| Measure Information | 2021 Reporting Period |
|---|---|
| CMS eCQM ID | CMS111v9 |
| Short Name | ED-2 |
| NQF Number | Not Applicable |
| Description |
Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status |
| Initial Population |
Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED |
| Steward | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Continuous Variable measure |
| Measure Type | Process measure |
| Improvement Notation |
Improvement noted as a decrease in the median value |
| Guidance |
This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit. Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following: 1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or 2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient" The decision to admit inpatient must be performed during the ED visit that is within 1 hour of the inpatient admission and prior to the patient departing the ED. The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED. This eCQM is an episode-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
| Next Version | |
| Previous Version | No Version Available |
Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| Measure Information | 2021 Reporting Period | 2022 Reporting Period | 2023 Reporting Period |
|---|---|---|---|
| Title | Median Admit Decision Time to ED Departure Time for Admitted Patients | Median Admit Decision Time to ED Departure Time for Admitted Patients | Median Admit Decision Time to ED Departure Time for Admitted Patients |
| CMS eCQM ID | CMS111v9 | CMS111v10 | CMS111v11 |
| Short Name | ED-2 | ED-2 | ED-2 |
| NQF Number | Not Applicable | Not Applicable | Not Applicable |
| Description |
Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status |
Median time (in minutes) from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status |
Median time (in minutes) from admit decision time to time of departure from the emergency department (ED) for emergency department patients admitted to inpatient status |
| Initial Population |
Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED |
Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED |
Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) | Centers for Medicare & Medicaid Services (CMS) |
| Measure Scoring | Continuous Variable measure | Continuous Variable measure | Continuous Variable measure |
| Measure Type | Process measure | Process measure | Process measure |
| Improvement Notation |
Improvement noted as a decrease in the median value |
Improvement noted as a decrease in the median value |
Improvement noted as a decrease in the median value |
| Guidance |
This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit. Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following: 1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or 2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient" The decision to admit inpatient must be performed during the ED visit that is within 1 hour of the inpatient admission and prior to the patient departing the ED. The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED. This eCQM is an episode-based measure. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit. Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following: 1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or 2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient" The decision to admit inpatient must be performed during the ED visit that is within 1 hour of the inpatient admission and prior to the patient departing the ED. The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED. Patients with behavioral health emergencies are stratified because often these situations are confounded by policies and practices in the community that are beyond the control of any individual hospital and present the hospital with quality and safety circumstances different from those of the acute medical patients (Joint Commission, 2012). Recent peer-reviewed studies also demonstrate the need for dedicated emergency mental health services, supplying evidence that the clinical needs for these patients substantively differ from the non-psychiatric population (American College of Emergency Physicians (ACEP), 2017; Lester, 2018). This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM. |
This measure specification delineates how to calculate the duration from the Decision to Admit to the departure from an Emergency Department (ED) visit. Decision to Admit: Documentation of the decision to admit the patient from the ED that is closest to the inpatient admission and since admission processes vary at different hospitals this can use either of the following: 1. An Order- A) admission order (this may be an operational order rather than the hospital admission to inpatient status order), B) disposition order (must explicitly state to admit), C) documented bed request, or D) documented acceptance from admitting physician. This is not the "bed assignment time" or "report called time". Or 2. An Assessment- an ED evaluation that results in a decision to "Admit Inpatient" The decision to admit inpatient must be performed during the ED visit that is within one hour of the inpatient admission and prior to the patient departing the ED. The specification provides elements from the clinical electronic record required to calculate the median time, i.e., the duration from the decision to admit to the time the patient physically departed the ED. Patients with behavioral health emergencies are stratified because often these situations are confounded by policies and practices in the community that are beyond the control of any individual hospital and present the hospital with quality and safety circumstances different from those of the acute medical patients (Joint Commission, 2012). Recent peer-reviewed studies also demonstrate the need for dedicated emergency mental health services, supplying evidence that the clinical needs for these patients substantively differ from the non-psychiatric population (American College of Emergency Physicians (ACEP), 2017; Lester, 2018). The measure population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Next Version | CMS111v10 | CMS111v11 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Standards Update
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Revised stratification narrative and logic to reflect standards change impacting representation of primary diagnosis.
Measure Section: Stratification
Source of Change: Measure Lead
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Revised notation relating to the median time calculation and removed verbiage related to reporting requirements to provide clarity.
Measure Section: Guidance
Source of Change: Measure Lead
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Revised the Decision to Admit explanation to only include concepts electronically capturable and to add a second option of using an assessment that results in a decision to admit inpatient.
Measure Section: Guidance
Source of Change: Measure Lead
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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Revised narrative to align with verbiage in other hospital measures and provide clarity in the statement.
Measure Section: Initial Population
Source of Change: ONC Project Tracking System (Jira): CQM-3654
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Revised narrative to clarify admission source is any different facility as identified by location or CMS Certification Number (CCN).
Measure Section: Measure Population Exclusions
Source of Change: Measure Lead
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Revised narrative to include 'median' and clarify intent.
Measure Section: Measure Observations
Source of Change: Measure Lead
Logic
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Revised the logic to include facility location, location period, and location code for the Emergency Department to ensure other locations are not inadvertently captured.
Measure Section: Initial Population
Source of Change: ONC Project Tracking System (Jira): CQM-3654
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Revised comment within the stratification logic to improve conciseness. Comments consist of forward slash-asterisk (/*) and asterisk-forward slash (*/).
Measure Section: Stratification
Source of Change: Measure Lead
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Removed extraneous logic in stratification 1 to make concise.
Measure Section: Stratification
Source of Change: Measure Lead
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Revised logic to include 'Assessment, Performed' with a result to provide another option for capturing a decision to admit prior to departing the ED. Created functions for both the decision to admit assessment and for the decision to admit order which are used in the initial population and measure observation logic. Therefore, the initial population logic has been replaced with the define statement 'ED Encounter with Decision to Admit' and measure observation logic interval will coalesce the two new functions 'AdmitDecisionUsingAssessmentDuringLastEDBeforeDeparture' and 'AdmitDecisionUsingEncounterOrderDuringLastEDandBeforeDeparture.'
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Modified Global.ED Encounter and replaced 'RelatedEDVisit' by creating a function named 'LastEDEncounter' to ensure the most recent ED encounter is calculated throughout the measure.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).
Measure Section: Multiple Sections
Source of Change: Standards Update
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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
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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
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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
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Added a new function 'AdmitDecisionUsingAssessmentDuringLastEDBeforeDeparture' to capture the decision to admit assessment, time, and evaluation result that was performed during the last ED visit. Two data elements were created for this logic using 'Assessment, Performed': 'Admit Inpatient' and 'Emergency Department Evaluation'.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Modified initial population and the function 'DepartureTime' to include ED facility location and facility relevant period and to assess if the encounter end date is maximum to capture the ED departure time and ensure the ED facility location and period are not null. This aligns with eCQM Logic and Guidance and the HQMF that only ED encounters where the measure observation can be calculated are included.
Measure Section: Multiple Sections
Source of Change: ONC Project Tracking System (Jira): QRDA-837
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value Set Decision to Admit to Hospital Inpatient (2.16.840.1.113883.3.117.1.7.1.295): Deleted 1 SNOMED CT code (76464004) based on expert review and/or public feedback, as it does not represent a decision to admit to inpatient.
Measure Section: Terminology
Source of Change: Measure Lead
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Value Set Hospital Settings (2.16.840.1.113762.1.4.1111.126): Deleted 38 SNOMED CT codes to create a more focused list and based on expert review and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Value Set Psychiatric/Mental Health Diagnosis (2.16.840.1.113883.3.117.1.7.1.299): Added 2 SNOMED CT codes (787769002, 787770001) and deleted 1 SNOMED CT code (21000000) based on terminology update.
Measure Section: Terminology
Source of Change: Measure Lead
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Developed two new value sets related to the new 'Assessment, Performed' decision to admit concept, to ensure standardized capture of the concept: Admit Inpatient (2.16.840.1.113762.1.4.1111.164) and Emergency Department Evaluation (2.16.840.1.113762.1.4.1111.163).
Measure Section: Terminology
Source of Change: Measure Lead