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Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data

Specifications
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CMS529v1.html 49.41 KB
CMS529v1.zip 61.85 KB
CMS529v1-TRN.xlsx 25.5 KB

General eCQM Information

CMS Measure ID CMS529v1
NQF Number 2879e
Measure Description

This logic is intended to extract electronic clinical data. This is not an electronic clinical quality measure and this logic will not produce measure results. Instead, it will produce a file containing the data that CMS will link with administrative claims to risk adjust the Hybrid HWR outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results obtained from encounters for adult Medicare Fee-For-Service patients admitted to acute care short stay hospitals.

Initial Population All Medicare Fee-For-Service encounters age 65 and older at the start of an inpatient admission, who are discharged during the measurement period (length of stay <365 days). NOTE: All Medicare Fee-For-Service encounters meeting the above criteria should be included, regardless if Medicare Fee-For-Service is the primary, secondary, or tertiary payer.
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Cohort measure
Improvement Notation

No actual measure score will be generated by hospitals. Instead hospitals will report the data values for each of the core clinical data elements for all encounters in the Initial Population. These core clinical data elements will be linked to administrative claims data and used by CMS to calculate results for the Hybrid HWR measure.

Guidance

These specifications are for use for data with discharges that occur between July 1, 2021 and June 30, 2022. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2023.

This logic guides the user to extract the FIRST resulted HWR-specific core clinical data elements for all Medicare Fee-For-Service encounters for patients age 65 or older (Initial Population) directly admitted to the hospital or admitted to the same facility after being treated in another area such as the emergency department or hospital outpatient location.

The logic supports extraction of the FIRST set of HWR-specific core clinical data elements in two different ways depending on if the patient was a direct admission, meaning that the patient was admitted directly to an inpatient unit without first receiving care in the emergency department or other hospital outpatient locations within the same admitting facility:

1. If the patient was a direct admission, the logic supports extraction of the FIRST resulted vital signs within 2 hours (120 minutes) after the start of the inpatient admission, and the FIRST resulted laboratory tests within 24 hours (1440 minutes) after the start of the inpatient admission.

2. If the patient has values captured prior to admission, for example from the emergency department, pre-operative, or other outpatient area within the hospital, the logic supports extraction of the FIRST resulted vital signs and laboratory tests within 24 hours (1440 minutes) PRIOR to the start of the inpatient admission. All clinical systems used in inpatient and outpatient locations within the hospital facility should be queried when looking for core clinical data element values related to a patient who is subsequently admitted.

Value sets for the laboratory tests represent the LOINC codes currently available for these tests. If the institution is using local codes to capture and store relevant laboratory test data, those sites should map that information to the LOINC code for reporting of the core clinical data elements.

NOTE: Do not report ALL values on an encounter during their entire admission. Only report the FIRST resulted value for EACH core clinical data element collected in the appropriate timeframe, if available.

For each encounter please also submit the following Linking Variables:

CMS Certification Number,

Health Insurance Claim Number (HICN) or Medicare Beneficiary Identifier (MBI),

Date of Birth,

Sex,

Inpatient Admission Date, and

Discharge Date.

This version of the specifications uses Quality Data Model (QDM) version 5.5. Please refer to the Electronic Clinical Quality Improvement (eCQI) Resource Center for more information on the QDM.

Meaningful Measure Admissions and Readmissions to Hospitals
Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Added National Quality Forum (NQF) number: 2879e.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Updated the measurement period.

    Measure Section: Measurement Period

    Source of Change: Measure Lead

  • Updated measure scoring to 'cohort' to better align with measure intent.

    Measure Section: Measure Scoring

    Source of Change: Measure Lead

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated header language to clarify which version of the specifications should be used for the reporting period.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added additional timing clarification to guidance for extraction of first lab results and vital signs to better align with specification logic.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated header language to clarify the intent is to report encounters discharged during the measurement period.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (Jira): CHM-11

  • Updated header language to clarify the measure includes encounters where the patient is 65 years or older at the start of the inpatient admission.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated header language to clarify Medicare can be the primary, secondary, or tertiary payer.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (Jira): CHM-16

  • Updated header language to clarify the result timestamp.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (Jira): CHM-15

  • Updated header language to better reflect measure intent.

    Measure Section: Multiple Sections

    Source of Change: Expert Work Group Review

Logic

  • Updated measure logic from QDM-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource center (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Global Common Library function to 'Hospitalization with Observation Length of Stay' to better align with measure intent to capture lab results and vital signs from Observation stays and Emergency Department visits.

    Measure Section: Measure Population

    Source of Change: Standards Update

  • Updated QDM timing attribute for 'Physical Exam, Performed' to 'relevantDatetime' to better align with measure intent.

    Measure Section: Functions

    Source of Change: Standards Update

  • Updated all functions logic to return a tuple - Encounter ID, lab/vital signs results, and timing of results, to assist with returning the intended data for measure calculation.

    Measure Section: Functions

    Source of Change: Expert Work Group Review

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated QDM datatype from 'Patient Characteristic Payer' to 'Participant' data element; Updated the ‘Participant’ timing logic to not include periods that start and end before the encounter.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated measure library name for brevity.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated Initial Population to be defined by ‘Inpatient Encounters’.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Replaced value set Heart Rate LOINC (2.16.840.1.113762.1.4.1045.149) with direct reference code LOINC code (8867-4) based on interoperability standards.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Oxygen Saturation in Arterial Blood by Pulse Oximetry (2.16.840.1.113762.1.4.1045.151) with direct reference code LOINC code (59408-5) based on interoperability standards.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Respiratory Rate LOINC (2.16.840.1.113762.1.4.1045.130) with direct reference code LOINC code (9279-1) based on interoperability standards.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Systolic Blood Pressure LOINC (2.16.840.1.113762.1.4.1045.163) with direct reference code LOINC code (8480-6) based on interoperability standards.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services to align with updated measure specifications.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Value set 2.16.840.1.113762.1.4.1045.152: Renamed to Body temperature to better align with value set naming conventions.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set 2.16.840.1.113762.1.4.1045.119: Renamed to Sodium lab test to better align with value set naming conventions.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Bicarbonate Lab Test (2.16.840.1.113762.1.4.1045.138) with value set Bicarbonate lab test (2.16.840.1.113762.1.4.1045.139) to better support this updated clinical concept.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Bicarbonate lab test (2.16.840.1.113762.1.4.1045.139): Added 8 LOINC codes (19223-7, 2026-3, 2027-1, 20565-8, 77143-6, 19232-8, 19233-6, 1963-8) based on expert input on common codes for these tests.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set White blood cells count lab test (2.16.840.1.113762.1.4.1045.129): added 1 LOINC code (33256-9) based on feedback on common codes for these tests.

    Measure Section: Terminology

    Source of Change: Expert Work Group Review

  • Value set Glucose lab test (2.16.840.1.113762.1.4.1045.134): Added 16 LOINC codes based on feedback on common codes for these tests.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Medicare payer (2.16.840.1.113762.1.4.1104.10): Deleted 7 SOP codes (11, 111, 112, 113, 119, 19, 523) and added 1 SOP code (14) based on clinical input on codes used for Medicare fee-for-service.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-10

  • Added direct reference code for Birth date (LOINC Code (21112-8)) to align with other eCQMs.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Acute care hospital Inpatient Encounter (2.16.840.1.113883.3.666.5.2289) with value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307) to better harmonize with other eCQMs.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-20

Last Updated: Aug 18, 2020