Purpose:

To provide a method by which each patient's episode of care results, by measure, may be reviewed.  This is especially useful when needing to identify which episodes of care have affected the Observed Rate or Observation Value of the measure.

Accessing the Report:

From the eCQM Submission menu, select the Quality Improvement tab.

Open

• Select the measure you wish to see the patient results for within the “Select Measures” drop-down box on the left-side of the page.

• You may further narrow the Patient Results by:

  • Selecting the Quarter if data was submitted for multiple quarters

  • Selecting the specific Population Breakdown item from the Waterfall chart (e.g., click on the bar for “Not in Population”, “Does Not Meet”, etc.)

• On the lower right-hand side of the page, click on the “Review patient results” button.

  • Each Episode of Care that was processed against the selected measure appears in the Patient Results list.

• After reviewing or exporting this report, click the ‘<< Back’ button on the lower right-hand side of the page to go back to the Quality Improvement page.

If you filtered the report and decide that you desire to review the entire report instead, click on the ‘Review results for all measures’ button on the bottom left-hand side of the Patient Results list and the list will re-display with all of the data available on the Quality Improvement page.

Export Report

This list can be exported by clicking on the Export button - indicated below the table on the page.  The downloaded file is an Excel file (xlsx).

Open

Columns within the Report:

The Patient Results list provides the following information for each Episode of Care that was processed against the measure.  

• Batch ID - This is the DDSP’s Batch ID associated to the uploaded zip file. This will assist users with access to multiple hospitals for upload purposes who use the Multi-HCO Batch Upload function.

• QRDA File ID

• Patient ID - This is the Patient ID that is contained within the QRDA I document for the patient

• HCO ID - This is the Joint Commission’s ID for the hospital.

• Zip Name - This is the name of the zip file in which the active QRDA I document was submitted.

• QRDA I File Name - This is the name of the active QRDA I document in which the patient was submitted.

• Transmission Time - This is the time that the file was processed by the DDSP.

• Quarter - This matches the quarter which was selected before the “Review patient results” button was clicked.

• Measure - This matches the measure which was selected before the “Review patient results” button was clicked.

The following columns in the Patient Results list matches the Population breakdown and shows how each patient’s episode of care was processed against the selected eCQM and, if appropriate, selected quarter and/or population breakdown for that eCQM. 

(Example Image Pending)

False means the episode of care is not in that breakdown on the Waterfall Chart and True means that it is.  An episode of care may be in multiple breakdowns (True) on the Waterfall Chart.  For example:

• Episodes of care that are in the Numerator of a proportion measure, are also in the “Initial Population”, “Measure Population”, and “Denominator” breakdowns.

• Episodes of care that are not in the Numerator of a proportion measure, in addition to the above are also in the “Cases Failing Measure” breakdown.

The columns are as follows.  The definition of each column is the same as the associated population breakdown on the waterfall chart.

(Example Image Pending)

• Not in Initial Population (True/False)

• Initial Population (True/False)

• Does Not Meet (True/False)

• Measure Population (True/False)

• Exclusion (True/False)

• Exception (True/False)

• Denominator/Population (True/False)

• Cases Failing the Measure (True/False)

• Numerator (True/False)

• Measure Observation Value - Continuous variable (CV) measures:  This is the measure observation that was calculated for encounter for the measure.  This is the value that is used to calculate the hospital's Median Observed Value.

Additional columns in the Patient Results list (in order from left to right):

(Example Image Pending)

• Final Outcome - This column contains the final outcome for the patient’s episode of care.

• Encounter ID - This is the Encounter ID contained within the QRDA I document for the Episode of Care

• Admit Date - This is the admission date of the encounter.

• Discharge Date - This is the discharge date of the encounter.