eCQM CMS50v4 uses the 'fulfulls' construct which is provided in a QRDA1 submission as an sdtc:inFulfillmentOf1 element. If the optional sdtc:inFulfillmentOf1 element is present then the sdtc:id is required (CONF:28386). However, there is no assertion in the ESAC provided Schematron rules for this CONF number so, if the 'id' is not provided the submission will pass validation and be accepted.

Here is the wording of that constraint in the 2016 Base QRDA-1 HL7 IG, Vol2 (i.e. "HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture Category I (QRDA I); Release 1, DSTU Release 3 - US Realm, Draft Standard for Trial Use, Volume 2 - Templates and Supporting Material, June 2015"):

The ID must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text. The ID cannot have Null value (e.g., nullFlavor is not allowed).

c. This sdtc:actReference SHALL contain at least one [1..*] sdtc:id (CONF:1140-28386).

It should also be pointed out that note before the constrain is inadequate.

As explained in the 2016 Base QRDA-1 HL7 IG, Vol 1 (i.e.HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture Category I (QRDA I); Release 1, DSTU Release 3 - US Realm, Draft Standard for Trial Use, Volume 1 - Introductory Material, June 2015), there are only two ways to disallow an @nullFlavor. Either, explicitly require the attributes needed or explicitly disallow the @nullFlavor.

Here is the statement in that IG:

Any SHALL, SHOULD or MAY conformance statement may use nullFlavor, unless the nullFlavor is explicitly disallowed (e.g., through another conformance statement which includes a SHALL conformance for a vocabulary binding to the @code attribute, or through an explicit SHALL NOT allow use of nullFlavor conformance).

Figure 5: Attribute Required (nullFlavor not allowed)

1. SHALL contain exactly one [1..1] code (CONF:15407).
a. This code SHALL contain exactly one [1..1] @code="11450-4" Problem List (CodeSystem: LOINC 2.16.840.1.113883.6.1) (CONF:15408).

or

2. SHALL contain exactly one [1..1] effectiveTime/@value (CONF:5256).

I also want to mention that explicitly disallowing the @nullFlavor is problematic. The best way to disallow the @nullFlavor is almost always by adding an explicit constraints for the required attributes.

CONF:1140-28386 should be reworded this way:

The ID must equal another entry/id in the same document instance. Application Software must be responsible for resolving the identifier back to its original object and then rendering the information in the correct place in the containing section's narrative text.

c. This sdtc:actReference SHALL contain at least one [1..*] sdtc:id (CONF:1140-28386).
1. This sdtc:id SHALL contain exactly one [1..1] @root (CONF:1140-xxxx).
1. This sdtc:id SHALL contain exactly one [1..1] @extension (CONF:1140-xxxx).

Solution: A Schematron assertion needs to be added for CONF:28386.