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  1. eCQM Issue Tracker
  2. CQM-870

Required data elements for Reporting Strata for ED-1

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Minor Minor
    • Guidance, Measure
    • Phyllis Browne
    • 410-796-6231
    • Press Ganey Associates
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      Thank you for our questions. The ED-1 stratification descriptions in the header explains the intent of the stratification as such:
      Stratum 1 - all patients seen in the ED and admitted as an inpatient
      Stratum 2 - all patients seen in the ED and admitted as an inpatient who do not have a diagnosis consistent with psychiatric/mental health disorders
      Stratum 3 - all patients seen in the ED and admitted as an inpatient who have a diagnosis consistent with psychiatric/mental health disorders

      The clause in stratum 1 is identical to measure population clause, aiming for the total of all strata. Stratum 3 contains psychiatry patients and stratum 2 has non-psychiatry patients. The measure population (same as stratum 1 in this case) includes both psychiatry and non-psychiatry patients and therefore, the diagnosis active is not required in the measure population logic.
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      Thank you for our questions. The ED-1 stratification descriptions in the header explains the intent of the stratification as such: Stratum 1 - all patients seen in the ED and admitted as an inpatient Stratum 2 - all patients seen in the ED and admitted as an inpatient who do not have a diagnosis consistent with psychiatric/mental health disorders Stratum 3 - all patients seen in the ED and admitted as an inpatient who have a diagnosis consistent with psychiatric/mental health disorders The clause in stratum 1 is identical to measure population clause, aiming for the total of all strata. Stratum 3 contains psychiatry patients and stratum 2 has non-psychiatry patients. The measure population (same as stratum 1 in this case) includes both psychiatry and non-psychiatry patients and therefore, the diagnosis active is not required in the measure population logic.
    • CMS55v1/NQF0495
    • Reporting Strata criteria for ED-1 Median Time from ED Arrival to ED Departure for Admitted ED Patients

      Reporting Stratum 1's only criteria is that the ED visit is within 1 hour of the start of the Inpatient Encounter (AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient" )

      In addition, neither the Initial Patient Population nor the Measure Population criteria stipulate requiring a Principal Diagnosis, Active.

      So please confirm if no Active Principal Diagnosis is present, the case is still in Reporting Stratum 1.

      In addition, Reporting Stratum 2 specifies there is NOT an Active Principal Psychiatric/Mental Health Diagnosis. Does this mean that if no Active Principal Diagnosis exists the case would fall into Reporting Stratum 2 as well? It again does not stipulate that there must be an Active Principal Diagnosis, or is this implied?.

            sharonj.giarrizzo-wilson Sharon J. Giarrizzo-Wilson (Inactive)
            pbrowne Phyllis Browne (Inactive)
            Phyllis Browne (Inactive)
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