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ED Measure Recommendations

Change Review Process MeetingNovember 2015

Lisa NelsonLantana Consulting Group

Last Updated: November 9, 2015

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Quality Measure Results for Episodes of Care

that Span Multiple CCNs Recap

• Emergency Department process quality measures include timing logic that spans 2 kinds of encounters (ED Visits and Inpatient Encounters)occuring in a series.– ED-1 & ED-2 focus on Inpatient Encounters where there was an ED Visit that concluded

within an hour before or concurrent with the start of the IP Encounter.– ED-3 focuses on ED Visits where no IP Encounter started within 6 hours after the ED Visit

ended.• Do the measure definitions work as expected when the two encounters occur at

facilities from distinct CCNs?• Several JIRA tickets from implementers

– CQM-1475, CQM-1499, CQM-1598, CQM-1341, CQM-1345, CQM-1645, CQM-1610, CQM-1605, CQM-1063

CCN stands for CMS (Centers for Medicare and Medicaid Services) Certification Number. A CCN uniquely identifies a reporting entity. It may encompass multiple facilities.

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Measure intent: What is the episode of care?

• Most inpatient measures are looking for data encompassed in a single episode of care:

An episode of care is defined as the health care services given during a certain period of time, usually during a hospital stay (e.g., from the day of arrival or admission to the day of discharge).

Source: Specifications Manual for National Hospital Inpatient Quality Measures

• For a patient who is admitted to inpatient care, the episode of care can include care provided in the ED and while in observation status, prior to the inpatient admission

When measuring Emergency Department processes, what is the episode of care?

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ConsiderationsMeasure ED-1 (CMS55) ED-2 (CMS111) ED-3 (CMS32)Measure Item Count Encounter, Performed:

Encounter InpatientEncounter, Performed: Encounter Inpatient

Encounter, Performed: Emergency Department Visit

Initial Population Inpatient Encounters ending during the measurement period with Length of Stay less than or equal to 120 days.

Inpatient Encounters ending during the measurement period with Length of Stay less than or equal to 120 days.

Emergency department encounters discharged during the measurement period.

Measure Population Inpatient Encounters preceded by an ED Visit

Inpatient Encounters where a decision to admit was made during the preceding ED Visit

IP and not ED Visits that end with a subsequent Inpatient Encounter

Measure Population Exclusions

None None Patient Expired during visit

Measure Observation Discharge Datetime minus Admission Datetime

Decision to Admit Datetime minus Admission Datetime

Facility Location Departure Datetime minus Facility Location Arrival Datetime

Stratification S1: M S2: not M

S1: MS2: not M

S1: MS2: T and not union of M and TS3: All not in S1 or S2

M = Primary Diagnosis is a Mental Health DisorderT = Transferred to an Acute Care hospital (environment) within 6 hours of the end of the ED visit.

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Conclusions• Tangly logic and inconsistent measure design,

largely due to the history of their development (siloed due to IP vs OP)

• The current intention is for ED-1 and ED-3 to be a “companion set” of “complementary measures” for Median Time from ED Arrival to ED Departure which look at two different situations:– 1. ED visit was part of a larger “episode of care”

(admitted patients)– 2. ED visit was not part of a larger “episode of care”

(discharged patients)

• ED-2 is just like ED-1, but measures a different observation—median time to decision to admit– ED-2 can be “carried” in this discussion as a “shadow

measure” following the same approach as ED-1

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Prior Recommendations (Sept.)• All measures intended to assess ED Visit process throughput should use

the ED Visit as the Measure Item Count– Eliminates use of the Inpatient Encounter to find the ED Visits– Affects ED-1 and ED-2– Achieves greater consistency across all three ED measures

• To measure only ED Visits that are not part of a larger episode of care, define the Measure Population Exclusion using the Encounter, Performed: Discharge Disposition attribute– Eliminates logic that depends on availability of data about subsequent encounters which

may not be present in the EHR for the CCN being assessed.– Affects ED-1, ED-2, ED-3– May create opportunity to improve how we address the issues associated with episodes

of care that include transfer to other “departments” before ending up as an Inpatient Encounter, like ED to Cath Lab to Inpatient, or ED to Observation Unit to Inpatient. (paradigm shift: episode of care = a set of encounters not limited by “facility”)

• Clarify the meaning of the term “facility” in the measure definition to better explain how the CCN id effects the notion of “facility”?

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Current Recommendation – logic• Initial Population – no change• Measure Population

– ED-1 (ED-2) Use new timing to account for possible gap in Observation Status

– ED-3 Remove exclusion for ED Visits that are not a part of a larger “episode of care”

• Measure Exclusion– ED-1 (ED-2) Add exclusion for ED Visits transferred from another hospital

setting (alignment)– ED-3 Add exclusion for ED Visits that are part of a larger “episode of care”,

use new timing to account for possible gap in Observation Status• Measure Observation

– ED-1 (ED-2) Use Facility Location Arrival Datetime– ED-1 Use Facility Location Departure Datetime with clarified definition– ED-3 no change

*The time that the patient departed the specific facility location related to the encounter

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Current Recommendation – strata• Stratification

– ED-1 (ED-2) segment for: • S1: M AND: Encounter, Performed: ED Visit (Diagnosis: M) VS M

(harmonization)• S2: not M AND NOT: Encounter, Performed: ED Visit (Diagnosis:M) VS M

(harmonization)– ED-3 segment for:

• S1: M Aligned with D2, Change to VS M (harmonization)• S2: T Aligned with D3, Change to VS T (alignment)• S3: Not M AND Not T Aligned with D, Change to VS T (alignment)• S4: M AND T Needed to compute the logical strata relationships

*The time that the patient departed the specific facility location related to the encounter

M -M

T

-T

Measure Observation

S2

S1

S4

S3

Think Sudoku

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Summary of Current RecommendationsMeasure ED-1 (CMS55) ED-2 (CMS111) ED-3 (CMS32)Measure Item Count Encounter, Performed:

Encounter InpatientEncounter, Performed: Encounter Inpatient

Encounter, Performed: Emergency Department Visit

Initial Population Inpatient Encounters ending during the measurement period with Length of Stay less than or equal to 120 days.

Inpatient Encounters ending during the measurement period with Length of Stay less than or equal to 120 days.

Emergency department encounters discharged during the measurement period.

Measure Population Inpatient Encounters preceded by an ED Visit using new timing gap

Inpatient Encounters where a decision to admit was made during the preceding ED Visit using new timing gap

Same as IP

Measure Population Exclusions

Patients transferred from another hospital care setting

Patients transferred from another hospital care setting

Patient Expired during visit;ED Visits that end with a subsequent Inpatient Encounter using new timing gap

Measure Observation Facility Location Departure Datetime minus Facility Location Arrival Datetime

Decision to Admit Datetime minus Admission Facility Location Arrival Datetime

Facility Location Departure Datetime minus Facility Location Arrival Datetime

Stratification S1: M S2: not M

S1: MS2: not M

S1: MS2: TS3: not M AND not TS4: M AND T

M = Encounter, Performed: (Diagnosis: Mental Health Disorder)T = Transferred to an Acute Care or VA hospital (environment) within 6 hours of the end of the ED visit.

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Assessment of Recommendation

Up-side:• Clearer purpose• Clearer logic• Incorporation of new QDM • New approach for addressing

Observation Status• Restored/improved

alignment with paper measure

• Acute Care & VA Hospital VS will have more than one concept

Down-side:• More changes…• Complex issues to understand• Triggers a need to add a concept

to the Acute Care VS – will have to do Harmonization analysis, scan for usage interdependencies– Make a new grouping VS that

combines Acute Care VS with additional concepts.

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Motion:

• Support making proposed changes to ED-1 (ED-2) and ED-3

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Discussion

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Vote

• Support making proposed changes to ED-1 (ED-2) and ED-3?– Support making these changes– Don’t support making these changes– Not sure, need more time to consider the

proposed changes