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Transmission Chapter
Version 2010A1

National Hospital Quality Measure Data Transmission

Introduction

This section of the manual is provided to highlight the unique data transmission specifications for national hospital quality measure data for The Joint Commission compared to the Centers for Medicare & Medicaid Services (CMS) and the QIO Clinical Warehouse.

This section is divided into five parts: Joint Commission National Hospital Quality Measure Data Transmission, CMS National Hospital Quality Measure Data Transmission Guidelines for Submission of Data, Transmission Data Element List, and Transmission Data Processing Flow.

The Joint Commission section provides information related to the transmission of national hospital quality measure data to the Joint Commission’s Data Warehouse.

The CMS transmission section provides the user with the data standards required for submission to the QIO Clinical Warehouse.

The Guidelines for Submission of Data includes an overview of the data required to be submitted to the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse, as well as the Hospital Clinical Data XML file layout and the Hospital Initial Patient Population Data XML file Layout.

The Transmission Data Element List describes the data elements that are either used to identify the hospital and measure set associated to the transmitted data or are calculated by the vendor using the hospital’s patient-level data and measure results. These data elements are not used in the Initial Patient Population Algorithms or Measure Algorithms.

The Transmission Data Processing Flow contains information regarding the order in which both the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse evaluates the national hospital quality measures. In addition, it highlights the processing differences between the two warehouses.

Joint Commission National Hospital Quality Measure Data Transmission

Overview

The Joint Commission requires three different data transmissions related to the national hospital quality measure data. All of these transmissions are submitted by performance measurement systems and follow the same data transmission schedule used to submit ORYX data to The Joint Commission. The most significant items related to the transmission of national hospital quality measure data are listed here, but this is not an exhaustive list. Refer to the appropriate documents as detailed below for more information.

Hospital Initial Patient Population Data

The Joint Commission collects Initial Patient Population and sampling information by Measure Set. This data is required to be submitted to The Joint Commission on a quarterly basis. All Initial Patient Population and sampling data will be submitted in an XML file that adheres to the Hospital Initial Patient Population Data XML File Layout specifications and guidelines provided later in this section. Each file may contain data for only one provider.

Hospital Clinical Data

Hospital clinical data is required to be submitted to The Joint Commission no less than on a quarterly basis. All patient-level data submitted to The Joint Commission must adhere to the Hospital Clinical Data XML File Layout specifications and guidelines provided later in this section. The hospital clinical data submitted to The Joint Commission is anonymous because no hospital identifiers or direct patient identifiers are included in the Hospital Clinical Data XML File.

Each case must have a separate XML file. For example, if 12 records have been abstracted, there must be 12 separate XML files. If more than one measure set has been abstracted for a single patient stay, then a separate XML file must be created for each measure set. Each measure set can only be abstracted once for the same medical record.

The Joint Commission will utilize the same XML file layout, guidelines, and edits as CMS with the following exceptions:

  • Unique Key Identifier: The Joint Commission’s Data Warehouse uses a different key identifier than the QIO Clinical Warehouse due to the Joint Commission’s data being blinded as to whom the hospital and patient are:
    • Performance Measurement System Identifier – not part of the file, captured at the point the file is uploaded to The Joint Commission
    • Vendor Tracking ID – fictitious identifier generated by the measurement system to differentiate between individual patient records across their client hospitals
    • Admission Date
    • Discharge Date
    • Measure Set
  • Transaction Processing: Data can be added, replaced, and deleted during the current reporting quarter using the Action-Code in the XML file. In order to replace or delete an existing file at The Joint Commission, the files must match on the unique key data elements as defined above.
  • Measure Selection: Data that passes all edits and contains all data required to calculate the measures will be accepted as long as at least one hospital has selected the measure set for the reporting quarter with the performance measurement system that is submitting the data.
  • Sample: All EOC records included in the sample, or if the hospital is not sampling the Initial Patient Population, must be transmitted to The Joint Commission. This is true regardless of whether or not any measure for the record calculates to a Measure Category Assignment = “X”.
  • Data Elements Not Accepted by The Joint Commission: The following data elements may be transmitted to CMS, but cannot be transmitted to The Joint Commission because the data transmitted to The Joint Commission is anonymous. Files transmitted to The Joint Commission that contain the following data will be rejected:
    • Provider Identifier (Medicare Provider ID)
    • National Provider Identifier (NPI)
    • Healthcare Organization Identifier
    • Hospital Patient Identifier
    • Patient HIC #
    • First Name
    • Last Name
    • Race
    • Hispanic Ethnicity
    • Postal Code
  • Data Elements Required by The Joint Commission That Are Not Required by CMS: In order to support the Joint Commission’s data quality analysis and continuous measure verification process the following data elements are required to be transmitted for each measure in the measure set.
    • Measure Category Assignment
    • Measurement Value
    • Predicted Value

  • A fictitious identifier is generated by the measurement system to differentiate between individual patient records across their client hospitals because the Joint Commission’s data are blinded as to whom the hospital and patient are. The following data element is used to transmit this fictitious identifier.
    • Vendor Tracking ID

Aggregate Data

Aggregate hospital data is required to be submitted to The Joint Commission no less than on a quarterly basis.

  • Technical Manual: Performance measurement systems will reference the applicable version of the ORYX Technical Implementation Guide for instructions and data element definitions that pertain to the transmission of aggregate data for both ORYX and national hospital quality measure data.
  • Stratified national hospital quality measures: Although a stratified measure will often be referred to as a single measure (such as measure SCIP-Inf-1), the overall rate and the individual strata measures will actually be transmitted to The Joint Commission in the aggregate HCO-level data as a series of measures, using a number of pre-determined transmission ID numbers.
  • Missing and Invalid Data: The following data elements are required for national hospital quality measures and must be included in the health care organization (HCO)-level data transmission file. These will not be used for traditional ORYX data. The data elements include:
    • Number of Cases With An Influenza Vaccination
    • Number of Rejected Cases
    • Number of Cases with UTD Allowable Values
    • ICD Population Size
    • Sample
Refer to the “HCO-Level Data Elements” and “Electronic Data Interchange” sections of the ORYX Technical Implementation Guide for a complete set of definitions, allowable values, and edits related to these data elements.

  • Identifiers used to transmit aggregate national hospital quality measure data: The performance measure identifiers used to transmit aggregate HCO-level data to The Joint Commission are presented in this section. See Tables 1 to Table 6 that follow for the transmission identifiers used to transmit aggregate HCO-level national hospital quality measure data to The Joint Commission.
  • ORYX data re-transmission: The Joint Commission acknowledges that it is appropriate to allow ORYX data to be updated. We are interested in assuring the best possible data quality, especially in light of public reporting. Toward that end, we routinely accept retransmission of up to seven quarters of aggregate national hospital quality (core) measures, as well as aggregate non-core measure data with each regularly scheduled transmission deadline, for the purposes of updating data for the ORYX Performance Measure Reports, national comparison group data, and the health care organization Quality Report postings. These retransmitted data may be inclusive of updated data previously submitted and/or data that may have been erroneously omitted.

Measurement systems are required to correct their recognized data integrity issues and retransmit up to seven quarters of updated aggregate national hospital quality (core) measures and aggregate non-core measure data (due to the rolling quarters of the ORYX Performance Measure Reports that display up to 24 months of data) by the next regularly scheduled quarterly transmission deadline. Retransmission of corrected aggregate data from issues emanating at the client health care organization-level is encouraged whenever feasible. It is the responsibility of the measurement system to notify their clients that updated data were retransmitted to The Joint Commission, and that the subsequent Quality Report posting and future ORYX Performance Measure Reports will reflect these data. It is important to note, these retransmitted data will refresh the following quarter’s ORYX Performance Measure Reports and Quality Report (core only), and update the national comparison group rates (core only).

Refer to the ORYX Performance Measurement System Agreement, ORYX Data Retransmission Process, for further details and associated fees that apply. Measurement system inquires related to the retransmission of ORYX data should be directed to oryxdq@jointcommission.org.

Information The Joint Commission Provides To Core Performance Measurement Systems

Risk Adjustment: The Joint Commission will provide core measurement systems with risk adjustment model information for the national hospital quality measures (AMI-9, PR-1, PR-2, and PR-3) that require risk adjustment. Measurement systems must apply the risk model information to their patient-level data and generate aggregate risk adjustment data for submission to The Joint Commission as a part of HCO-level data elements. Additional specifics include:

  • Measurement systems will have access to current national hospital quality measure risk model information files through the Performance Measurement System Extranet Track (PET).
  • Details related to the risk model information file, its usage by measurement systems, and a list of significant risk factors are provided in the ORYX Risk Adjustment Guide. This guide is available to the public on the Joint Commission’s website and, in addition, it is available to performance measurement systems via the Joint Commission’s extranet site for measurement systems (PET).
  • National hospital quality measure risk models must not be used for any purposes other than calculating risk-adjusted data elements.
  • For assistance with the national hospital quality measure risk model information, please contact the ORYX statistical support e-mail box at oryxstat@jointcommission.org.

National Comparison Group: The Joint Commission will provide core measurement systems participating in the ORYX national hospital quality measure initiative with national comparison group data. Measurement systems may use this information to prepare feedback reports for client organizations. Additional details in regard to this process include:

  • Measurement systems will have access to national comparison group data through the Performance Measurement System Extranet Track (PET).
  • Refer to the ORYX Data Quality Manual for the list of national comparison group data elements and related information.
  • National ORYX comparison group data must not be used for any purposes other than creating national hospital quality measure feedback reports for client organizations.
  • For assistance with the national hospital quality measure national comparison group, please contact the ORYX statistical support e-mail box at oryxstat@jointcommission.org.

Table 1 – Acute Myocardial Infarction Measures

Set Measure ID Transmission ID Start Date End Date Measure Short Name
AMI-1 14229 1 Jul 2002 ongoing Aspirin at Arrival
AMI-2 14230 01 Jul 2002 Ongoing Aspirin Prescribed at Discharge
AMI-3 14231 01 Jul 2002 Ongoing ACEI or ARB for LVSD
AMI-4 14228 01 Jul 2002 Ongoing Adult Smoking Cessation Advice/Counseling
AMI-5 14232 01 Jul 2002 Ongoing Beta-Blocker Prescribed at Discharge
AMI-6 14234 01 Jul 2002 Ongoing Beta-Blocker at Arrival
AMI-7 14226 01 Jul 2002 Ongoing Median Time to Fibrinolysis
AMI-7a 14236 01 Jul 2004 Ongoing Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival
AMI-8 14227 01 Jul 2002 Ongoing Median Time to Primary PCI
AMI-8a 14235 01 Jul 2004 Ongoing Primary PCI Received Within 90 Minutes of Hospital Arrival
AMI-9 14233 01 Jul 2002 Ongoing Inpatient Mortality
AMI-T1a       LDL Cholesterol Assessment (Optional Test Measure)
AMI-T2       Lipid-Lowering Therapy at Discharge (Optional Test Measure)

Table 2 – Heart Failure Measures

Set Measure ID Transmission ID Start DateSorted ascending End Date Measure Short Name
HF-1 14335 01 Jul 2002 Ongoing Discharge Instructions
HF-2 14336 01 Jul 2002 Ongoing Evaluation of LVS Function
HF-3 14339 01 Jul 2002 Ongoing ACEI or ARB for LVSD
HF-4 14337 01 Jul 2002 Ongoing Adult Smoking Cessation Advice/Counseling

Table 3 – Pneumonia Measures

Set Measure ID Transmission ID Start Date End Date Measure Short Name
PN-2 14442 01 Jul 2002 Ongoing Pneumococcal Vaccination
PN-7 14451 01 Jul 2004 Ongoing Influenza Vaccination
PN-3a 14452 01 Jul 2005 Ongoing Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival
PN-3b 14453 01 Jan 2006 Ongoing Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital
PN-4 14445 01 Jul 2002 Ongoing Adult Smoking Cessation Advice/Counseling
PN-5 14444 01 Jul 2002 Ongoing Antibiotic Timing (Median)
PN-5a       Initial Antibiotic Received Within 8 Hours of Hospital Arrival - RETIRED
PN-6b 14450 01 Jul 2004 Ongoing Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Non ICU Patients
PN-5b 14448 01 Jul 2004 Ongoing Initial Antibiotic Received Within 4 Hours of Hospital Arrival
PN-5c 14454 01 Apr 2007 Ongoing Initial Antibiotic Received Within 6 Hours of Hospital Arrival (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)
PN-6       Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients
PN-6a 14449 01 Jul 2004 Ongoing Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients – Intensive Care Unit (ICU) Patients

Table 4 – Pregnancy and Related Conditions Measures

Set Measure ID Transmission ID Start Date End Date Measure Short Name
PR-1 14547 01 Jul 2002 Ongoing VBAC
PR-2 14548 01 Jul 2002 Ongoing Inpatient Neonatal Mortality
PR-3 14555 01 Jul 2002 Ongoing Third or Fourth Degree Laceration

Table 5 – Surgical Care Improvement Project Measures

Set Measure ID Transmission ID Start Date End Date Measure Short Name
SCIP-Inf-1a 14657 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Overall Rate
SCIP-Inf-1b 14658 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - CABG
SCIP-Inf-1c 14659 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Other Cardiac Surgery
SCIP-Inf-1d 14660 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hip Arthroplasty
SCIP-Inf-1e 14661 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Knee Arthroplasty
SCIP-Inf-1f 14662 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Colon Surgery
SCIP-Inf-1g 14663 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Hysterectomy
SCIP-Inf-1h 14664 01 Jul 2004 Ongoing Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision - Vascular Surgery
SCIP-Inf-2a 14666 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Overall Rate
SCIP-Inf-2b 14667 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - CABG
SCIP-Inf-2c 14668 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Other Cardiac Surgery
SCIP-Inf-2d 14669 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Hip Arthroplasty
SCIP-Inf-2e 14670 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Knee Arthroplasty
SCIP-Inf-2f 14671 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Colon Surgery
SCIP-Inf-2g 14672 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Hysterectomy
SCIP-Inf-2h 14673 01 Jul 2004 Ongoing Prophylactic Antibiotic Selection for Surgical Patients - Vascular Surgery
SCIP-Inf-3a 14675 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Overall Rate
SCIP-Inf-3b 14676 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time – CABG
SCIP-Inf-3c 14677 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 48 Hours After Surgery End Time - Other Cardiac Surgery
SCIP-Inf-3d 14678 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Hip Arthroplasty
SCIP-Inf-3e 14679 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Knee Arthroplasty
SCIP-Inf-3f 14680 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Colon Surgery
SCIP-Inf-3g 14681 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time – Hysterectomy
SCIP-Inf-3h 14682 01 Jul 2004 Ongoing Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time - Vascular Surgery
SCIP-Inf-4 14684 01 Jul 2006 Ongoing Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose
SCIP-Inf-6 14685 01 Jul 2006 Ongoing Surgery Patients with Appropriate Hair Removal
SCIP-Inf-7 14686 01 Jul 2006 Ongoing Colorectal Surgery Patients with Immediate Postoperative Normothermia
SCIP-Card-2 14688 01 Oct 2006 Ongoing Surgery Patients on Beta-Blocker Therapy Prior to Admission Who Received a Beta-Blocker During the Perioperative Period
SCIP-venous-thromboembolism-1 14690 01 Oct 2006 Ongoing Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
SCIP-venous-thromboembolism-2 14691 01 Oct 2006 Ongoing Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery
SCIP-Inf-1       Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision
SCIP-Inf-2       Prophylactic Antibiotic Selection for Surgical Patients
SCIP-Inf-3       Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

Table 6 – Children’s Asthma Care Measures

Set Measure ID Transmission ID Start Date End Date Measure Short Name
CAC-1a 14900 01 Apr 2007 Ongoing Relievers for Inpatient Asthma (age 2 through 17 years) – Overall Rate
CAC-1b 14901 01 Apr 2007 Ongoing Relievers for Inpatient Asthma (age 2 through 4 years)
CAC-1c 14902 01 Apr 2007 Ongoing Relievers for Inpatient Asthma (age 5 through 12 years)
CAC-1d 14903 01 Apr 2007 Ongoing Relievers for Inpatient Asthma (age 13 through 17 years)
CAC-2a 14905 01 Apr 2007 Ongoing Systemic Corticosteroids for Inpatient Asthma (age 2 through 17 years) – Overall Rate
CAC-2b 14906 01 Apr 2007 Ongoing Systemic Corticosteroids for Inpatient Asthma (age 2 through 4 years)
CAC-2c 14907 01 Apr 2007 Ongoing Systemic Corticosteroids for Inpatient Asthma (age 5 through 12 years)
CAC-2d 14908 01 Apr 2007 Ongoing Systemic Corticosteroids for Inpatient Asthma (age 13 through 17 years)
CAC-3 14910 01 Apr 2007 Ongoing Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver
CAC-2       Systemic Corticosteroids for Inpatient Asthma
CAC-1       Relievers for Inpatient Asthma

CMS National Hospital Quality Measure Data Transmission

Overview

Data collected for Centers for Medicare & Medicaid Services (CMS) is transmitted to the QIO Clinical Warehouse, CMS’s central repository for clinical data. All data submitted is required to meet transmission requirements. The file layout requirements are included in the sections that follow.

Hospitals currently submit patient-level clinical data to the QIO Clinical Warehouse, and hospitals submit the Medicare and non-Medicare Initial Patient Population Size (by measure set or stratum for SCIP) and designation of sampling for the Medicare and non-Medicare sample size. Please refer to the Hospital Clinical Data XML File Layout and/or the Hospital Initial Patient Population Data XML File Layout for specific national hospital quality measure data transmission requirements. Additionally, please refer to the QualityNet website for the current annual Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) submission requirements for patient-level clinical data and Initial Patient Population data.

Submission of Hospital Clinical Data

Hospital Clinical Data is submitted to the QIO Clinical Warehouse on a quarterly submission schedule. All clinical data submitted to the QIO Clinical Warehouse must adhere to the Hospital Clinical Data XML File Layout specifications provided later in the transmission section. Each case must have a separate XML file. For example, if you have 12 records that you have abstracted, you must have 12 separate XML files. If you have abstracted more than one Measure Set for a patient stay, then a separate XML file must be created for each Measure Set. Each Measure Set can only be abstracted once for the same medical record.

Submission of Hospital Initial Patient Population Data

CMS collects Initial Patient Population Size and declaration of sampling, by Measure Set on a quarterly basis. For hospitals submitting the Hospital Initial Patient Population Data, information may be submitted via an XML file to the QIO Clinical Warehouse. All Initial Patient Population data submitted to the QIO Clinical Warehouse must adhere to the Hospital Initial Patient Population Data XML File Layout specifications provided later in the transmission section. Each file may contain data for only one provider.

Additional guidelines related to the submission of Hospital Clinical Data and Hospital Initial Patient Population Data are outlined below.

CMS and Joint Commission Guidelines for Submission of Data

Overview

The below guidelines are for the submission of Hospital Clinical Data and Hospital Initial Patient Population Data to both CMS and The Joint Commission. Additionally, for the current QIO Clinical Warehouse Edits Documents (Error Messages and Measure Messages) please refer to the QualityNet website. For the Joint Commission’s Hospital Clinical Data Edit and Algorithm Error Messages, please refer to the Joint Commission’s extranet for measurement systems (PET).

CMS and Joint Commission Guidelines for Submission of Hospital Clinical Data


Minimum Data Requirements Note: Prior to processing measure outcomes all data will be verified according to the rules in the data transmission section and the edits documents. Case submitted to the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse that do not meet the requirements outlined in these documents will be rejected.
Allowable Measure Set Combination per Patient Episode of Care Submission of multiple files for different measure sets for a single episode of care are allowable for the following Measure Set combinations:
  1. QIO Clinical Warehouse and Joint Commission’s Data Warehouse
    1. HF and SCIP
    2. AMI and SCIP
    3. PN and SCIP
  2. Joint Commission’s Data Warehouse only
    1. PR and SCIP for mothers age 18 and older
    2. PR and HF for mothers age 18 and older
    3. PR and AMI for mothers age 18 and older
    4. PR and PN for mothers age 18 and older
    5. PR and CAC for mothers age 18 and older
Submission of multiple files for the same episode of care will not be accepted into either the QIO Clinical Warehouse or Joint Commission’s Data Warehouse for the following Measure Set combinations:
  1. HF and PN
  2. HF and AMI
  3. AMI and PN
Submission of multiple files for the same episode of care will not be accepted into the Joint Commission’s Data Warehouse for the following Measure Set combinations:
  1. CAC and AMI
  2. CAC and HF
  3. CAC and PN
  4. CAC and SCIP
Requirements for XML Tags and Associated Data Do not put spaces between XML tags and associated data. Cases with inappropriate spaces will be rejected from both the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse.
Export File Character Limitations Cases exported for submission to the QIO Clinical Warehouse may not have greater than 50 characters in the file name. Performance measurement systems should refer to the ORYX Technical Implementation Guide for guidelines related to file naming for submission of data to the Joint Commission’s Data Warehouse.
Missing Data Policy All cases submitted to the QIO Clinical Warehouse and Joint Commission’s Data Warehouse must have all data required to calculate the measures. Files submitted which are missing data required to calculate measures (any case that would result in a Measure Category “X” assignment) will be rejected from both warehouses. These cases should be reviewed by the provider and resubmitted with an allowable value indicated for any data element that was missing. Please refer to the Missing and Invalid Data Section for additional information.

In addition, all cases submitted with data related to antibiotic administration, VTE Prophylaxis and Procedures are required to be complete when submitted to the QIO Clinical Warehouse or the Joint Commission’s Data Warehouse. If the abstractor, after due diligence, is not able to determine an answer, a value of “UTD” must be selected for the applicable data element. This includes:
  • Cases related to the patient’s receipt of antibiotics. Antibiotic Administration Name, Antibiotic Administration Date, Antibiotic Administration Time and Antibiotic Administration Route must be complete for each dose of antibiotics submitted. A dose is considered any row of antibiotics that contain all allowable answer values for the above listed data elements. If a case is submitted to the QIO Clinical Warehouse or the Joint Commission’s Data Warehouse with missing data for any dose of antibiotics, the case will be rejected.
  • For the data element VTE Prophylaxis, allowable values 1-7 are required to include a corresponding answer to the data element VTE Timely. Please see the data element definitions for further details on allowable values. If the VTE Prophylaxis field is populated with an allowable value of 1-7 and the corresponding VTE Timely field is missing, the entire case will be rejected. If the VTE Prophylaxis field is populated with an allowable value of A, then the VTE Timely element is not required to be submitted.
  • ICD-9-CM Principal Procedure Code and ICD-9-CM Other Procedure Codes require the data element ICD-9-CM Principal Procedure Date and ICD-9-CM Other Procedure Dates to be submitted with the case. Please see the data element definitions for further details on allowable values. If the case is missing the corresponding allowable answer value, the case will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse
Data Elements Not Accepted by The Joint Commission The following data elements are transmitted to CMS, but cannot be transmitted to The Joint Commission. Files transmitted to The Joint Commission that contain the following data will be rejected:
  • Provider Identifier (Medicare Provider ID)
  • National Provider Identifier (NPI)
  • Healthcare Organization Identifier
  • Hospital Patient Identifier
  • Patient HIC #
  • First Name
  • Last Name
  • Race
  • Hispanic Ethnicity
  • Postal Code
Data Elements Not Accepted by CMS The following data elements must be transmitted to The Joint Commission, but cannot be transmitted to CMS. Files transmitted to CMS that contain the following data will be rejected:
  • Measure Category Assignment
  • Measurement Value
  • Predicted Value
Required Patient Identifiers Based on Payment Source
  1. All cases submitted to the QIO Clinical Warehouse are required to include the “Hospital Patient Identifier”. Please refer to the data dictionary for the definition of this data element.
  2. All cases submitted to the QIO Clinical Warehouse where a Payment Source-Medicare (PMTSRCE) equals “Yes” requires a valid Patient HIC# (PTHIC) for data transmission. (Refer to Definition of Valid Patient HIC below.)
Definition of Valid Patient HIC (PTHIC)

Note: CMS only for transmission of data to the QIO Clinical warehouse.
General Rules:
  • No embedded dashes or spaces or special characters
  • Must have both alpha and numeric characters
  • Alpha characters must be upper case
  • Length cannot be more than 12 or less than 7 characters
  • For alphanumeric values, do not allow all numeric values to be 9’s. For example do not allow 1 alpha + 999999999, etc.

If First Character is Numeric
Suffix rules:
  • If the first character is numeric, (0-9), then the first 9 characters must be numeric. For example:
    • IF HIC # length = 10, THEN Rule = 9 numeric + 1 alpha
    • IF HIC # length = 11, THEN Rule = 9 numeric + 1 alpha + 1 numeric OR 9 numeric + 2 alpha

If First Character is Alpha
Prefix rules:
  • If the first character is alpha, (0-9), there must be 1-3 alpha characters followed by 6 or 9 numbers. For example:
    • IF HIC # length = 7, THEN Rule = 1 alpha + 6 numeric
    • IF HIC # length = 8, THEN Rule = 2 alpha + 6 numeric
    • IF HIC # length = 9, THEN Rule = 3 alpha + 6 numeric
    • IF HIC # length = 10, THEN Rule = 1 alpha + 9 numeric
    • IF HIC # length = 11, THEN Rule = 2 alpha + 9 numeric
    • IF HIC # length = 12, THEN Rule = 3 alpha + 9 numeric
Unique Record Key (What fields make a record unique?) QIO Clinical Warehouse:
Provider ID, Hospital Patient Identifier, Admission Date, Discharge Date and Measure Set

Joint Commission’s Data Warehouse:
Performance Measurement System Identifier, Vendor Tracking ID, Admission Date, Discharge Date, and Measure Set
Principal and Other Diagnosis Codes Effective March 1, 2007,
The National Uniform Billing Committee has implemented a Present on Admission indicator for Principal and Other Diagnosis codes. Data submitted to the QIO Clinical Warehouse and Joint Commission’s Data Warehouse must have the Present on Admission Indicator removed prior to submission. Failure to remove the indicator will result in cases being rejected from both warehouses.

Patient-Level Clinical Data XML File Layout

The XML File Layout is divided into the following five main sections (Please refer to Hospital Clinical Data XML File Layout for details).

Submission
  1. Type – Describes the setting for which the data is being collected (Hospital)
  2. Data – Describes the type of data being submitted (Clinical).
  3. Version – Describes the version of the XML file layout.
  4. Action-Code – Describes the action intended with the submission of the file. Options include:
    1. Add (applicable to a file submitted for the first time for the hospital/time period or to a file being submitted as a replacement of an existing file already submitted for a provider).
    2. Delete (utilize when the file is submitted for the purpose of deleting a file already submitted to the QIO Clinical Warehouse or Joint Commission’s Data Warehouse.)
Note: In order to replace or delete an existing file utilizing the Add or Delete action codes, the files must match on the following fields:
QIO Clinical Warehouse - Provider ID, Hospital Patient Identifier, Admit Date, Discharge Date and Measure Set.
Joint Commission’s Data Warehouse - Performance Measurement System Identifier, Vendor Tracking ID, Admission Date, Discharge Date, and Measure Set.
File Audit Data

Note: This section is not required
  1. Create-Date – Indicates the date the file was created.
  2. Create-Time – Indicates the time the file was created.
  3. Create-By – Indicates who created the file.
  4. Version – Indicates the version of the file being submitted.
  5. Create-by-Tool – Indicates the software tool utilized to create the file.
Abstraction Audit Data

Note: This section is not required
  1. Abstraction-Date – Indicates the date the file was abstracted.
  2. Abstractor-id – Indicates the person who abstracted the file.
  3. Total-Abstraction-Time – Indicates the time required to abstract the file (in seconds)
  4. Comments – Area for entry of any comments regarding the abstraction.
Provider Data elements in this section of the XML file relate to Provider identification. These data elements include:
  1. Provider-ID (Medicare Provider ID - Required)
  2. NPI
  3. HCOID
Patient Data elements in this section of the XML file relate to patient demographic information such as First Name and Last Name, Birthdate, Sex, Race, Hispanic Ethnicity, and Postal Code.
Episode of Care Data in this section of the XML file relate to the acute inpatient stay and clinical data associated with the stay. Examples of associated data elements include:
  1. Admission Date
  2. Discharge Date
  3. Patient HIC #
  4. Vendor Tracking Identifier
  5. Hospital Patient Identifier
  6. Measure Set
  7. Clinical Questions and answer codes
The Joint Commission Data in this section of the XML file support the Joint Commission’s data quality analysis and continuous measure verification process of the performance measurement systems. The following data elements are required to be transmitted to The Joint Commission for each measure in the measure set.
  1. Measure Category Assignment
  2. Measurement Value
  3. Predicted Value

Please refer to the data dictionary for further definition of these data elements.

Abstraction Software Skip Logic and Missing Data

Skip logic allows hospitals and vendors to minimize abstraction burden by using vendor software edit logic to bypass abstraction of data elements not utilized in the measure algorithm. However, these bypassed elements also negatively impact data quality and the hospital’s CMS chart audit validation results when elements are incorrectly abstracted and subsequent data elements are bypassed and left blank.

The use of skip logic by hospitals and ORYX vendors is optional and not required by CMS and The Joint Commission. Hospitals should be aware the potential impact of skip logic on data quality, abstraction burden, and CMS chart audit validation scores. Vendors and hospitals utilizing skip logic should closely monitor the accuracy rate of abstracted data elements, particularly data elements placed higher in the algorithm flow (e.g., Comfort Measures data element).

Historically, CMS chart audit validation results have been used in previous payment years as one of many requirements in the Reporting Hospital Quality for Annual Payment Update (RHQDAPU) program. Please refer to the Federal Register and the QualityNet website for the current payment year’s proposed and final requirements for acute care Inpatient Prospective Payment System (IPPS) hospitals.

Hospital Initial Patient Population Data XML File Layout

The XML File Layout is divided into the following five main sections (Please refer to Hospital Initial Patient Population Data XML File Layout for details).

Submission
  1. Type – Describes the setting for which the data is being collected (Hospital)
  2. Data – Describes the type of data being submitted (Population).
  3. Version – Describes the version of the XML file layout.
  4. Action-Code – Describes the action intended with the submission of the file. Options include:
    1. Add (applicable to a file submitted for the first time for the hospital/time period or to a file being submitted as a replacement of an existing file already submitted for a provider).
    2. Delete (utilize when the file is submitted for the purpose of deleting a file already submitted to the QIO Clinical Warehouse or Joint Commission’s Data Warehouse.)

Note: In order to replace or delete an existing file at the utilizing the Add or Delete action codes, the files must match on:
QIO Clinical Warehouse - Provider ID, Time-Period and Measure-Set
Joint Commission’s Data Warehouse - Health Care Organization ID, Time-Period and Measure-Set
File Audit Data

Note: This section is not required
  1. Create-Date – Indicates the date the file was created.
  2. Create-Time – Indicates the time the file was created.
  3. Create-By – Indicates who created the file.
  4. Version – Indicates the version of the file being submitted.
  5. Create-by-Tool – Indicates the software tool utilized to create the file.
Provider Data Data elements in this section of the XML file relate to Provider identification. These data elements include:
  1. Provider-ID (Medicare Provider ID - Required)
  2. NPI
  3. HCOID
Time Period Time-Period – Dates in this field should reflect the discharge time period related to the data being submitted. Time period start and end dates must reflect full month increments, and may not be greater than one month. Files submitted to the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse are required to contain a three monthly time periods which comprise the calendar quarter for which data is being submitted.

Example: If the Hospital Initial Patient Population File is being submitted for second quarter 2007, the file must contain the following time periods and appropriate associated data (including all data elements is the Population Details section that follows):
April 2007
May 2007
June 2007

Files submitted with time periods that do not meet the above requirements will be rejected from the QIO Clinical Warehouse and the Joint Commission’s Data Warehouse.
Population Details
  1. Measure-Set – Indicates the Measure Set for which the data is being submitted (Valid Ids include HF, AMI, PN, SCIP, PR, and CAC).
  2. Stratum – Indicates the stratum or sub-population related to the data being submitted. (Note: This applies to SCIP, PR, and CAC only).

Additional data elements include Initial Patient Population Size – Medicare, Initial Patient Population Size – Non-Medicare, Sampling Frequency, Sample Size – Medicare, and Sample Size – Non-Medicare. Please refer to the Transmission Data Dictionary for further definition of these data elements. Please refer to Hospital Initial Patient Population Data XML File Layout for further information on details of the XML file format. All data elements are based on discharges that occurred during the associated time period.


Related Topics

Related Topics
d. Missing and Invalid Data Chapter
a. Table of Contents
j1. Transmission Alphabetical Data Dictionary
j. National Hospital Quality Measure Data Transmission
j2. Joint Commission and CMS Data Processing Flow

Transmission Chapter
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)