ACEP E-QUAL Network FAQ
What are the ACEP Emergency Quality (E-QUAL) Network learning collaboratives?
The ACEP E-QUAL Network offers learning collaboratives in three key areas to demonstrate the value of emergency care:
- Improving outcomes for patients with sepsis
- Reducing avoidable imaging in low risk patients through implementation of ACEP’s Choosing Wisely recommendations
- Advanced imaging for low back pain
- Head CT scan after minor head injury
- Chest CT for pulmonary embolus
- Abdominal CT for renal colic
- Head CT for syncope
- Improving the value of ED evaluation for low risk chest pain by reducing avoidable testing and hospital admissions
What is the mission of the ACEP E-QUAL Network?
The ACEP E-QUAL has two equal parts of its mission:
- Engage EDs and clinicians in the three clinical initiatives outlined above
- Serve as a resource to CMS supported Practice Transformation Networks (PTNs)
What are the benefits to participating in ACEP E-QUAL Network learning collaboratives?
There are numerous benefits ranging from local support to national incentives:
- Gain access to toolkits including best practices, and sample guidelines
- Get Access to benchmarking data
- Gain national recognition for your successes
- Get your clinicians access to high-quality eCME for free
- Meet CMS Improvement Activity requirements of the new CMS Quality Payment Program (Merit Based Incentive Payment System (MIPS))
What resources will the learning collaboratives provide to participating sites?
Each learning collaborative will be a distinct national campaign launched under the common mission and model of E-QUAL. Each learning collaborative includes three stages:
- Recruitment & Enrollment
- Enrollment Pledge
- Quality Readiness Assessment Survey
- Learning Collaborative Participation Sign Up
- Learning Period (9 months)
- Monthly Webinars
- Introduction to tool kit, guidelines and other informational materials
- Online E-QUAL Portal Activities
- CME and MOC activities
- Benchmarking data
- Office Hours
- Wrap Up
- Data and Summary Reports
- Lessons Learned Evaluation
- eCME & MOC credit
- Meet CMS PQRS requirements
What methods of quality improvement will be incorporated across the three learning collaboratives?
- Developing quality improvement toolkits for each learning collaborative
- eCME modules
- Maintenance of Certification (MOC) Assessment of Performance in Practice credit
- Data collection and reporting for benchmarking
- Aligning clinical quality activities and the CMA Quality Payment Program
- E-QUAL metrics are aligned with and can be reported using the ACEP Clinical Emergency Data Registry (CEDR) also used for quality reporting to CMS.
- Support clinician completion of Improvement Activities (IAs) for the Merit-based Incentive Payment System (MIPS) programs.
- Disseminating these products simultaneously through several channels:
- Scientific meetings and educational conferences
- Social media partnerships (e.g. ALiEM)
- Patient-facing materials
What is CEDR?
The Clinical Emergency Data Registry (CEDR) is a CMS Qualified Clinical Data Registry (QCDR) designed to accept data from practicing emergency clinicians in order to:
- Provide a unified method for ACEP members to collect and submit quality data
- to meet Physician Quality Reporting System (PQRS) reporting requirements
- Earn MOC, Ongoing Professional Practice Evaluation (OPPE) credit
- Promote the highest quality of emergency care for our patients.
- Demonstrate the value of emergency care.
- Facilitate appropriate emergency care research.
Do you have to participate in CEDR in order to be enrolled into the ACEP E-QUAL learning collaboratives?
No, participation in CEDR is not a requirement to enroll/participate in the learning collaboratives. However, if you are participating in CEDR, data collection and reporting for EQUAL collaboratives can be facilitated by using CEDR to submit scores to EQUAL.
Will our E-QUAL quality metric scores be used by CMS?
No, E-QUAL metrics are intended for benchmarking and local quality improvement. E-QUAL will only report participation in a learning collaborative to CMS, not actual scores.
If I use CEDR to report scores to E-QUAL, will they also be reported to CMS?
No, CEDR can be used to submit quality data to E-QUAL for benchmarking purposes to meet Improvement Activity (IA) requirements of the Quality Program, while also submitting scores on different quality measures to CMS for the Quality category requirements of the MIPS program.
How do you join the ACEP E-QUAL Network?
Visit the E-QUAL homepage and click on E-QUAL initiatives portal button to begin the enrollment process. For questions on how to enroll contact firstname.lastname@example.org
Who should I contact with any questions about EQUAL?
For more information on how to join the ACEP SAN please contact Nalani Tarrant, Project Manager at email@example.com.
Where can I find more information on the ACEP E-QUAL Network?
For more information on the ACEP E-QUAL Network and upcoming activities/events, visit http://www.acep.org/equal/.
I was enrolled in E-QUAL by another member at our site, how to I start receiving E-QUAL updates and e-mails?
Champions of each site will receive the E-QUAL updates and emails. If you are part of a site that is enrolled into an E-QUAL learning collaborative please contact your site champion who can provide you access to the portal account.
What is the anticipated timeline for the launch of the three clinical initiatives?
E-QUAL will offer each learning collaborative once a year to maximize participation and to align our offerings with CMS programs and ACEP & ABEM offerings. 2018 enrollment is now open for all three learning collaborative. Deadlines to enroll in each 2018 learning collaborative:
|Sepsis Initiative Wave III
||February 21, 2018
|Avoidable Imaging Initiative Wave III
||March 22, 2018
|Chest Pain Initiative Wave II
||April 19, 2018
How do we access the E-QUAL portal?
Champions of the participating sites will receive an e-Mail invite to activate their E-QUAL portal. Each participating site is required to have at least one Champion who will be responsible for completing that site's E-QUAL portal Activities.
What is the webinar schedule?
All webinars will be pre-recorded and posted on the E-QUAL website. Please visit the E-QUAL website (www.acep.org/equal) for webinar details.
What is the process for accessing E-QUAL's CME content?
Our CME are located in the E-QUAL webpages for each learning collaborative: Sepsis, Avoidable Imaging, & Chest Pain. After clicking a CME link you will be asked to sign in with your ACEP ID/Password. If you have not created a free account, please do so here. Once logged in, click the "Launch" button and follow the succeeding prompts to begin your selected CME.
Are other clinicians (i.e. physician’s assistants) counted in our total group number?
This depends on how you report to CMS. If your site reports as a group (often the preferred and easiest method for emergency clinicians), then all clinicians that charge Medicare (Part B) under the same Tax Identification Number (TIN) should be included in your group number.
On which parameters does CMS base reimbursement?
E-QUAL only submits an aggregate of site-specific data to CMS. Since, participation in E-QUAL is aligned with the Improvement Activity (IA) category for the new CMS Merit Based Payment Incentive Program (MIPS), CMS will base reimbursement only upon participation.
Please note that the quality category is based on actual quality measure scores, and that you can use the ACEP Clinical emergency data registry CEDR to support your quality reporting needs.
How does participation in E-QUAL affect our site's ability to avoid MIPS penalties and gain bonuses?
For 2018, downward adjustment (or a penalty) can be avoided by participating in the program and completing at least one improvement activities (E-QUAL actually can earn you credit for more than one improvement activity) or submit one quality measure in the quality category (E-QUAL participation does not meet any Quality category requirements). However, to be eligible for any of the over $500 million CMS is authorized to provide increase in payments (or bonuses), participation in the Quality category and full participation in Improvement Activity is likely required. The greater than 90-day requirement applies to both Quality and Improvement Activity categories to be eligible for bonus. While CMS has not provided any detailed description of bonus eligibility, we believe that clinicians that receive full Improvement Activity Credit (40 points for 2018, possible through full participation in E-QUAL) and report multiple measures for the Quality Category for greater than 90 days (possible through CEDR, but again not based on E-QUAL) will likely score above national averages and receive bonus payments.
Must our site perform a 90-day “best-practices” intervention aligned with CMA IA guidelines?
While the CMS MIPS program requires that a Improvement Activity (IA) require 90 days, there is not time requirement for each E-QUAL learning collaborative. Rather, because the total length of each EQUAL learning collaborative exceeds the 90 day requirement, participation in E-QUAL is considered sufficient to fully meet all approved IAs.
Can one provider recruit others to perform some of the initiatives even if only he/she registered?
Yes, each E-QUAL collaborative is designed to support team and group based practice improvement. additional individuals associated with your group’s account on the E-QUAL portal can help with the monthly activities.
How does our site attest earned IA credits to CMS?
At the end of the learning collaborative, E-QUAL will provide each participating ED site a certificate for use as evidence for any audit/attestation of the IAs completed by that site and the ECs/NPIs submitted to E-QUAL as working at that site.
Current CMS guidance regarding IA reporting is available on the QPP website.
Keep up-to-date with the latest QPP information by subscribing to the QPP listserv. Visit the QPP website, scroll to the bottom of the page and click "Subscribe to Updates".
Will our entire group receive CME credit if only our clinical leaders listen to the webinar recordings?
No. Each provider that is interested in CME credit will need to review the webinar and take the post quiz. Each CME approved webinar is worth 1 credit. CME credit is different from IA credit
Do you need to be an ACEP member to participate in E-QUAL?
No, you do not need to be an ACEP member to participate in E-QUAL
Our site is small enough to be eligible for submitting outside the E-QUAL timeframes in order to accommodate the 20-case minimum. Does this mean we can submit cases more recent than the timeframe, as well?
Yes, but only to fulfill the 20-case minimum.
E-QUAL team review the items we upload in the various Activities to make sure
what we have submitted is appropriate and acceptable?
Yes, we will be reviewing all the activities and letting you know which
activities are incomplete and/or which uploads need to be fixed.
If our group enters an E-QUAL collaborative, but finds we are unable to fulfill its requirements, can our group back out without incurring a penalty? Additionally, would this hinder our ability to participate in future Waves or other IA activities?
A site can pull out of an E-QUAL collaborative without incurring penalties or inhibiting participation in other E-QUAL Waves or IA activities.
What is the accepted ACEP definition for sepsis?
ACEP does not have an official definition. Your site will apply the definition associated with the method used for data submission in the Benchmarking activities.
- Sites using the SEP-1 method will adhere to the CMS definition.
- Sites using the CEDR metric or Quick Chart Review method will adhere to the ACEP CEDR Quality Improvement definition. The ICD 10 coding logic for these methods can be downloaded in Activity II.
After trying to construct an Electronic Health Record (EHR) query to identify Septic Shock cases, we are finding that several patients do not have either Sepsis or Septic Shock. Does E-QUAL have any guidance on the construction of EHR queries?
The definition used for the E-QUAL Quick Chart Review Option mirrors the definition used for the CEDR Sepsis Measure Denominators. To avoid the capture of cases without sepsis we recommend you limit your query to cases in which the ED Clinical Impression, and not the inpatient discharge diagnosis, maps to the provided code list. Also, please note that in order to ensure better capture of septic shock and severe sepsis while minimizing capture of general sepsis the denominator logic includes important Boolean logic:
To identify Sepsis and Septic Shock patients, query the EHR for ED Clinical Impressions with the following logic:
- Septic Shock diagnostic code, OR
- Combination of an Infection AND Hypotension (low blood pressure) diagnostic codes.
Please see the linked data submission guide: QCR | SEP-1.
Does the diagnosis code for sepsis need to be from the ED visit or the admitting diagnosis?
Either is accepted by E-QUAL. You should identify cases based on data available to your site.
Our sites did not receive specific information regarding our performance on blood cultures, antibiotics, fluids, or lactate in our E-QUAL Benchmarking report. Is this information available to us?
Yes, this information is found on the 2nd page of your site-specific SEP-1 report in the compliance table. It should be noted that these recommendations are only conditional.
In the initial benchmarking activity, our site pulled cases of simple sepsis from our database. Many of the measures abstracted from the sepsis bundle apply to only severe sepsis and septic shock. Therefore, simple sepsis cases will fail for fluids, vasopressors, repeat lactates, etc, resulting in a worse than expected performance. I believe the follow-up benchmarking should specify only severe sepsis and septic shock cases, and clarify ICD codes so that a site’s performance reflects what measures is used for which diagnosis.
The intention of the quick chart review denominator is to parallel the denominator used by the ACEP CEDR. This denominator is considered more specific for severe sepsis and septic shock than broader lists of codes, but it may identify cases of sepsis on occasion. If you have any suggestions on the removal of codes or changes to the coding logic, please submit them to firstname.lastname@example.org.
Our site's charts show whether a lactate had been performed, but they do not document the values. For these inputs, our site filled in "Yes" & "Zero". How can we ensure our site is fully credited in Activity 10 for performing a lactate?
Instead of "Zero", please enter the code "888" if your site does not have the information available.
Can our site use the severe sepsis code R65.20?
The E-QUAL Sepsis Initiative and Toolkit supports using best practices for these patients. Currently, to improve comparability of benchmarking reports, we are asking all sites to only use the codes provided in our Data Submission Guide. At this time, severe sepsis code R65.20 is not included in the E-QUAL Sepsis Initiative.
What are the submission dates for Activities 2 & 10?
Activity 2 dates are October – December 2016, and Activity 10 dates are July – September 2017
Are there specific reasons for the quarters given in Activities 2 & 10?
Since many sites use SEP-1 for data submission, we matched the quarters to SEP-1 reporting periods. Furthermore, this allows for the Activities to be done during 2017, ensuring MIPS credits.
Looking forward, if sites develop the capacity to capture and report monthly data, then we would love to make benchmarking more frequent. If Champions or their sites have any ideas or future needs please pass them along, and we will bring them to our Steering Committee for discussion.
Where does our site submit the attestations for Activities 5 & 8?
You will be prompted within each activity to upload a screenshot.
How many points in Section 7 require our site's commitment? Would discrepancies among our 4 divisions create any issues or affect other attestations?
We expect discrepancies in attestation between sites, as each ED is often at a different stage of quality improvement. At the end of each Wave, E-QUAL will provide certificates noting which IA activities were completed by your ED site. Your group will then be required to attest to CMS as an entire TIN, based on the participation of sites for which CMS has not set explicit guidance yet.
fulfill the high-weighted activity labeled “Participation in CAHPS or other
supplemental questionnaire" that is listed on the QPP MIPS IA summary
The IA activity labeled
“Participation in CAHPS or other supplemental questionnaire” is not an approved
credit for E-QUAL. To understand which IA’s have been approved for E-QUAL
please look at the document titled “Use ACEP Tools to
meet your CPIA/MIPS Requirement”
What are the
E-QUAL’s parameters for differentiating minor versus serious head injury?
In order to reduce burden on sites and facilitate data collection, E-QUAL will use ED clinical impression or diagnostic codes to identify head injury patients. The Data Submission Guide details all necessary codes.
What is the difference between CT Utilization and CT Yield?
The CT Utilization metric asks for how many CTs your sites performed, and the CT Yield metric asks how good your site is at asking for CTs. In general, sites with a high ratio of CT Utilization/CT Yield rates can improve their imaging efficiency. They are also related because the CT Utilization numerator equals the CT Yield denominator.
Can E-QUAL provide any rules or guidelines for the CT Head/Syncope? Should we include:
- Patients coded with both syncope and stroke who received CT Heads in the workup for neurologic deficit, or
- Patients coded with syncope and who received CT Head for head trauma evaluation because of a resulting fall?
The goal of the CT Head/Syncope measure is to identify isolated syncope cases or cases in which syncope is the reason for ordering the CT.
- The patients who received CT Heads while being evaluated for stroke do not need to be counted.
- In the case of patients with possible head trauma (this is a known challenge with this quality improvement metric), we would encourage sites to leave these cases in to reduce data collection burdens and ensure that results are more comparable between sites.
For the CT for PE measure, is our site supposed to eliminate any CTs that are completely related to trauma, or are those supposed to be in our numbers for benchmarking?
It is an understandable limitation that patients receiving chest imaging just for trauma may get captured, but we did so to make it easier for sites, initially. CTs ordered alongside other scans as part of a trauma scan should be excluded. Currently, we have not provided any guidance concerning exclusion purely based on diagnostic codes. Note that both chest CT codes are included in the numerator.
After configuring our sites EHR system, we are having difficulty identifying patients for the Avoidable Imaging learning collaborative. Does E-QUAL have any guidance on the construction of EHR queries?
To maximize your capture of the denominator using the EHR, you should limit the identification of cases for metrics using diagnostic codes to the ED Clinical Impressions. However, for metrics specific to all ED visits, look up and use the procedure codes (HCPCS/CPT) linked to each ED visit.
Please see the linked data submission guide.
1 (Activity 2), which value should be included for Total Adult Visits: Total
Back Pain visits or Total ED Visits?
are looking for Total Annual ED Visits. After selecting a specific target metric, the activity will ask for that
specific visit count.
My site is
not participating in CEDR, and we do not have access to reporting or data from
our site’s radiology department. If we pull the ER charts for all syncope
patients, then determine whether CTs were ordered for patients with no
neurological deficit, will that suffice?
that will suffice. Pull the charts for syncope patients and use the guideline codes
to determine if patients received a CT. Determining whether patients had
neurological deficit is not necessary as EQUAL metrics are based on utilization
and not appropriateness to reduce data collection burdens.
Four of our
EDs are either Level 2 or Level 1 trauma centers. How would our sites separate
chest CTs performed for trauma from those performed for PE?
belief is that the code used for the numerator is traditionally used for PE
chest CTs, not trauma chest CTs. If it is possible, we would recommend to have
your site include a denominator for patients that only received chest CTs and
you can exclude visits in which patients received head, cervical spine or
abdominal CT imaging in addition to chest CT imaging.
pediatric patients included in the Chest Pain or Avoidable Imaging IA? If
not, are our PEM physicians excluded from this part of MIPS?
remaining Activities do include pediatric emergency physicians, and activities
regarding best practices are still relevant.
your site’s PEM physicians are excluded from MIPS is based on the MIPS
eligibility criteria. For more information on this, please visit the QPP website. You will need to see if your site
charges enough Medicare dollars. If your PEM physicians have a separate TIN,
they will have to report and participate in IA separately.
provide some benchmark values for the ideal number or ordered labs and/or radiology
studies per patient?
we currently do not have any benchmark values to provide. Our goal is to have
benchmarking reports as part sites submitting data to E-QUAL. However, we do
recommend looking at variation across the group.
individually reviewed our billing company’s ED visit report for patients (18
years or older) that were admitted or discharged with a diagnosis of syncope
(R55, T67.1, I95.1, or F48.8) and determined for which patients were
non-contrast CT-Heads ordered. Any cases with a history of head trauma or
abnormal neurologic exam were excluded. Additionally, the billing company
sorted the reports by ordering provider.
process suffice for the statement needed in Activity 2?
it will suffice. For EQUAL utilization metrics determining whether the patient
received a CT is sufficient and determining whether patients had neurological
deficit is not necessary
ACEP or E-QUAL published any specific literature regarding the ordering of head CTs for patients diagnosed with
current benchmarks regarding CT utilization for syncope have not been well
described. In the future, E-QUAL hopes to publish benchmarks based on data
collected through the subsequent Waves of the Avoidable Imaging learning
2, our billing company can provide the denominator (number of patients which
fit the population criteria), but they cannot provide the numerator (number of
patients who received a CT/MRI) unless we billed for interpretation. We do not
always bill for interpretation, so could our site input confident estimate for
the numerator, instead?
We understand that
obtaining imaging data is of variable difficulty for different sites, but our
hope is that through participation in E-QUAL sites will develop the
relationships and data streams necessary for these basic utilization
measures. The E-QUAL model is designed
to help sites develop capacities in data collection, interpretation and
benchmarking as a core approach to quality improvement.
Rather than submit
estimates for Activity 2, your site can submit Activity 10 and still receive
MIPS credits. Unfortunately, your site will not receive a benchmarking report.
If you do not believe your site will be able to complete either Activities 2 or
10, this may limit the total number of MIPS credit that can be earned as
several Activities require the ability to collect and review actual data.
pediatric patients included in the Chest Pain or Avoidable Imaging IA? If
not, are our PEM physicians excluded from this part of MIPS? They have a
focused on pediatrician patients can participate, but please note that the
benchmarking reports will need to be interpreted carefully; we have not created
a separate data collection mechanism for pediatric-only EDs. We have not
developed specific content or metrics, for the Chest Pain collaborative, that
are specific to pediatric emergency medicine.
your site’s PEM physicians are excluded from MIPS is based on the MIPS
eligibility criteria. For more information on this, please visit the QPP website. If your PEM physicians have a
separate TIN, they will have to report and participate in IA separately.
How can our sites participate in the Chest Pain benchmarking if we do not have access to our site’s records for imaging studies ordered during hospital or observation stays?
For participation in Wave I of the Chest Pain Collaborative, the ability to capture, submit, and benchmark on ED disposition is required, however reporting on imaging metrics is considered optional as data availability may vary between ED sites. We do encourage all sites to build relationships with the hospital, radiology, or cardiology to capture and submit imaging data, as this is a cornerstone to future quality improvement initiatives and will be required in a future Wave of E-QUAL.
Please see the linked data submission guide.
We are trying to complete Activity 2, but we are having some challenges with obtaining data specifically related to the number for each of the types of advanced cardiac imaging that was completed the patients treated during January – March 2017. Can E-QUAL provide some clarification & guidance for obtaining and reporting these values?
This data is optional, and if it cannot be obtained you will receive benchmarking reports limited to the disposition metrics. However, this data is often obtained by partnering with the hospital’s IT group or with the medical or cardiology service that manages the stress testing for hospital patients. They can obtain a list of ED patients that received stress testing and what type. Each of these tests is billed by the hospital using the HCPCS codes provided in the data submission guide.
What is the
minimum time interval in which our ED could safely use for repeat troponin?
EDs use 2, 3, and 4 hour troponin protocols, and these time intervals will be
discussed on several of our Chest Pain webinars. For more information on the
E-QUAL Chest Pain webinar schedule, please check our Chest Pain
Initiative website. All CME approved webinars are worth 1 credit, and are
recorded and posted online every month.
I do not see specific CEDR metrics for reducing avoidable testing and admissions for low risk chest pain patients. How is the data entered/received to measure progress?
While CEDR does not currently include any chest pain metrics, we are working towards integrating CEDR and EQUAL in chest pain in two ways. First, for 2018, we hope to offer the chest pain metrics in CEDR, for EQUAL use only. This is not for quality reporting to CMS, but to reduce your burden in data collection and reporting for EQUAL. In 2017 and 2018, for sites not in CEDR, the chest pain metrics can be collected or calculated by working with your billing company or your hospital IT staff by identifying the chest pain patient based on ICD-10 codes, and then querying the ED disposition for each visit.