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 HWM outcome measure. It is designed to extract the first resulted set of vital signs and basic laboratory results 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 contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. All rights reserved.

LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc.

These performance specifications are not clinical guidelines and 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.

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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 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); National Provider Identifier (NPI) for MA patients; 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 core clinical data elements 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, 2025 and June 30, 2026. The associated Hospital Specific Report (HSR) is anticipated to be released in Spring 2027. 

This logic guides the user to extract the FIRST resulted 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 set of HWM-specific CCDEs 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 (physical exams) 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 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 core clinical data elements.

NOTE: It is recommended hospitals only report the FIRST resulted value 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 resulted 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 multiple imputation will be used to impute a value based on the characteristics of the CCDE reported.

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); 
National Provider Identifier (NPI) for MA patients;   
Medicare Beneficiary Identifier (MBI);
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 eCQI Resource Center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

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 value for vital signs (physical exams) resulted within the 24 hours prior to the inpatient admission. If no values were resulted in the 24 hours prior to the admission (for example, for patients directly admitted to the hospital) report the first value resulted within 2 hours after the start of the inpatient admission. 

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 value resulted within the 24 hours prior to admission. If there are no values in the 24 hours prior to admission, report the first value resulted within 24 hours after the start of the inpatient admission. 

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: Do not report ALL values on a hospitalization during the entire admission. 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.