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

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 Hospital-Wide Mortality (HWM) outcome measure. It is designed to extract the first vital signs and resulted laboratory tests obtained from hospitalizations for adult Medicare Fee-For-Service (FFS) and Medicare Advantage (MA) patients admitted to acute care hospitals.

Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. This material includes SNOMED Clinical Terms (R) (SNOMED CT [R]) which is used by permission of the International Health Terminology Standards Development Organization (IHTSDO). All rights reserved. SNOMED CT (R), was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO. This material contains content from LOINC (http://loinc.org). LOINC is copyright (C) Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/license. LOINC (R) is a registered United States trademark of Regenstrief Institute, Inc.

These performance specifications are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

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For a detailed description of how the core clinical data elements (CCDEs) are used in the Hybrid HWM measure risk adjustment model, see the Hybrid HWM Measure Methodology Report on CMS.gov here: https://qualitynet.cms.gov/inpatient/measures/hybrid/methodology

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The intent of this logic is to extract the FIRST resulted set of clinical data elements from hospital electronic health records (EHRs) for all qualifying hospitalizations. The data will be linked with administrative claims to risk adjust the Hybrid HWM outcome measure. This work addresses stakeholder concerns that clinical data garnered from patients and used by clinicians to guide diagnostic decisions and treatment, are preferable to administrative claims data when profiling hospitals’ case mix. We are calling the list of data elements for extraction the "HWM-specific core clinical data elements" (CCDE). The CCDEs are the first set of vital signs and basic laboratory tests resulted from hospitalizations for adult Medicare FFS and MA patients, age 65 through 94 years (Initial Population), after they arrive at the hospital to which they are subsequently admitted. For example, this first set of data values are often captured in the emergency department or in the pre-operative area, sometimes hours before a patient is admitted to that same facility.
 

 Hospitalizations over the age of 94 years are not included to avoid holding hospitals responsible for the survival of the oldest elderly patients, who may be less likely to have survival as a primary goal. While we acknowledge that many elderly patients do have survival beyond 30 days as a primary goal for their hospitalization, with input from our Technical Expert Panel and work groups, we decided to only include hospitalizations between 65 and 94 years of age.
 

 These CCDEs were selected because they: 1. reflect patients' clinical status when they first present to the hospital; 2. are clinically and statistically relevant to patient outcomes; 3. are consistently obtained during adult inpatient hospitalizations based on current clinical practice; 4. are captured with a standard definition and recorded in a standard format across providers; and 5. are entered in structured fields that are feasibly retrieved from current EHR systems (YNHHSC/CORE, 2015).
 

 Additional data called Linking Variables are used to link EHR data files with administrative claims data for CMS to calculate results for the Hybrid HWM measure, which are: CMS Certification Number (CCN); Medicare Beneficiary Identifier (MBI); Inpatient Admission Date; and Discharge Date.

The logic is not meant to guide or alter the care patients receive. The purpose of this CCDE logic is to extract clinical data that are already routinely captured in EHRs from hospitalizations for adult patients. It is not intended to require that clinical staff perform additional measurements or tests that are not needed for diagnostic assessment or treatment of patients.

No actual measure score will be generated by hospitals. Instead, hospitals will report the data values for each of the CCDEs for all hospitalizations in the Initial Population. These CCDEs will be linked to administrative claims data and used by CMS to calculate results for the Hybrid HWM measure.

Reference Type: Citation

Reference Text: 
Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE) Prepared for CMS. (2015). 2013 Core Clinical Data Elements Technical Report (Version 1.1). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/Core-Clinical-Data-Elements-and-Hybrid-Measures.zip

HWM-Specific Core Clinical Data Elements

These specifications are for use for data with discharges that occur between July 1, 2027 and June 30, 2028. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2029.
 

 As this is a hybrid outcome measure, the electronic specifications contained within this document only cover the case-mix risk-adjustment variables, which ultimately need to be combined with the claims data to calculate an outcome. The logic contained here cannot be used alone to calculate outcome or performance.
 

 This logic guides the user to extract HWM-specific CCDEs for all Medicare FFS and MA hospitalizations for patients aged 65 through 94 years (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 performed vital signs and resulted laboratory tests, where the result is not null, during the patient encounter or episode of care. This may include values captured after inpatient admission, as well as prior to inpatient admission, for example from the emergency department, pre-operative, or other outpatient areas associated with the hospital, as long as the values fall within the allowed timeframes specified in the measure logic. All clinical systems used in inpatient and outpatient locations associated with the hospital facility should be queried for core clinical data element values related to a patient who is subsequently admitted.
 

 Patients who start oxygen therapy during the ED encounter OR patients who receive oxygen therapy that starts 1 hour or less before the start of the ED encounter will be flagged in the logic and the information will be incorporated into the risk adjustment models. Rationale: patients who arrive on oxygen may appear in better condition, that is, having a higher oxygen saturation due to oxygen administration, that is not truly reflective of the patient's status upon arrival.
 

 Value sets for the laboratory tests are represented using Logical Observation Identifiers Names and Codes (LOINC) 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 CCDEs.
 

 NOTE: It is recommended hospitals only report the FIRST values for EACH core clinical data element collected in the appropriate timeframe, if available. Hospitals may also choose to report ALL values on an encounter during their entire admission; however, only the first valid values are utilized in the logic for measure calculation.
 

 For each CCDE, it is recommended that hospitals report the below Unified Code for Units of Measure (UCUM) units, however, any unit may be submitted. Where the reported unit is not easily converted to the requested UCUM units, the value will be set to missing and the median value reported for that CCDE will be imputed.

 
  
  
 
 

  

   

    
CCDE
   
   

    
UCUM Unit
   
  
  

   

    
Bicarbonate
   
   

    
meq/L
    
mmol/L
   
  
  

   

    
Creatinine
   
   

    
mg/dL
   
  
  

   

    
Heart rate
   
   

    
{Beats}/min
   
  
  

   

    
Hematocrit
   
   

    
%
   
  
  

   

    
Oxygen saturation (by pulse oximetry)
   
   

    
%
   
  
  

   

    
Platelet
   
   

    
10*3/uL
   
  
  

   

    
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
   
  
 

For each hospitalization please also submit the following Linking Variables:

 

  
CMS Certification Number (CCN);
 
 

  
Medicare Beneficiary Identifier (MBI);
 
 

  
Inpatient Admission Date;
 
 

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

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All Medicare FFS and MA hospitalizations for patients aged 65 through 94 years at the start of an inpatient admission, where the length of stay is less than 365 days, and the hospitalization ends during the measurement period.
NOTE: All Medicare FFS and MA hospitalizations meeting the above criteria should be included, regardless of whether Medicare FFS/MA is the primary, secondary, or tertiary payer.

For hospitalizations in the Initial Population, report the FIRST performed vital signs (physical exams) during the current hospitalization. The physical exam CCDEs are as follows:
 

 Body Temperature
 

 Heart rate
 

 Oxygen saturation (by pulse oximetry)
 

 Systolic blood pressure
 

 For laboratory test results, report the FIRST resulted laboratory tests where the result is not null during the current hospitalization.
 

 The laboratory tests CCDEs are as follows:
 

 Bicarbonate (or carbon dioxide, see Bicarbonate Lab Test value set)
 

 Creatinine
 

 Hematocrit
 

 Platelet
 

 Sodium
 

 White blood cell count
 

 First values for the CCDEs may be resulted in the emergency department or other hospital outpatient locations within the hospital facility before a patient is subsequently admitted to the same hospital. First values for these data elements may also be resulted in an inpatient location for directly admitted patients who do not receive care in the emergency department or other hospital outpatient/same-day surgery locations before admission.
 

 NOTE: Hospitals may choose to submit all, or only report the FIRST resulted value for EACH CCDE collected in the appropriate timeframe, if available. For every patient in the Initial Population, also identify payer, race, ethnicity, and sex.