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Median Admit Decision Time to ED Departure Time for Admitted Patients

eCQMs for 2021 Reporting Period

Specifications
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General eCQM Information

CMS Measure ID CMS111v9
Short Name ED-2
NQF Number Not Applicable
Measure 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
Measure 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.

Meaningful Measure Admissions and Readmissions to Hospitals
Previous Version
Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated disclaimer.

    Measure Section: Disclaimer

    Source of Change: Standards Update

  • Revised stratification narrative and logic to reflect standards change impacting representation of primary diagnosis.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • 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

  • 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

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

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • 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

  • 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

  • Revised narrative to include 'median' and clarify intent.

    Measure Section: Measure Observations

    Source of Change: Measure Lead

Logic

  • 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

  • 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

  • Removed extraneous logic in stratification 1 to make concise.

    Measure Section: Stratification

    Source of Change: Measure Lead

  • 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

  • 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

  • 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

  • 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 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

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

Last Updated: Jun 24, 2020