Thanks everyone for all the guidance and clarifications provided!

Thank you Ping.

Thank you for the comments. There was an issue in The Joint Commission rule engine that ED Observation Value would be calculated from ED encounter start and end time when ED facility is missing from ED encounter. This issue has been resolved as of Jan 26, 2018. If this file is submitted now, it would receive Measure Population (MSRPOPL) as outcome and null as Observation Value.

This is to clarify that if a patient is having ED encounter without facility location, The Joint Commission will not calculate the Observation Value and will give null to the Observation Value. The patient would still be evaluated for "Initial Population", "Measure Population", and "Measure Population Exclusions". However, even if the outcome is in “Measure Population” (MSRPOPL), this patient would not be included in the Joint Commission aggregation process for ED Median time calculation because of null Observation Value.

We will pass your file to TJC and will update you with their finding. Thanks.

Thanks for your promptly response clarifying 2018 expectation.
About my second question, I understand the Measure Observation would not be calculated. However, we submitted a file (attached) to TJC (2017 reporting period) with a ED encounter without ED location times, and the report back from TJC had a measure calculation of 129 for ED-1. It seems the calculation was based on ED encounter start/end times (there are no ED location start/end times). However, based on the solution to the Jira, no measure calculation should it be in the report.

Hi Isbelia,

To your question about 2018 reporting period, the measure logic of ED-2 (CMS111v6) was updated as you shown above. Both TJC and HQR are in agreement that their measure engines would follow the eCQM specifications, so yes, for CMS111v6, facility location would be required for evaluating Initial Population and Measure Population. Your statement is correct that, for 2018, an ED encounter without ED location should be included in ED-1 IPP but not in the IPP for ED-2.

For your question about measure calculation. To clarify, for 2017 reporting period, TJC does not calculate the patient for "Measure Observation", because Measure Observation is specified as:
Median:
Datetimediff:
"Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)"
"Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient (start datetime)"

However, the patient would still be calculated for "Initial Population", "Measure Population", and "Measure Population Exclusions".

HQR measure engine does the same. The error message returned when the patient was not calculated for Measure Observation due to missing facility location, might be a little misleading, but the patient was calculated still for Initial Population, Measure Population, and Measure Population Exclusions.

Please let us know, if you still have questions regarding this.

Hello Yan,

Based on the solution provided, no measure calculation would be done. However, we have examples of files submitted to TJC where the measure calculation was done and provided in the mismatch report. The file attached had the following outcomes in the report:
MeasureName eED-1b
CalcMeasureCategory MSRPOPL
XmtMeasureCategory IPOP
CalcMeasureValue 129

Can you please provide clarification about this and to my previous question?

Thanks.

Hello Yan,

Thank you for the information provided. This question is marked as 'Resolved' but I have a additional question:

For 2018 reporting year, the IPP logic for ED-2 measure includes 'facility location departure datetime'. Does that mean that for 2018, an ED encounter without ED location should be included in ED-1 IPP but no in the IPP for ED-2?
ED-2 (2018 reporting year IPP logic)
Initial Population =
AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient
AND: "Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient" satisfies all:
starts during "Occurrence A of Encounter, Performed: Emergency Department Visit"
starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)"

Thanks.

Hello Isbelia,

After their investigation, HQR team has confirmed that:
"When the facility location is missing, message id 20160110 should be returned for measure observations.
20160110 [Message #] EXCLUDED: Unable to perform measure calculation, time and date requirements not present. Measure Exclusion

Initial Population, Measure Population and Measure Population Exclusions will still be evaluated."

For your question, the measure engines of HQR and TJC are aligned in terms of evaluating Measure Population of ED-1 and ED-2. The measure engine follows the eCQM specifications. The eCQM specifications for both ED-1 and ED-2 do not specify facility location, the patient will be evaluated for Measure Population without ED location. However, the patient will not be evaluated for Measure Observation, since the Measure Observation criteria specifies facility location.

Hi Isbelia, sorry for the delay. We have been trying to get a final confirmation of exactly how HQR system handles this. Hope to get back to you shortly.

Hello Yan,
Any update from the HQR team on this matter?
Thanks.

Hi Isbelia, there was initial discussion last week. We are following up with the HQR team again. Thanks.

Hello Yan,

Do you have any update about this matter?

Thanks.

Hi Isbelia, we will discuss this with both CMS and TJC and hope to provide you an update soon. Thanks for your patience.