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  • evaluate the Initial Population and Observed Rate/Observation Value for eCQMs associated to active patient (accepted QRDA ) I documents).

  • review patient data (QRDA I document) to understand how they processed against the eCQM logic.

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  • Measures: The measure selected in the ‘Select Measures’ control.

  • Active Patients: For the selected Measure and Quarter, count of all unique patients (i.e., QRDA I document) that are in the Initial Population of the eCQM.

  • Episodes of Care: For the selected Measure and Quarter, count of all unique encounters that the Active Patients had during the calendar quarter.

  • A patient that is discharged one time during the calendar quarter will have a one-to-one relationship between “active patient” and “episode of care”. 

  • A patient that is discharged three times during the calendar quarter, will have a one-to-three relationship such that there is one “active patient” related to the three “episode of cares”care”. 

For example:

  • If there are five (5) “active patients” in the eCQM for the calendar quarter with one (1) encounter each, the number of “episodes of care” equals five (5).

  • If there is one (1) “active patient” discharged five times during the calendar quarter, the number of “episodes of care” equals five (5).

  • If there are five (5) “active patients” during the calendar quarter where:

    • two (2) were discharged two (2) times and

    • three (3) were discharged one (1) time,

    • the number of “episodes of care” equals seven (7)

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Clicking this button will take you to a new page that will display how each patient's episode of care processed against the measure.

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Definitions for the Waterfall Chart Population Breakdown for the Selected Measure:

Page Element

eCQM processed against

Episodes of Care

Count of all Active episodes of care evaluated by the eCQM. 

Info

Note: QRDA I documents are evaluated by an eCQM if the Measure Section within the document states that the measure should be processed.  In this manner, hospitals can add or remove measures from those they wish to evaluate or submit.

Not in Initial Population

Count of episodes of care which did not pass the Initial Population logic. 

  • The Not in Initial Population is calculated as the [Episodes of Care - Initial Population]

Initial Population

Count of episodes of care evaluated which meet the Initial Population as documented in the specification

Does Not Meet

Count of episodes of care in the Initial Population that does not meet the measure population criteria for the measure

Measure Population

Count of episodes of care that meet the population criteria for the measure

  • Depending on the measure, it can be the same count as the Initial Population or a subset of the Initial Population if the measure further constrains the Initial Population (e.g., Ischemic and Hemorrhagic stroke patients)

  • The Measure Population is calculated as the [Initial Population minus Does Not Meet]

Exclusion

Count of episodes of care that are removed from the Measure Population because they meet specific criteria that made it clinically unnecessary for the patient to receive the numerator clinical action.

  • In proportion measures, these episodes of care are removed before determining if the Numerator criteria are met

  • In continuous variable measures, these episodes of care are removed before calculating the measure’s Observation value

Exception

  • Proportion measures: Count of episodes of care removed from the Measure Population because the Numerator criteria were not met

    • Exceptions are generally provider or patient determined reasons for refusing certain clinical actions

  • Continuous Variable measures: not applicable

Denominator / Population

  • "Denominator" for Proportion eCQMs: Count of episodes of care for which the measure applies after removing those episodes of care that were either excluded or had exceptions 

    • The Denominator value is used when calculating the Observed Rate

    • Denominator = [Measure Population minus (Exclusions plus Exceptions)]

  • "Population" for Continuous Variable eCQMs: Count of episodes of care used to calculate the Observation Value

    • Population = [Measure Population minus Exclusions]

Cases Failing the Measure

  • Proportion measures:  Count of Denominator episodes of care which do not meet the Numerator criteria

  • Continuous Variable measures: not applicable

Numerator

  • Proportion measures: Count of episodes of care which meet the processes or outcomes evaluated by the measure

    • Numerator = [Denominator minus Cases Failing the Measure]

  • Continuous Variable measures: not applicable

How each element of the page affects the other page elements:

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The counts at the top of the page adjust as the elements on the page are modified.  Clearing these selections returns the counts back to their original state.

Page Elements

User Action

Population Breakdown
for the Selected Measure

Select Measures

Select Quarters

Documents

Population Breakdown for the Selected Measure

Clicking a measure result (population bar) within the Waterfall Chart

Highlights population bar for that measure result

No change

Displays quarter(s) for which patient data exists with that measure result

Displays the patient’s active QRDA I document(s) which received the measure result

Select Measures

Clicking a specific measure

Displays measure result breakdown for selected measure

Displays selected Measure in drop-down box

Displays quarter(s) for which patient data exists for the selected measure

Displays each patient’s active QRDA I document in the Initial Population of selected measure

Select Quarter

Clicking a specific quarter to further filter the measure data

Displays measure result breakdown for selected measure and quarter

No Change

Highlights selected Quarter

Displays each patient’s active QRDA I document in the Initial Population of selected measure and quarter

Active Documents

Clicking a specific patient’s QRDA I document

Displays measure result for the selected patient

No Change

Displays quarter associated for the selected QRDA I

Highlights selected patient’s QRDA I document

Clear Selection

Clicking ‘Clear Selection’ button

Returns the entire page back to its original state

  Important Information for Using the Quality Improvement page

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