| eCQM Title | Equity of Emergency Care Capacity and Quality REHQR |
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|---|---|---|---|
| eCQM Identifier (Measure Authoring Tool) | eCQM Version Number | 0.2.000 | |
| CBE Number | Not Applicable | GUID | 50cb43d5-d3d0-438e-ab4b-42db2744128b |
| Measurement Period | January 1, 20XX through December 31, 20XX | ||
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) | ||
| Measure Developer | Yale New Haven Health Service Corporation/ Center for Outcomes Research and Evaluation | ||
| Endorsed By | None | ||
| Description |
This measure's main objectives are to capture variation in equity of emergency care and measure capacity and quality of emergency care to support hospital quality improvement. The measure aims to reduce patient harm and improve outcomes for patients requiring emergency care in an emergency department (ED) in Rural Emergency Hospitals (REHs). Emergency care capacity is inclusive of several concepts pertaining to crowding in an ED. This measure will be designed to align with incentives to promote improved care and to help identify where patients do not receive equitable access to emergency care. The measure intends to capture established outcome metrics that quantify capacity and access of care in an ED including for patients with mental health disorders. Additional disparities in ED care are well documented for patients of older age, by race and ethnicity, primary language, and insurance status; such documented disparities include significantly longer ED wait times, higher left without being seen rates, and longer total length of stay in the ED. |
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| Copyright |
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. ICD-10 copyright 2024 World Health Organization. All Rights Reserved. CPT(R) contained in the Measure specifications is copyright 2004-2024 American Medical Association. |
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| Disclaimer |
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. 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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| Measure Scoring | Proportion | ||
| Measure Type | Intermediate Clinical Outcome | ||
| Stratification |
Four cohorts of the measure will be calculated, stratified by age and mental health visits. The measure's outcome will be stratified by race and ethnicity, primary language, and insurance status to best address equity of emergency care. A history of mental health disorders does not automatically exclude or include patients in the strata; the principal diagnosis defines inclusion in the appropriate strata. For the purposes of this measure, mental health disorders do not include substance use disorders. Stratification by age will be reported for patients less than 18 years of age and patients 18 years of age and older, for both mental health and non-mental health cohorts. All references to “ED” indicate an ED visit that occurred at an REH. Total score and score for the following strata will be reported: Non-Mental Health Visits Stratification 1: all patients aged less than 18 years seen in the ED who do not have an ED encounter principal diagnosis consistent with mental health disorders. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification. Stratification 2: all patients aged 18 years and older seen in the ED who do not have an ED encounter principal diagnosis consistent with mental disorders. Patients who have an ED encounter principal diagnosis consistent with substance use disorders will be included in this stratification. Mental Health Visits Stratification 3: all patients aged less than 18 years seen in the ED who have an ED encounter principal diagnosis consistent with mental health disorders. Stratification 4: all patients aged 18 years and older seen in the ED who have an ED encounter principal diagnosis consistent with mental health disorders. |
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| Risk Adjustment |
While the HOQR version of this measure will utilize volume standardization to address differences in patient population between hospitals, this REH version will not because all REHs are within the same volume strata. |
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| Rate Aggregation |
NA |
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| Rationale |
This measure aims to reduce patient harm and improve outcomes for patients requiring emergency care in an ED by addressing the variation in equity of emergency care and measuring the capacity and quality of emergency care. There are long-standing concerns about parameters that impact the quality and timeliness of care in the ED. Currently, there are no national metrics to assess the proportion of patients impacted by the quality of timely ED care. |
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| Clinical Recommendation Statement |
Changes in care provision and workflow are anticipated from implementing this ECCQ REH eCQM. To improve time to place a patient in a treatment space (as defined by the numerator below), changes in care may include improving patient flow processes, triaging interventions (such as inclusion of predictive models or different clinical deployment), or increased availability and access to outpatient clinical and social services. Other changes in care may include increases in local healthcare capacity including mental health care (mental health liaisons, co-located mental health services, or specialist psychiatry services), and use of ‘hospital home’ care models. Furthermore, changes to the following may also be considered: staffing models, ED observation units, diagnostic testing and imaging processes, or physical changes to ED layout. Such changes may result in the following: decreased waiting room time, decreased door to provider times, higher proportion of patients seen within 1 hour, decrease in proportion of patients who leave without being evaluated, better management of mental health illnesses, reduced length of stay in the ED, decreased turnaround time for diagnostic tests and imaging, improve time to treatment, and decreased ambulance diversion. Changes in clinician or patient-reported outcomes and costs may include the following: improved patient experience, decrease in morbidity and mortality, increased ED revenue, and improved patient outcomes. |
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| Improvement Notation |
Improvement noted as a decrease in measure score (decrease in proportion of eligible visits that meet the numerator criteria). |
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| Reference |
Reference Type: CITATION Reference Text: 'American Medical Association. 2022. What is Behavioral Health. https://www.ama-assn.org/delivering-care/public-health/what-behavioral-health' |
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| Reference |
Reference Type: CITATION Reference Text: 'Centers for Disease Control and Prevention. Emergency Department Visits. https://www.cdc.gov/nchs/fastats/emergency-department.htm (2021).' |
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| Reference |
Reference Type: CITATION Reference Text: 'ECQI Resource Center. Median Admit Decision Time to ED Departure Time for Admitted Patients.' |
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| Definition |
Mental Health: Mental health generally refers to mental health disorders, life stressors and crises, and stress-related physical symptoms. Mental health care refers to the prevention, diagnosis, and treatment of those conditions. For this measure, mental health cohorts will be defined separately from substance use disorders. ED Observation: ED observation stays, defined as an observation encounter where the patient remains physically in an area under control of the emergency department and under the care of an emergency clinician inclusive of observation in a hospital bed. ED observation involves placing patients in observation status after their initial evaluation, allowing for continued assessment, treatment, and the determination of a safe disposition. ED observation stays are generally longer than routine ED visits and may allow time to evaluate a patient’s response to treatment. |
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| Guidance |
Measure Score Calculation The measure score is first calculated at the individual ED level as the proportion of ED visits where any one of the four outcomes occurred. Scores will be standardized z-scores by ED case volume strata (defined in ED visit volume bands of 20,000 visits). For CCN’s with more than one ED, volume-adjusted z-scores are then combined as a weighted average for that CCN. A z-score of greater than zero means worse performance and less than zero means better performance, compared to like ED's. |
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| Transmission Format |
TBD |
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| Initial Population |
Includes all ED visits at REHs associated with patients of all ages, for all-payers, during the performance period. Patients can have multiple visits during a performance period; each visit is eligible to contribute to the outcome. |
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| Denominator |
Equals Initial Population |
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| Denominator Exclusions |
None |
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| Numerator |
The numerator is comprised of any ED visit in the denominator with any quality gap in access; if the patient experiences any of the following during a visit, the visit is included in the numerator: 1. The patient waited longer than 1 hour to be placed in a treatment room or dedicated treatment area that allows for audiovisual privacy during history-taking and physical examination; or 2. The patient left the ED without being evaluated by a physician/advanced practice nurse/physician’s assistant, or 3. The patient boarded (time from Decision to Transfer (order) to ED departure for transferred patients) in the ED for longer than 4 hours, or 4. The patient had an ED length of stay (LOS) (time from ED arrival to ED physical departure as defined by the ED depart timestamp) of longer than 8 hours. |
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| Numerator Exclusions |
ED encounters with ED observation stays will be excluded from criteria #3 (ED LOS). Transfers out to a facility will be excluded from criteria #3 (ED LOS). |
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| Denominator Exceptions |
None |
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| Supplemental Data Elements |
For every patient in the Initial Population, also identify county, ethnicity, payer, primary language, race, sex, state and zip code. |
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"ED Encounter" union "ED Triage"
"Initial Population"
None
"Time to Treatment Room Greater Than 60 Minutes" union "ED Arrival Left Without Being Seen" union "Boarded Time Greater Than 240 Minutes" union "ED Length of Stay Greater Than 480 Minutes"
"ED Observation during ED Encounter" union "Discharged to Another Facility"
None
( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
where not exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
where not exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
where exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
where exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
"Denominator" EDEncounter where "TransferDecisionUsingOrder"(EDEncounter) 241 minutes or more before "EDDepartureTime"(EDEncounter)
"Initial Population"
"ED Length of Stay Greater Than 480 Minutes" EDEncounter where EDEncounter.dischargeDisposition in "Discharge To Acute Care Facility"
"ED Triage" EDTriage where EDTriage.dischargeDisposition ~ "Patient left without being seen (finding)"
["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] EDEncounter where EDEncounter.relevantPeriod ends during day of "Measurement Period"
( "ED Encounter" union "ED Triage" ) EDEncounter where AgeInYearsAt(date from start of EDEncounter.relevantPeriod) >= 18
( "ED Encounter" union "ED Triage" ) EDEncounter where AgeInYearsAt(date from start of EDEncounter.relevantPeriod) < 18
"Denominator" EDEncounter where "EDArrivalTime"(EDEncounter) 481 minutes or more before "EDDepartureTime"(EDEncounter)
( "ED Length of Stay Greater Than 480 Minutes" EDStay
with "ED Observation Status" EDO
such that ( EDO.relevantPeriod during EDStay.relevantPeriod
or EDO.authorDatetime during EDStay.relevantPeriod
)
)
( ["Encounter, Performed": "Emergency Department Observation"]
union ["Encounter, Order": "Emergency Department Observation"] ) EDObs
with "Denominator" EDEncounter
such that ( EDObs.relevantPeriod during EDEncounter.relevantPeriod
or EDObs.authorDatetime during EDEncounter.relevantPeriod
)
["Encounter, Performed": "Triage"] EDTriage where EDTriage.relevantPeriod during day of "Measurement Period"
"ED Encounter" union "ED Triage"
"Time to Treatment Room Greater Than 60 Minutes" union "ED Arrival Left Without Being Seen" union "Boarded Time Greater Than 240 Minutes" union "ED Length of Stay Greater Than 480 Minutes"
"ED Observation during ED Encounter" union "Discharged to Another Facility"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
where not exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
where not exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients Less Than 18 Years" EDEncounter
where exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
( "ED Encounter or Triage of Patients 18 Years and Older" EDEncounter
where exists ( EDEncounter.diagnoses Diagnosis
where Diagnosis.code in "Mental Health Diagnosis without Substance Use Disorders"
and Diagnosis.rank = 1
)
)
"Denominator" EDEncounter where "EDArrivalTime"(EDEncounter) 61 minutes or more before "EDTreatmentRoomTimeArrivalTime"(EDEncounter)
Last(EDEncounter.facilityLocations Location
where Location.code in "Emergency Department Location"
and Global."HasStart"(Location.locationPeriod)
return start of Location.locationPeriod
sort ascending
)
Last(Encounter.facilityLocations Location
where Location.code in "Emergency Department Location"
and Global."HasEnd"(Location.locationPeriod)
return
end of Location.locationPeriod
sort ascending
)
Last(EDEncounter.facilityLocations Location
where Location.code in "Emergency Department Treatment Location"
and Global."HasStart"(Location.locationPeriod)
return start of Location.locationPeriod
sort ascending
)
not (
end of period is null
or
end of period = maximum DateTime
)
not ( start of period is null
or start of period = minimum DateTime
)
Last((["Encounter, Order": "Decision to Transfer"]) TransferOrder
with ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] ED
such that TransferOrder.authorDatetime during ED.relevantPeriod
return TransferOrder.authorDatetime
sort ascending
)
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer Type"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
| Measure Set |
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|---|---|---|---|