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Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM)

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Measure Information 2022 Reporting Period 2023 Reporting Period
Name Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM) Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM)
CMS Measure ID CMS844v2 CMS844v3
Short Name Hybrid HWM Hybrid HWM
NQF Number Not Applicable 3502e
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 HWM 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.

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 HWM 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 to 94 years 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.

All Medicare Fee-For-Service encounters age 65 to 94 years 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) Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Proportion measure 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 HWM measure.

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 HWM measure.

Guidance

This logic guides the user to extract the FIRST resulted HWM-specific core clinical data elements for all Medicare Fee-For-Service encounters for patients age 65 to 94 (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 HWM-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.

These specifications are for use for data with discharges that occur between July 1, 2023 and June 30, 2024. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2025.

This logic guides the user to extract the FIRST resulted HWM-specific core clinical data elements for all Medicare Fee-For-Service encounters for patients age 65 to 94 (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 HWM-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 core clinical data element, please report values using one of the appropriate units of measurement listed below, which represent valid UCUM codes:

Core Clinical Data Element                                          UCUM Unit

Bicarbonate-----------------------------------meq/L

                                                                                            mmol/L

Creatinine-------------------------------------mg/dL

                                                                                            umol/L

Heart rate-------------------------------------{Beats}/min

Hematocrit ------------------------------------%

Oxygen saturation (by pulse oximetry)-----------%{Oxygen}

Platelet----------------------------------------10*3/uL

                                                                                            10*9/L

                                                                                            /mm3

Sodium---------------------------------------meq/L

                                                                                           mmol/L

Systolic blood pressure------------------------mm[Hg]

Temperature----------------------------------Cel

                                                                                           [degF]

 

White blood cell count ------------------------{Cells}/uL

                                                                                          10*3/uL

                                                                                          10*9/L

                                                                                          /mm3

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.

The initial 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 version of the specifications uses Quality Data Model (QDM) version 5.6. Please refer to the QDM page for more information on the QDM.

Meaningful Measure Risk Adjusted Mortality Risk Adjusted Mortality
Next Version No Version Available No Version Available
Previous Version No Version Available

Measure Information 2023 Reporting Period
CMS Measure ID CMS844v3
Short Name Hybrid HWM
NQF # 3502
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 HWM 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 to 94 years 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 HWM measure.

Guidance

These specifications are for use for data with discharges that occur between July 1, 2023 and June 30, 2024. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2025.

This logic guides the user to extract the FIRST resulted HWM-specific core clinical data elements for all Medicare Fee-For-Service encounters for patients age 65 to 94 (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 HWM-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 core clinical data element, please report values using one of the appropriate units of measurement listed below, which represent valid UCUM codes:

Core Clinical Data Element                                          UCUM Unit

Bicarbonate-----------------------------------meq/L

                                                                                            mmol/L

Creatinine-------------------------------------mg/dL

                                                                                            umol/L

Heart rate-------------------------------------{Beats}/min

Hematocrit ------------------------------------%

Oxygen saturation (by pulse oximetry)-----------%{Oxygen}

Platelet----------------------------------------10*3/uL

                                                                                            10*9/L

                                                                                            /mm3

Sodium---------------------------------------meq/L

                                                                                           mmol/L

Systolic blood pressure------------------------mm[Hg]

Temperature----------------------------------Cel

                                                                                           [degF]

 

White blood cell count ------------------------{Cells}/uL

                                                                                          10*3/uL

                                                                                          10*9/L

                                                                                          /mm3

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.

The initial 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 version of the specifications uses Quality Data Model (QDM) version 5.6. Please refer to the QDM page for more information on the QDM.

Meaningful Measure Risk Adjusted Mortality
Previous Version

Release Notes

Header

  • Updated the measurement period dates.

    Measure Section: Measurement Period

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added guidance on appropriate units of measurement for each core clinical data element, represented by valid UCUM codes, to support implementation.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Added reference to the reporting period dates associated with this version of the specifications.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated guidance to indicate patients in Acute Hospital Care at Home programs are included in the initial population.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.

    Measure Section: Guidance

    Source of Change: Standards/Technical Update

  • Updated the order of the core clinical data elements list to alphabetize the items for improved readability.

    Measure Section: Supplemental Data Elements

    Source of Change: Measure Lead

Logic

  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical Update

  • Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.

    Measure Section: Multiple Sections

    Source of Change: Standards/Technical 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/Technical 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 Sodium lab test (2.16.840.1.113762.1.4.1045.119): Added 1 LOINC code (77139-4) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

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

    Measure Section: Terminology

    Source of Change: Annual Update

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

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced direct reference code LOINC code (59408-5) with value set Oxygen Saturation by Pulse Oximetry (2.16.840.1.113762.1.4.1045.151) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Bicarbonate lab test (2.16.840.1.113762.1.4.1045.139): Added 3 LOINC codes (69964-5, 97543-3, 97544-1) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Body temperature (2.16.840.1.113762.1.4.1045.152): Added 4 LOINC codes (11289-6, 60830-7, 60833-1, 76010-8) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Creatinine lab test (2.16.840.1.113883.3.666.5.2363): Added 2 LOINC codes (35203-9, 77140-2) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 15, 2022