The Joint Commission’s Perinatal Measures: Choosing Between Abstracted or Electronic

With little fanfare, The Joint Commission for the first time is allowing accredited hospitals to submit their perinatal care measures digitally as electronic clinical quality measures (eCQMs) rather than manually as chart-abstracted measures. For quality leaders, this accreditation policy change can either be a challenge or an opportunity, depending on your situation.

In this blog post, we’ll walk you through some of the short-term challenges and long-term opportunities of submitting your perinatal care measures as eCQMs. We’ll also point you to the resources you’ll need to help you make the right decision for your department, your hospital and, most importantly, your patients.

Perinatal Care Measures 101

First, let’s make sure you know the perinatal measures that we’re talking about. If your hospital delivers more than 300 babies a year, you have to submit chart-abstracted measure data on the following four measures:

• PC-01: Elective delivery
• PC-02: Cesarean section
• PC-05: Exclusive breast milk feeding
• PC-06: Unexpected complications in term newborns

If your hospital delivers fewer than 300 babies a year, you only have to submit PC-01, which means, as a matter of practicality, you could stop reading now. That’s because The Joint Commission’s eCQM option only applies to hospitals submitting all four perinatal measures.

More info: 2021 Joint Commission ORYX Requirements

But back to those of you submitting all four. For you, the electronic versions of the same measures are ePC-01, ePC-02, ePC-05 and ePC-06.

As we said above, if you decide to submit these traditionally chart-abstracted measures as eCQMs, you must submit all four perinatal care measures as eCQMs. You can’t submit some as eCQMs and others as chart-abstracted measures. It’s all or none. You can’t convert them one at a time at your own pace.

Note: Hospitals are still required to submit aggregate chart-abstracted PC-01 data to CMS. 

Complexity of Perinatal Care Measures

Perinatal care measures are complex. There are many required data elements and sometimes, the data is difficult to capture for electronic reporting. Is the data in the mother’s record or is it in the newborn’s record? Is the data in the mother’s record at another hospital where she delivered her first baby? Does the data from different records match up, or do you have to reconcile it?

Perinatal care measures are also complex because the measures have strict requirements around documentation timing. If the date and time of documentation or of a related event do not fall within the inpatient admission or within a certain amount of time prior to or after delivery, for instance, the patients may not qualify for the measure correctly. Preparing for successful implementation of the PC eCQMs requires careful consideration of documentation practices and timing of documentation. You can learn more about the measure specifications in detail here. 

The Nuts and Bolts of Setting up Perinatal eCQMs

It's one thing to submit perinatal care measures as chart-abstracted measures. It’s much more complicated to wire them all together as eCQMs. Not only do you have to link your measures; you must also test and validate your eCQMs prior to submitting them to The Joint Commission. How long that set-up process takes, of course, depends on the resources available at your hospital.

The resources include the quality department, the IT department and all the affected clinical departments. This requires making sure that all the right people are involved in the process, forming a perinatal eCQM team to oversee the conversion, and having the right reporting tool that allows you to track your results on a daily and weekly basis.

We’d say that for most hospitals Medisolv works with, it likely would take six months to a year (or more) to switch all four perinatal measures to eCQMs and have them ready to report to The Joint Commission. As a result, for most hospitals, switching to perinatal eCQMs likely won’t happen until 2022 at the earliest.

Weighing the Decision to Switch to PC eCQMs

There’s a broader question: Is the switch worth it?

From a logistical standpoint, once you go through the pain of setting the four measures up as eCQMs, doing the validation and checking your results on a regular basis, submitting them will be a simpler process. It’s the same for any eCQM.

From a clinical care standpoint, when we implement new eCQMs, it often brings to light errors in clinical documentation that weren’t apparent when the same measures were abstracted from patients’ charts. An example might be discrepancies in gestational age. In one record, it’s documented as 38 weeks, and in another record, it’s documented at 37 weeks.

The accuracy of the information is critical when you’re trying to connect a structure or process with an outcome. One week or one day could mean the difference between a positive or negative outcome. If switching to perinatal eCQMs improves clinical documentation or flags correctable deviations from the standards of care for mothers and their newborns, then the switch likely will improve patient care.

In fact, given all the attention right now on the worrisome maternal mortality rate in the U.S., The Joint Commission is developing a new eCQM for severe obstetrical complications.

Yes, that new eCQM will mean more initial work for you and your quality department, just like the other four perinatal eCQMs. Like all eCQMs, planning for implementation, monitoring and improvement is important—but the work will be worth it.

Related: Learn more about the 2021 Joint Commission ORYX requirements on Medisolv.com.