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  1. eCQM Issue Tracker
  2. CQM-5395

ED-2 eCQM and Discharge from the ED

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Katrina Houston
    • 951-203-5394
    • The Johns Hopkins Hospital
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      ​
      Thank you for your questions on ED-2/CMS111, Median Admit Decision Time to ED Departure Time for Admitted Patients.

      The following is required to determine if the patient encounter qualifies for the ED-2/CMS111 Initial Population:

      An ED visit with admission time
      An ED visit with discharge time
      An ED visit with departure time
      A decision to admit to inpatient made during the ED visit
      Inpatient encounter admission time
      Inpatient encounter discharge time
      ED visit and inpatient encounter at the same facility

      The above data is used to calculate the initial population- Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED.

      The ED visit admission and discharge times are used to calculate if the decision to admit was made during the ED visit.
      The departure time is used to calculate if the decision to admit was made before the patient physically left the ED.
      The ED visit discharge and inpatient admission times are used to determine if the ED visit was within an hour of the inpatient admission.
      The Inpatient admission and discharge times are used to evaluate if the encounter was less than or equal to 120 days.

      The scenarios provided are missing pertinent information to determine if the patient would be included in the initial population. Hopefully, the above information is helpful but if it does not aid in determining inclusion, please feel free to add information to the scenarios and we will be happy to review again. Thank you.
      Show
      ​ Thank you for your questions on ED-2/CMS111, Median Admit Decision Time to ED Departure Time for Admitted Patients. The following is required to determine if the patient encounter qualifies for the ED-2/CMS111 Initial Population: An ED visit with admission time An ED visit with discharge time An ED visit with departure time A decision to admit to inpatient made during the ED visit Inpatient encounter admission time Inpatient encounter discharge time ED visit and inpatient encounter at the same facility The above data is used to calculate the initial population- Inpatient hospitalizations ending during the measurement period with length of stay less than or equal to 120 days, where the patient received services during the preceding emergency department (ED) visit at the facility when a decision to admit inpatient was made prior to departing the ED. The ED visit admission and discharge times are used to calculate if the decision to admit was made during the ED visit. The departure time is used to calculate if the decision to admit was made before the patient physically left the ED. The ED visit discharge and inpatient admission times are used to determine if the ED visit was within an hour of the inpatient admission. The Inpatient admission and discharge times are used to evaluate if the encounter was less than or equal to 120 days. The scenarios provided are missing pertinent information to determine if the patient would be included in the initial population. Hopefully, the above information is helpful but if it does not aid in determining inclusion, please feel free to add information to the scenarios and we will be happy to review again. Thank you.
    • CMS0111v10
    • We'd like to confirm that we are including and excluding patients appropriately from this population, per measure intent and specifications

      Could you please confirm how to handle the following scenarios - specifically, whether the patients should be included in the ED-2 population?:

      • ED Patient with orders for admit to inpatient completed at 13:00, Patient elopes from ED
      • ED Patient with orders for admit to inpatient completed at 13:00, Patient decides to leave AMA at 14:00.
      • ED Patient with orders for admit to inpatient completed at 13:00. At 16:00, Admit orders canceled and an order placed to discharge from ED. Patient discharged from ED at 16:30.
      • ED Patient with orders for admit to inpatient completed at 13:00, Patient discharged from ED 0100 next day.
      • ED Psychiatric patient order for admit to inpatient completed at 13:00. Order changed at 15:00 to transfer to another inpatient psychiatric facility. Patient discharged as transfer to acute psych facility at 19:00.

      Thank you for providing guidance--

            JLeflore Joelencia Leflore
            khouston Katrina Houston (Inactive)
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