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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Answered
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Moderate
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None
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None
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Katrina Houston
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951-203-5394
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The Johns Hopkins Hospital
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CMS0111v10
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Seeking to confirm understanding of measure specifications
In reference to ONC-JIRA CQM 5395, I’ve added information. Could you please confirm how to handle the following scenarios - specifically, whether the patients should be included in the ED-2 population?:
Please assume the following:
Patient arrives to ED 1/1/22 at 04:00…Inpatient Encounter start date/time = same date/time as decision to admit; patient stay is less than 120 days
- ED Patient with orders for admit to inpatient completed 1/1/22 at 13:00; patient is class of inpatient but physically in ED; Patient elopes from ED; Discharged from ED as ‘eloped’ 1/1/22 at 17:00. Should this patient be included in the population (since orders for admission are complete, but the patient never departed the ED for an inpatient unit)?
- ED Patient with orders for admit to inpatient completed at 13:00, patient is class of inpatient but in physically in ED; Patient decides to leave AMA at 14:00; Discharge AMA from ED 1/1/22 at 17:00. Should this patient be included in the population?
- ED Patient with orders for admit to inpatient completed at 13:00. Patient is class of inpatient but physically in ED. At 16:00, Admit orders canceled and an order placed to discharge from ED. Patient discharged to home from ED at 1/1/22 at 16:30. Should this patient be included in the population?
- ED Patient with orders for admit to observation completed at 13:00; patient is observation class, but physically in ED; observation orders canceled at 13:30 and orders for admission to inpatient completed at 14:00 (patient is obs class but physically in ED when these orders are written, inpatient class/physically in ED when orders are completed). Patient departs ED for inpatient unit 1/1/22 16:00. Patient arrives inpatient unit 1/1 16:10. Patient discharged from inpatient hospitalization 1/3/22 10:00. Should this patient be included in the ED-2 population, why or why not?
- ED patient with principal diagnosis psychiatric in nature – order for admit to inpatient psych completed 1/1/22 at 13:00. Order changed at 15:00 to transfer to another inpatient psychiatric facility. Patient discharged from ED as transfer to acute psych facility 1/1/22 at 19:00. Should this patient be included in the ED-2 population?
- ED Patient with orders for admit to inpatient completed 1/1/22 at 13:00; patient is inpatient class but physically in ED. At 16:00 patient departs ED for OR (inpatient class). Patient arrives on inpatient unit from OR following surgery (inpatient class) 1/1/22 at 18:00. Patient is discharged from inpatient unit 1/3/22 at 10:00. Should this patient be included in the ED-2 population?
Thank you for providing guidance--