Quality Measure Results for Episodes of Care

that Span Multiple CCNs

Change Review Process Meeting9/17/2015Lisa Nelson

Lantana Consulting Group

Issue Overview

• Emergency Department process quality measures include timing logic that spans 2 kinds of encounters (ED Visits and Inpatient Encounters)occuring in a series.– ED-1 & ED-2 focus on Inpatient Encounters where there

was an ED Visit that concluded within an hour before or concurrent with the start of the IP Encounter.

– ED-3 focuses on ED Visits where no IP Encounter started within 6 hours after the ED Visit ended.

• Do the measure definitions work as expected when the two encounters occur at facilities from distinct CCNs?CCN stands for CMS (Centers for Medicare and Medicaid Services) Certification Number.

A CCN uniquely identifies a reporting entity. It may encompass multiple facilities.

Measure intent: What is the episode of care?

• Most inpatient measures are looking for data encompassed in a single episode of care:

An episode of care is defined as the health care services given during a certain period of time, usually during a hospital stay (e.g., from the day of arrival or admission to the day of discharge).

Source: Specifications Manual for National Hospital Inpatient Quality Measures

• For a patient who is admitted to inpatient care, the episode of care can include care provided in the ED and while in observation status, prior to the inpatient admission

When measuring Emergency Department processes, what is the episode of care?

ED-1 AND ED-2Part I.

Measure intent – ED-1 and ED-2

ED-1 (CMS55) Median Time from ED Arrival to ED Departure for Admitted ED Patients

ED-2 (CMS111) Median Admit Decision Time to ED Departure Time for Admitted Patients

• Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

• Improvement noted as a decrease in the median value.

Measure design – ED-1 and ED-2Measure ED-1 (CMS55) ED-2 (CMS111)

Measure Item Count Encounter, Performed: Encounter Inpatient

Encounter, Performed: Encounter Inpatient

Initial Population Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.

Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.

Measure Population Inpatient Encounters preceded by an emergency department visit.

Inpatient Encounters where the decision to admit was made during the preceding emergency department visit.

Issue Details – ED-1 and ED-2CQM-1475 ED-1 (CMS55), ED-2 (CMS111)If a patient arrived in an emergency department in CCN 1 and is later discharged and readmitted to an IP unit in CCN 2, should the ED measure result be attributed to CCN 1? CCN 2? Or neither?Since the measure is in reference to the facility and the facility's ED, it's unclear whether or not the measure result should be attributed to CCN 2 (the IP CCN) since that is the "facility" even though the ED they came from in CCN 1 was not a part of that same facility.

ED

Arrival to the hospital (CCN #1)

Inpatient

Discharge from inpatient care

Admission at CCN#1, through ED at CCN#1

Episode of Care Scenarios

Episode of care

ED Inpatient

Arrival to the hospital (CCN #2)

ED

Arrival to the hospital (CCN #2)

Inpatient

Not all inpatient admissions come from ED with same CCN

Admission at CCN#2, through ED at CCN#1

Admission at CCN#2, through ED at CCN#2

Which ED visits will be measured for these two hospitals, CCN#1 and CCN#2?

ED

Arrival to the hospital (CCN #1)

Inpatient

Discharge from inpatient care

Admission at CCN #1, through ED at CCN #1

Episode of Care Scenarios

Episode of care

ED Inpatient

Arrival to the hospital (CCN #2)

ED

Arrival to the hospital (CCN #2)

Inpatient

Not all inpatient admissions come from ED with same CCN

Admission at CCN #2, through ED at CCN #1

Admission at CCN #2, through ED at CCN #2

Data in the EHR at CCN#1

Data in the EHR at CCN#2Does not include CCN#1 ED visit

The design of ED-1 and ED-2 will not include these ED visits in the IP for CCN#1

The ED measure for CCN#1 does not include all of its ED Visit data.

ED

Arrival to the hospital (CCN #1)

Inpatient

Discharge from inpatient care

Admission at CCN #1, through ED at CCN #1

Episode of Care Scenarios

Episode of care

ED Inpatient

Arrival to the hospital (CCN #2)

ED

Arrival to the hospital (CCN #2)

Inpatient

Not all inpatient admissions come from ED with same CCN

Admission at CCN #2, through ED at CCN #1

Admission at CCN #2, through ED at CCN #2

Data in the EHR at CCN#1

The design of ED-1 and ED-2 will include these ED visits in the MP for CCN#2, but how does that affect the mean scores for CCN#2’s ED process?

Assume the EHR at CCN#2 consumed a Transition of Care document from the ED visit at CCN#1 and now CCN#2 has data in their EHR about the prior ED Visit.

Data in the EHR at CCN#2Does include CCN#1 ED visit

The ED measure for CCN#2 includes ED Visit data that effects their performance.

ED-3Part 2.

Measure intent – ED-3

ED-3 (CMS32) Median Time from ED Arrival to ED Departure for Discharged ED Patients

• Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment.

• Improvement noted as a decrease in the median value.

Measure design – ED-3Measure ED-3 (CMS32)

Measure Item Count Encounter, Performed: Emergency Department Visit

Initial Population Emergency department encounters discharged during the measurement period.

Measure Population Emergency department encounters discharged during the measurement period.

Issue Details – ED-3CQM-1499 ED-3 (CMS32)The criteria in the specification for the measure population of CMS 32, which says “AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 6 hour(s) ends before start of "Encounter, Performed: Encounter Inpatient"”, does not state whether the IP encounter must be in the same CCN as the ED encounter for this exclusion. Such a patient would seem to meet the spirit of stratification 3 - Transferred to Another Acute Care Facility, but it is unclear whether they should in fact be excluded based on becoming an Inpatient within 6 hours of the ED visit.Similarly, how would you define a "facility" in regards to this measure logic? Could it be multiple physical buildings, making it very similar/equivalent to a CCN? Or is each hospital building considered a separate facility in regards to these measures?

Arrival to the hospital (CCN #1)

Discharge from inpatient care

Admission at CCN #1, through ED at CCN #1

Episode of Care Scenarios

Episode of care

ED Inpatient

Arrival to the hospital (CCN #2)

Arrival to the hospital (CCN #2)

Not all inpatient admissions come from ED with same CCN

Admission at CCN #2, through ED at CCN #1

Admission at CCN #2, through ED at CCN #2

ED Inpatient

ED Inpatient

ED

ED Inpatient

ED Inpatient

ED

> 6 hrs.

> 6 hrs.

Data in the EHR at CCN#1

The design of ED-3 will include these ED visits in the IP and MP for CCN#1

These ED Visits really should be excluded from the MP for CCN#1

Episode of care

ConsiderationsMeasure ED-1 (CMS55) ED-2 (CMS111) ED-3 (CMS32)

Measure Item Count Encounter, Performed: Encounter Inpatient

Encounter, Performed: Encounter Inpatient

Encounter, Performed: Emergency Department Visit

Initial Population Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.

Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.

Emergency department encounters discharged during the measurement period.

Measure Population Inpatient Encounters preceded by an emergency department visit.

Inpatient Encounters where the decision to admit was made during the preceding emergency department visit.

Emergency department encounters discharged during the measurement period.

Recommendations• All measures intended to assess ED Visit process throughput should use

the ED Visit as the Measure Item Count– Eliminates use of the Inpatient Encounter to find the ED Visits– Affects ED-1 and ED-2– Achieves greater consistency across all three ED measures

• To measure only ED Visits that are not part of a larger episode of care, define the Measure Population Exclusion using the Encounter, Performed: Discharge Disposition attribute– Eliminates logic that depends on availability of data about subsequent encounters which

may not be present in the EHR for the CCN being assessed.– Affects ED-1, ED-2, ED-3– May create opportunity to improve how we address the issues associated with episodes

of care that include multiple departments (“encounters”) before ending up as an Inpatient Encounter, like ED to Cath Lab to Inpatient, or ED to Observation Unit to Inpatient. (paradigm shift: episode of care = a set of encounters not limited by “facility”)

• Clarify the meaning of the term “facility” in the measure definition to better explain how the CCN id effects the notion of “facility”?

Discussion