DDS Platform− Use the following link:

https://apervita.net/a/jointcommissionddsp

Note: It is the same link as the CY2018 Platform




Existing HCOs – DDS Platform Access

Upon accessing the link and logging in, the first user sees an initialization screen.

Note: This is shown once for each HCO workspace and for the first user accessing the platform.

Then, the user is automatically directed to the DDS Platform Welcome Screen.



Existing HCOs – Legal Documentation

− 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.



Existing HCOs – Access to Previous Year’s Platforms



Onboarding ProcessNew HCOs


Existing vs. New HCOs

− Existing HCOs− Have used the Direct Data Submission Platform

for CY2018 eCQM Data Submission

− New HCOs− Will start using the Direct Data Submission for

CY2019 eCQM Data Submission



New HCOs – Onboarding Process

− In May, organizations will receive an email containing a link to an online form regarding the onboarding process. − Email will be sent to:

− ORYX Contact− Chief Quality Officer Contact− Primary Accreditation Contact

− Via the online form, HCOs provide information to assist with onboarding, including a preferred week to begin onboarding.

− Based on the choice, HCOs are onboarded every week between the months of May 2019 and January 2020.



New HCOs – Browser Information− Access the Direct Data Submission Platform using an

internet browser.− Supported internet browser versions:

Browser Supported Version(s)

Internet Explorer Version 11 (supported on Windows 7, 8.1 and 10)

Microsoft Edge 41.16299.15.0 and above

Google Chrome 61.0.3163.100 (Official Build and above)

Firefox 52.0.2 and above

Safari (on Mac) 10.1.1 (12603.2.4) and above



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

(DDS) Platform support communication is sent: [email protected]


mailto:[email protected]



New HCOs - Email Invitation

Click here to accept the invitation

Note the sender email

address



New HCOs – Email Invitation− Any issues with the invitation email, contact the Joint

Commission at [email protected].− In the email subject line, include:

− DDS Participant− HCO ID#

− Invitations to access DDS platform are sent to designated contact.

− Once designated contact is onboarded, they can invite other users and manage permissions.




New HCOs - Registration



New HCOs – 2 Factor Authentication

⎻ 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.



New HCOs – Legal DocumentationDuring registration, the users review and accept the following legal documents:

Who What FrequencyAny User accessing the platform

Terms of Service (ToS) Once

Designated Contact Business Associate Agreement (BAA) with Apervita

each HCO Workspace

Designated Contact End User License Agreement (EULA) with Joint Commission

each HCO Workspace



DDS Platform – Welcome Page and Main Menu


Note: The screenshots for slides 26 – 31 have been removed.


DDS Platform – Invite and Manage Users




DDS Platform – Upload Data




DDS Platform – Data Accuracy




DDS Platform – Quality Improvement




DDS Platform – Submit Data




Invitation Link vs. Platform Link− The invitation link expires within 15 days.

− Note: The invitation email comes from [email protected]

− Once the invitation link is used to register on the DDS Platform, the link cannot be used to access the platform.

− Users must use the platform link to access DDS Platform: https://apervita.net/a/jointcommissionddsp

− Bookmark this link in browser for easy access.





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



User Management


User Permissions− There are 2 key permissions on the Platform

− Invite and Manage Users− Allows for inviting other users to the platform− Allows for managing users’ permissions

− Upload and Submit Data− Allows for uploading data to the platform− Allows for submitting data to the Joint Commission

− In addition, there is a “view only” access, which means that the user does not have either permission listed above.

− By default, the “DDS Designated contact” has both permissions.

− Users on the Direct Data Submission Platform can have access to multiple HCO workspaces.



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.



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.



Platform Education/Help


Platform Education – Coming Soon− Webinar 1: Comprehensive demo of the Joint Commission DDS Platform

− Webinar 2: April 23, 2019 PIQ Webinar: CY 2019 DDS Platform

− In addition, short videos for main pages of the platform (3-5 minutes each)

− Invite and Manage Users− Upload Data− Upload Summary− Data Accuracy− Quality Improvement− Submit Data− Source Viewer− Logic Explorer− Multi-HCO View



Onboarding/Login Issues

− For help related to Onboarding/Login Issues− Contact us at: [email protected]− In the email, include:

• DDS Participant• Your HCO ID




Platform Issues− For help related to anything else on the Platform use the DDS

Platform Service Desk.− The Direct Data Submission Platform has help screens and

links to assist with answering common questions.− HCO users can access this information using the

button available on the top right of every screen on the Platform.

− HCO users can also open a support ticket using the same button to reach the Direct Data Submission Platform

Service Desk.− Joint Commission and Apervita staff respond to inquiries in a

timely manner.



Platform Issues – “Need Help?” on all screens



Platform Issues – “Need Help?” on all screens



Platform Issues – Create a support ticket



Maintenance Message

Message users see when the Platform is undergoing maintenance



Error MessageMessage users see if there is an error on the

Platform



DDS Platform Service DeskQuestion:

− What is the difference between The Joint Commission’s Service Desk and Apervita Service Desk?

Answer:

− The Joint Commission’s Service Desk provides support to HCOs using the Direct Data Submission Platform.

− All tickets must come through The Joint Commission Service Desk

− Apervita provides support to organizations other than The Joint Commission.

− Apervita’s Service Desk is for customers using other Apervita services.− For the purposes of Direct Data Submission Platform, DO NOT use

Apervita’s Service Desk.



The Joint CommissioneCQM Reporting Requirements


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



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



CY2019 eCQM Reporting Requirements

− Minimum of four of thirteen available eCQMs, applicable to the services provided and patient populations served

− Minimum of one self-selected calendar quarter− All hospitals use Direct Data Submission Platform− The platform closes on March 16, 2020 8 PM CST

Joint Commission ORYX eCQM Requirements Hospitals (with an ADC >10)



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.



Important Resources


Recap/Next Steps− Existing HCOs have access to platform now.− New HCOs will receive communication(s) in early May to

confirm their onboarding information and additional material.

− Pre-Recorded Webinars will be available soon.− Office hours occur once a month beginning May 2019

through February 2020.− TJC encourages HCOs to plan ahead and to onboard early.

− Adequate time is needed to ensure a successful upload and submission.



DDS Platform Worksheet – Coming soon− The Joint Commission offers a

worksheet to assist organizations with the CY2019 eCQM data submission.

− The worksheet is a useful tool with key milestones to guide HCOs through the process and allow for timely submission.

− Will be posted on The Joint Commission Website: https://www.jointcommission.org/performance_measurement.aspx


https://www.jointcommission.org/performance_measurement.aspx


Performance Measurement – Joint Commission Website



Pioneers in Quality – Joint Commission Website



Office Hours Schedule

Office Hours Dates

May 14, 2019

June 18, 2019

July 9, 2019

August 13, 2019

September 10, 2019

October 8, 2019

November 12, 2019

December 10, 2019

January 14, 2020

February 11, 2020

− Once a month office hours− Webinar-based format with the

ability to ask questions via the “Questions” function.

− Staffed by The Joint Commission and Apervita team to answer questions from HCOs.

− Content of the office hours includes recently asked questions and tips for successful use of the Platform and data submission.



We look forward to working together to ensure the successful submission of CY2019 eCQM data to The Joint Commission.


Documents

Pioneers in Quality™ - Joint Commission...Chief Quality Officer Contact − Primary Accreditation Contact −Via the online form, HCOs provide information to assist with onboarding,