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

Hybrid eCQMs for 2022 Reporting Period

General eCQM Information

CMS Measure ID CMS529v2
Short Name Hybrid HWR
NQF Number 02879
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
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, 2022 and June 30, 2023. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2024.

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 (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Meaningful Measure Admissions and Readmissions to Hospitals
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated NQF number to remove 'e' designation as this measure is not an eCQM.

    Measure Section: NQF Number

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated hyperlink to CMS QualityNet website.

    Measure Section: Risk Adjustment

    Source of Change: Measure Lead

  • Added wording about standard supplemental data elements (Ethnicity, Sex, Payer, and Race) to better align with QRDA reporting requirements.

    Measure Section: Supplemental Data Elements

    Source of Change: ONC Project Tracking System (Jira): CHM-49

  • Updated language about reporting results within the 24 hours prior to admission to better align with intent.

    Measure Section: Supplemental Data Elements

    Source of Change: ONC Project Tracking System (Jira): CHM-50

  • Updated the measurement period dates and guidance section dates to correspond with the updated version of the measure.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Logic

  • Removed the patient payer coverage timing requirements to simplify logic and implementation of the measure.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CHM-44

  • Replaced Participation datatype with Patient Characteristic Payer datatype to better define the initial population.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CHM-45

  • Updated Global.'Inpatient Encounter' definition by adding 'day of' to ensure all cases within the measurement period are captured and evaluated in the initial population.

    Measure Section: Definitions

    Source of Change: Annual Update

  • Added four standard supplemental data elements (Ethnicity, Sex, Payer, and Race) to logic to better align with QRDA reporting requirements.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (Jira): CHM-49

  • Updated the names of Clinical Quality Language (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 the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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 Body temperature (2.16.840.1.113762.1.4.1045.152): Added 1 LOINC code (76011-6) based on review by technical experts, SMEs, and/or public feedback..

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set ONC Administrative Sex (2.16.840.1.113762.1.4.1) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-49

  • Added value set Race (2.16.840.1.114222.4.11.836) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-49

  • Added value set Ethnicity (2.16.840.1.114222.4.11.837) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-49

  • Added value set Payer (2.16.840.1.114222.4.11.3591) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: ONC Project Tracking System (Jira): CHM-49

Last Updated: Jul 08, 2021