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  1. eCQM Issue Tracker
  2. CQM-5092

CMS111v9 ED Observation patients

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
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    • LISA WOLF
    • 928-263-3473
    • Kingman Regional Medical Ctr
    • ​Thank you for the question. CMS 111 Median Admit Decision Time to ED Departure Time for Admitted Patients does not include observation patients. The measure includes emergency department patients admitted to inpatient status.​
    • CMS0111v10
    • CMS111v9/NQFna
    • Unable to complete validation and submit QRDA file

      During validation we found several patients who were discharged from the ED to Observation before an Inpatient unit. Our Observation unit is not considered inpatient. Should these patients be included in the CMS 111v9 measure? If so, which admission date/time should we use; the date/time they were admitted to Observation or the Inpatient unit? Our CMS ID is 030055. Below is the measure description we received from our EHR vendor who is gathering the eCQM data.

      Median admit decision time for ED departure time for admitted patients (ED2)
      Description: Median time (in minutes) from the admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

            JLeflore Mathematica EH eCQM Team
            LISAWOLFKRMC LISA WOLF
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