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  2. CQM-7541

OP-40 eCQM clarification of definition of ED arrival time

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your question regarding CMS996v4 and CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We interpret your inquiry to understand how the ED arrival time is defined within the measure’s three numerator criteria: (i) time between ED arrival and fibrinolysis is 30 minutes or fewer, or (ii) time between ED arrival and PCI performed is 90 minutes or fewer, or (iii) time between ED arrival and ED transfer is 45 minutes or fewer. The STEMI measure defines ED arrival time using the facility locationPeriod attribution. In the STEMI measure, ED arrival time is defined by the startTime of the patient’s physical arrival to the first location during the emergency department visit, which is indicated by the startTime of SNOMEDCT 4525004 Emergency department patient visit (procedure) here: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.292/expansion/eCQM%20Update%202024-05-02. Please note you may need to create an account to view this code. The startTime of the locationPeriod attribution addresses the time that the patient arrived at the location or the time that the encounter began (admission time).

      Please work with your EHR vendor to align ED arrival time with the time of the patient’s physical arrival to the first location during the ED encounter. In a normal ED workflow, the patient’s admission time is not always close to the time they are first roomed. The QDM V5.6 (https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf) and the eCQI resource center (https://ecqi.healthit.gov/mcw/2025/qdm-dataelement/encounterperformed.html) can provide more information regarding the locationPeriod attribution in the ED encounter for this measure (“Encounter, Performed”). Please let us know if you have any outstanding questions.
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      Thank you for your question regarding CMS996v4 and CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We interpret your inquiry to understand how the ED arrival time is defined within the measure’s three numerator criteria: (i) time between ED arrival and fibrinolysis is 30 minutes or fewer, or (ii) time between ED arrival and PCI performed is 90 minutes or fewer, or (iii) time between ED arrival and ED transfer is 45 minutes or fewer. The STEMI measure defines ED arrival time using the facility locationPeriod attribution. In the STEMI measure, ED arrival time is defined by the startTime of the patient’s physical arrival to the first location during the emergency department visit, which is indicated by the startTime of SNOMEDCT 4525004 Emergency department patient visit (procedure) here: https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.117.1.7.1.292/expansion/eCQM%20Update%202024-05-02 . Please note you may need to create an account to view this code. The startTime of the locationPeriod attribution addresses the time that the patient arrived at the location or the time that the encounter began (admission time). Please work with your EHR vendor to align ED arrival time with the time of the patient’s physical arrival to the first location during the ED encounter. In a normal ED workflow, the patient’s admission time is not always close to the time they are first roomed. The QDM V5.6 ( https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf ) and the eCQI resource center ( https://ecqi.healthit.gov/mcw/2025/qdm-dataelement/encounterperformed.html ) can provide more information regarding the locationPeriod attribution in the ED encounter for this measure (“Encounter, Performed”). Please let us know if you have any outstanding questions.
    • CMS0986v3
    • CMS0986v4
    • CMS0996v4
    • We are trying to determine the OP-40 definition of ED arrival time. Please see below.

      Regarding the above eCQM I am noting the following in the OP-40 eCQM definition: The percentage of emergency department (ED) patients with a diagnosis of ST-segment elevation myocardial infarction (STEMI) who received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival. The measure is intended for use at the facility level in a CMS accountability program, through which it may be publicly reported. I am writing to ask how ED arrival is defined within the measure? Is it when the patient physically enters the emergency department? The OP-40 definition is somewhat confusing as it states "the start time is the time the patient arrived at the location. The time the encounter began (admission time)." Our admission time reflects when the patient is "roomed" and not necessarily when they physically entered/arrived to the ED. Please clarify.
      Your case number CS2373161

            aweber Mathematica EH eCQM Team
            mmccarville@llu.edu Mara McCarville
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