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CMS Measure ID: CMS111v8    Performance/Reporting Period: 2020    Version: 8    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

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent hospital environments where a patient received inpatient or outpatient care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category Encounter or attribute Admission Source. The intent of this data element is to identify hospital environments where a patient may receive inpatient or outpatient care.
Inclusion Criteria: Includes only relevant concepts associated with hospital environment and all its children. Codes used are to be SNOMED CT codes only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Admission Source: Hospital Settings value set (2.16.840.1.113762.1.4.1111.126)

QDM Attribute and Definition (QDM Version 5.4)

admissionSource

The location from which the patient was admitted (e.g., physician referral, facility from which the patient was transferred).
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures that are commonly used for capturing an emergency decision to admit a patient to an inpatient hospital setting.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify an emergency decision to admit a patient to an inpatient hospital setting.
Inclusion Criteria: Includes only relevant concepts associated with codes representing an emergency decision to admit a patient to an inpatient hospital setting using the SNOMED CT system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Order: Decision to Admit to Hospital Inpatient value set (2.16.840.1.113883.3.117.1.7.1.295)

QDM Datatype and Definition (QDM Version 5.4)

"Encounter, Order"

Data elements that meet criteria using this datatype should document that an order for the encounter indicated by the QDM category and its corresponding value set has been recommended.

Timing: The time the order is signed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures representing an emergency department encounter.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an emergency department encounter.
Inclusion Criteria: Includes only relevant concepts associated with an emergency department visit encounter using the SNOMED CT code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Emergency Department Visit 1 value set (2.16.840.1.113883.3.117.1.7.1.292)

QDM Datatype and Definition (QDM Version 5.4)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime -the time the patient arrived at the location;
  • stopTime -the time the patient departed from the location
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.4)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime -the time the patient arrived at the location;
  • stopTime -the time the patient departed from the location
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.4)

"Patient Characteristic Ethnicity"

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Patient Characteristic, Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.4)

"Patient Characteristic Payer"

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Patient Characteristic, Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.4)

"Patient Characteristic Race"

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic, Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.4)

"Patient Characteristic Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent diagnoses commonly used in the inpatient setting for psychiatric and mental health disorders.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attributes related to Diagnosis. The intent of this data element is to identify patients who have an active diagnosis of a psychiatric or mental health disorder.
Inclusion Criteria: Includes only relevant concepts associated with representing an active diagnosis for psychiatric and mental health disorders using ICD-10-CM and SNOMED CT codes systems.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Psychiatric/Mental Health Diagnosis value set (2.16.840.1.113883.3.117.1.7.1.299)

QDM Attribute and Definition (QDM Version 5.4)

principalDiagnosis

The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.