CEDR - Clinical Emergency Data Registry

Overview: Welcome to ACEP’s Clinical Emergency Data Registry

Upcoming Webinars

Reporting MIPS through CEDR Webinar
Mar 13, 2018 1:00 PM CDT

In depth review of the steps and process involved using CEDR for Group or Individual 2018 MIPS Reporting. Topics for this webinar will include selection of reportable measures, Advancing Care Information data entry, and Improvement Activity reporting through CEDR. After registering, you will receive a confirmation email containing information about joining the webinar.

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CEDR Quality Measures Webinar
May 8, 2018 1:00 PM CDT

A review of quality performance measures that are included in CEDR for 2018 reporting. After registering, you will receive a confirmation email containing information about joining the webinar.

Register Today!

A brief introduction video on CEDR with Dr. Stephen Epstein

As part of its ongoing commitment to providing the highest quality of emergency care, ACEP has developed the Clinical Emergency Data Registry (CEDR). This is the first Emergency Medicine specialty-wide registry at a national level, designed to measure and report healthcare quality and outcomes. It will also provide data to identify practice patterns, trends and outcomes in emergency care. CEDR is an evolving registry, which will support emergency physicians’ efforts to improve quality and practice in all types of EDs even as practice and payment policies change over the coming years. CEDR has been approved as "qualified clinical data registry" or QCDR by the Centers for Medicare and Medicaid Services to help emergency physicians and clinicians meet both CMS’ Physician Quality Reporting System (PQRS) reporting and potentially regional and national certification requirements.

Why Should You Participate?

Instead of being mired in an alphabet soup of reporting requirements, CEDR allows for a single data capture to fulfill the requirements of multiple programs, making your quality measure reporting more efficient. The healthcare environment is transitioning from volume-based to value-based payment for care. The CEDR registry will ensure that emergency physicians, rather than other parties, are identifying what practices work best and for whom.

The CEDR registry is being developed implemented under a sophisticated information technology infrastructure with ongoing development to support emerging quality needs of ACEP members. and will be implemented in a phased-in manner over the next year in terms of the number of participating EDs, scope and functionality. The initial testing and QCDR approval phase began in February 2015 with the participation of 5 EDs and is now being deployed to more than 800 EDs across the nation. and is now fully deployed.. Through the aggregation and organization of data on clinical effectiveness, patient safety, care coordination, patient experience, efficiency and system effectiveness, CEDR will provide clinicians with a definitive resource for informing and advancing the highest quality of emergency care.

CEDR Presentation Video at ACEP15

How can I get more information about CEDR?

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Advantages: ACEP’s CEDR is Better than Traditional PQRS QPP Reporting. Here’s Why:

A Physician Friendly System

The CEDR registry is designed to be physician-friendly. With little data entry burden to emergency clinicians or ED staff, clinical and patient data will be extracted, transformed and loaded into CEDR from the ED’s electronic health record system, practice management system, or administrative data system.

National and comparative data generated by the CEDR registry will support evidence-based shared decision making and guideline-informed physician practices. It will provide participating emergency clinicians with feedback regarding their individual- and/or ED-level performance on a range of process and outcome quality measures, benchmarked against their peers at national and regional levels. ACEP has been approved by the Centers for Medicare and Medicaid Services (CMS) for CEDR to serve as a “qualified clinical data registry” or QCDR, to help emergency physicians and clinicians meet both the CMS’ Physician Quality Reporting System (PQRS) reporting and regional and national certification requirements. For government policy-makers, the CEDR registry will provide further understanding around clinical effectiveness, patient safety, care coordination, patient experience, efficiency and system effectiveness.

Traditional MIPS registries Qualified Clinical Data Registries (QCDRs)
Provide quality data for Medicare patients only Provides quality data on patients from all payers
Limited to QPP measures Includes QPP measures plus up to 30 additional specialty specific measures
Requires new "cross-cutting" measures Does not require "cross-cutting" measure
Less control over quality measures reported More meaningful measures to choose from

How can I get more information about CEDR?

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About QCDRs

What is a Clinical Data Registry?

  • As part of its ongoing commitment to providing the highest quality of emergency care, ACEP has developed the CEDR registry, which has been qualified by CMS as a qualified clinical data registry (QCDR) for the 2017 Performance Year.
  • CEDR is the first Emergency Medicine specialty-wide registry at a national level, designed to measure and report healthcare quality and outcomes.
  • It will also provide data to identify practice patterns, trends and outcomes in emergency care.

What is a CMS Qualified Clinical Data Registry?

  • Provide a unified method for ACEP members to collect and submit Merit-Based Incentive Payment System (MIPS) data, MOC, OCC, Ongoing Professional Practice Evaluation (OPPE), outcome data, and other related or applicable quality and patient safety data to meet quality improvement and regulatory requirements.
  • Promote the highest quality of emergency care for our patients.
  • Demonstrate the value of emergency care.
  • Facilitate appropriate emergency care research.

What are the Benefits of CEDR?

  • Increased Medicare revenue Potentially increased revenue from private payers
  • Potentially increased revenue from private payers
  • Participation can cover all of your quality measure reporting requirements
  • TJC Ongoing Professional Practice Evaluation (OPPE)/ Focused Professional Practice Evaluation (FPPE) compliance
  • MOC Part IV activities (in conjunction with an ABEM approved MOC program) and MOL activities
  • Qualifies as a specialized registry for Meaningful Use (MU) Modified Stage 2 and 3 for Eligible Hospital and Critical Access Hospitals

Why Eligible Hospitals (EH) and Critical Access Hospitals (CAH) should participate in the CEDR registry?

  • CEDR is the most relevant specialized registry for EHs and CAHs under MU Modified Stage 2 and Stage 3
  • By submitting MU data to CEDR, EHs and CAHs may receive 1 credit for specialized registry submission (*Note: Although Emergency physicians do not qualify for MU, EHs and CAHs do)
  • EHs/CAHs can easily develop and monitor their level of quality measurement and improvement matrix
  • Provides EHs/CAHs the ability to identify interventions necessary to improve quality of care the hospital level

How can I get more information about CEDR?

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Frequently Asked Questions

ABEM-centric description of advantages of participation in CEDR

The ABEM Maintenance of Certification (MOC) Improvement in Medical Practice (IMP) requirements contribute to better patient care through ongoing assessment and improvement in the quality of care provided by you in the emergency department.

Participation in CEDR will assist you to easily fulfill this MOC requirement provided you:

  • Sign in and review your performance on the CEDR dashboard
  • Allow six months to ensure any substantive changes in your clinical practice have been accounted for in CEDR
  • Sign in and review your performance on the CEDR dashboard a second time to compare your performance
  • ABEM will receive notification each time you review your data, but will not have access to your individual performance on any CEDR measure. ABEM will not use this data to analyze individual performance on CEDR measures.

If you have any questions about how participation in CEDR gives you credit for your IMP requirement, please call ABEM at (517) 332-4800, ext. 383.

What is the Clinical Emergency Data Registry?

  • ACEP has developed the CEDR registry, as part of its ongoing commitment to provide the highest quality of emergency care.
  • CEDR is a qualified clinical data registry (QCDR) designated by CMS for the 2015 Performance Year.
  • CEDR is the first Emergency Medicine specialty-wide registry at a national level, designed to measure healthcare quality, outcomes, practice patterns and trends in emergency care.

What are the goals of CEDR?

  • To provide a unified method for ACEP members to collect and submit Merit-Based Incentive Payment System (MIPS) data, MOC, Ongoing Professional Practice Evaluation (OPPE), and other related and applicable quality and patient outcome elements to meet quality improvement and regulatory requirements.
  • To promote the highest quality of emergency care for patients.
  • To demonstrate the value of emergency care.
  • To facilitate appropriate emergency care research.

What is at risk for the Merit-Based Incentive Payment System (MIPS)?

Merit-Based Incentive Payment System Chart

What are the Benefits of CEDR?

  • Participation allows emergency physicians the opportunity to get MIPS credit for reporting more meaningful measures.
  • Increased Medicare revenue by avoiding penalties (up to 4% for the 2017 performance year).
  • Potential increased revenue from private payers.
  • Participation can cover all of your quality measure reporting requirements such as MOC Part IV activities (in conjunction with an ABEM approved MOC program), TJC Ongoing Professional Practice Evaluation (OPPE) compliance.

Why should Emergency Physicians participate in the CEDR registry?

  • Instead of being mired in an alphabet soup of reporting requirements, CEDR allows for a single data capture to fulfill the requirements of multiple programs, making quality measure reporting easier and more efficient.
  • The healthcare environment is transitioning from volume-based to value-based payment for care.
  • The CEDR registry will ensure that emergency physicians, rather than other parties, are identifying what practices work best and for whom.

What is the cost of CEDR participation?

  • There are two types of fee charged:
    1. CEDR transaction fee based on visit volume = $0.25 per visit
    2. Annual User fee = $100 per provider (ED Physician and Advanced Practice Provider)
  • The $100 Annual User Fees are waived for ACEP members and 100% Club for ACEP. For groups, hospitals, etc. where 100% of eligible ED providers are members of ACEP, the $100 fee is waived for all other provider’s ineligible to be ACEP members – i.e., non-boarded docs, APPS (PA and NP). For groups that are not 100% Club, only their ACEP members qualify for the waived fee, and all others - eligible docs and all ineligible people would pay the $100 annual user fee.

Will CEDR report our data directly to CMS for the Merit-Based Incentive Payment System (MIPS)

  • Once CEDR participants have signed a data release consent form, have reviewed their feedback, and selected the 6 measures, including one outcome measure, then, CEDR will submit a member’s measures to CMS for MIPS reporting purposes.
  • The final date to confirm interest in CEDR for 2016 participation is June 30, 2017, after that date physician groups would be signing up for the 2018 performance year.

Are physicians and physician groups able to review their data before it is sent to CMS?

  • Yes, qualified clinical data registries (QCDRs) are required to provide feedback reports to all participants a minimum of four times per year. Our technology partner FIGmd will provide members with a client account manager and a mapping analyst who will work to obtain data for all 44 measures in CEDR. Then the individual physician or group administrator will decide which 9 of the 41 measures should be reported to CMS.

How can I get more information about CEDR?

Email us today

2018 Measures

With the CEDR Qualified Clinical Data Registry (QCDR) option in 2018, emergency physicians and clinicians may choose to report the following QCDR Measures, QPP Measures, and eCQMs to receive credit for MIPS quality reporting. Quality Improvement (QI) measures and EQUAL measures are not eligible to be reported for MIPS Quality Reporting through CEDR.

QCDR Measures Supported

Scroll Table
ID Description Domain Type
ACEP19 Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Efficiency & Cost Reduction Process
ACEP20 Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Efficiency & Cost Reduction Process
ACEP21 Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding Efficiency & Cost Reduction Process
ACEP22 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism Efficiency & Cost Reduction Process
ACEP24 Pregnancy Test for Female Abdominal Pain Patients Patient Safety Process
ACEP25 Tobacco Screening and Cessation Intervention for ED Patients with Cardiovascular and/or Pulmonary Conditions Community -Population Health Process
ACEP29 Sepsis Management: Septic Shock: Repeat Lactate Level Effective Clinical Care Process
ACEP30 Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10% Effective Clinical Care Outcome
ACEP31 Appropriate Foley Catheter Use in the Emergency Department Patient Safety Process
ACEP32 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients Patient Experience of Care Outcome
ACEP33 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Supercenter EDs (80+) Patient Experience of Care Outcome
ACEP35 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in High Volume EDs (60k-79,999) Patient Experience of Care Outcome
ACEP36 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Average Volume EDs (40k- 59,999) Patient Experience of Care Outcome
ACEP37 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Moderate Volume EDs (20k- 39,999) Patient Experience of Care Outcome
ACEP38 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Low Volume EDs (19,999 and less) Patient Experience of Care Outcome
ACEP39 ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients in Freestanding EDs Patient Experience of Care Outcome
ACEP40 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients Patient Experience of Care Outcome
ACEP41 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Supercenter EDs (80k +) Patient Experience of Care Outcome
ACEP43 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in High Volume EDs (60k-79,999) Patient Experience of Care Outcome
ACEP44 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Average Volume EDs (40k-59,999) Patient Experience of Care Outcome
ACEP45 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Moderate Volume EDs (20k-39,999) Patient Experience of Care Outcome
ACEP46 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Low Volume EDs (19,999 and less) Patient Experience of Care Outcome
ACEP47 ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients in Freestanding EDs Patient Experience of Care Outcome
ACEP48 Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation Effective Clinical Care Process

Download QCDR Measures PDF

QPP Measures Supported

Scroll Table
ID Description NQS Domain Type
QPP66 Appropriate Testing for Children with Pharyngitis Efficiency & Cost Reduction Process
QPP76 Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections Patient Safety Process
QPP91 Acute Otitis Externa (AOE): Topical Therapy Effective Clinical Care Process
QPP93 Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of Inappropriate Use Efficiency & Cost Reduction Process
QPP116 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis Efficiency & Cost Reduction Process
QPP187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy (tPA) Effective Clinical Care Process
QPP254 Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain Effective Clinical Care Process
QPP255 Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure Effective Clinical Care Process
QPP317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Community/Population Health Process
QPP326 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Effective Clinical Care Process
QPP331 Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse) Efficiency and Cost Reduction Process
QPP332 Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin With or Without Clavulanate Prescribed for Patient with Acute Bacterial Sinusitis (Appropriate Use) Efficiency and Cost Reduction Process
QPP333 Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse) Efficiency and Cost Reduction Process
QPP415 Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older Efficiency & Cost Reduction Process
QPP416 Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years Efficiency & Cost Reduction Process
QPP419 Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination Efficiency & Cost Reduction Efficency

CMS QPP Measures Website

ECQMs Measures Supported

Scroll Table
ID Description Domain Type
ECQM66 Appropriate testing for children with pharyngitis Efficiency & Cost Reduction Process
ECQM317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Community/Population Health Process

QI Measures Supported

Scroll Table
ID Description Domain Type
ACEPQI01 Sepsis Management: Septic Shock: Blood Cultures Ordered Effective Clinical Care QI/Process
ACEPQI02 Emergency Medicine: Appropriate Use of Imaging for Recurrent Renal Colic Efficiency: Overuse QI/Process
ACEP26 Sepsis Management: Septic Shock: Lactate Level Management Effective Clinical Care QI/Process
ACEP27 Sepsis Management: Septic Shock: Antibiotics Ordered Effective Clinical Care QI/Process
ACEP28 Sepsis Management: Septic Shock: Fluid Resuscitation Effective Clinical Care QI/Process

Download CEDR QI Measures PDF

*QI measures are not eligible for 2018 MIPS Quality Reporting through CEDR.

IA Activities

Scroll Table
Subcategory IA ID IA Name Description Weitage
Beneficiary Engagement IA-BE-6 Care coordination agreements that promote improvements in patient tracking across settings Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan. High
Beneficiary Engagement IA-BE-14 Engage patients and families to guide improvement in the system of care. Engage patients and families to guide improvement in the system of care. Medium
Beneficiary Engagement IA-BE-21 Improved practices that disseminate appropriate self-management materials Provide self-management materials at an appropriate literacy level and in an appropriate language. Medium
Beneficiary Engagement IA-BE-12 Use evidence-based decision aids to support shared decision-making. Use evidence-based decision aids to support shared decision-making. Medium
Patient Safety and Practice Assessment IA-PSPA-4 Administration of the AHRQ Survey of Patient Safety Culture Administration of the AHRQ Survey of Patient Safety Culture and submission of data to the comparative database (refer to AHRQ Survey of Patient Safety Culture website http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html) Medium
Patient Safety and Practice Assessment IA-PSPA-17 Implementation of analytic capabilities to manage total cost of care for practice Build the analytic capability required to manage total cost of care for the practice population that could include one or more of the following: Train appropriate staff on interpretation of cost and utilization information; and/or Use available data regularly to analyze opportunities to reduce cost through improved care. Medium
Patient Safety and Practice Assessment IA-PSPA-15 Implementation of antibiotic stewardship program Implementation of an antibiotic stewardship program that measures the appropriate use of antibiotics for several different conditions (URI Rx in children, diagnosis of pharyngitis, Bronchitis Rx in adults) according to clinical guidelines for diagnostics and therapeutics Medium
Patient Safety and Practice Assessment IA-PSPA-19 Implementation of formal quality improvement methods, practice changes or other practice improvement processes Adopt a formal model for quality improvement and create a culture in which all staff actively participates in improvement activities that could include one or more of the following: Train all staff in quality improvement methods; Integrate practice change/quality improvement into staff duties; Engage all staff in identifying and testing practices changes; Designate regular team meetings to review data and plan improvement cycles; Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff; and/or Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families. Medium
Patient Safety and Practice Assessment IA-PSPA-20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance. Medium
Patient Safety and Practice Assessment IA-PSPA-18 Measurement and improvement at the practice and panel level Measure and improve quality at the practice and panel level that could include one or more of the following: Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or MIPS eligible clinician or group(panel); and/or Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level. Medium
Patient Safety and Practice Assessment IA-PSPA-2 Participation in MOC Part IV Participation in Maintenance of Certification (MOC) Part IV for improving professional practice including participation in a local, regional or national outcomes registry or quality assessment program. Performance of monthly activities across practice to regularly assess performance in practice, by reviewing outcomes addressing identified areas for improvement and evaluating the results. Medium
Patient Safety and Practice Assessment IA-PSPA-16 Use of decision support and standardized treatment protocols Use decision support and standardized treatment protocols to manage workflow in the team to meet patient needs. Medium
Care Coordination IA-CC-12 Care coordination agreements that promote improvements in patient tracking across settings Establish effective care coordination and active referral management that could include one or more of the following: Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/or Systematically integrate information from referrals into the plan of care. Medium
Care Coordination IA-CC-10 Care transition documentation practice improvements Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.). Medium
Care Coordination IA-CC-11 Care transition standard operational improvements Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or Partner with community or hospital-based transitional care services. Medium
Care Coordination IA-CC-5 CMS partner in Patients Hospital Engagement Network Membership and participation in a CMS Partnership for Patients Hospital Engagement Network. Medium
Care Coordination IA-CC-4 TCPI participation Participation in the CMS Transforming Clinical Practice Initiative. High
Population Management IA-PM-15 Implementation of episodic care management practice improvements Provide episodic care management, including management across transitions and referrals that could include one or more of the following: Routine and timely follow-up to hospitalizations, ED visits and stays in other institutional settings, including symptom and disease management, and medication reconciliation and management; and/or Managing care intensively through new diagnoses, injuries and exacerbations of illness. Medium
Population Management IA-PM-7 QCDR Participation Use of a QCDR to generate regular feedback reports that summarize local practice patterns and treatment outcomes,
including for vulnerable populations.
High
Behavioral and Mental Health IA-BMH-2 Tobacco use Tobacco use: Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including tobacco use screening and cessation interventions (refer to NQF #0028) for patients with co-occurring conditions of behavioral or mental health and at risk factors for tobacco dependence. Medium
Care Coordination IA-CC-8 Implementation of documentation improvements for practice/process improvements Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure). Medium
Behavioral and Mental Health IA-BMH-4 Depression screening and follow-up plan Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions, including depression screening and follow-up plan (refer to NQF #0418) for patients with co-occurring conditions of behavioral or mental health conditions. Medium
Behavioral and Mental Health IA-BMH-5 Major depressive disorder Regular engagement of MIPS eligible clinicians or groups in integrated prevention and treatment interventions including suicide risk assessment for mental health patients with co-occurring conditions of behavioral or mental health conditions Medium
Patient Safety & Practice Assessment IA-PSPA-6 Consultation of the Prescription Drug Monitoring program Clinicians would attest that, 60 percent for first year, or 75 percent for the second year, of consultation of prescription drug monitoring program prior to the issuance of a Controlled Substance Schedule II (CSII) opioid prescription that lasts for longer than 3 days. High
Achieving Health Equity IA-AHE-1 Engagement of new Medicaid patients and follow-up Seeing new and follow-up Medicaid patients in a timely manner, including individuals dually eligible for Medicaid and Medicare. High
Patient Safety & Practice Assessment IA-PSPA-8 Use of patient safety tools Use of tools that assist specialty practices in tracking specific measures that are meaningful to their practice, such as use of the Surgical Risk Calculator. Medium
Population Management IA-PM-10 Use of QCDR for Quality Improvement Participation in a QCDR, clinical data registries, or other registries run by other government agencies such as FDA, or private entities such as a hospital or medical or surgical society. Activity must include use of QCDR data for quality improvement (e.g., comparative analysis across specific patient populations for adverse outcomes after an outpatient surgical procedure and corrective steps to address adverse
outcome).
Medium
Patient Safety & Practice Assessment IA-PSPA-20 Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes Ensure full engagement of clinical and administrative leadership in practice improvement that could include one or more of the following: Make responsibility for guidance of practice change a component of clinical and administrative leadership roles; Allocate time for clinical and administrative leadership for practice improvement efforts, including participation in regular team meetings; and/or Incorporate population health, quality and patient experience metrics in regular reviews of practice performance.

EQUAL Measures Supported

Scroll Table
ID Description
EQUAL1 CT utilization for back pain
EQUAL2 EQUAL 2 XRay utilization for back pain
EQUAL3 MRI utilization for back pain
EQUAL4 CT utilization for minor head injury
EQUAL5 CT yield for minor head injury
EQUAL6 CT for renal colic
EQUAL7 CT for syncope
EQUAL8 CT utilization for pulmonary embolism
EQUAL9 CT yield for pulmonary embolism
EQUAL10 Chest pain admission rate
EQUAL11a Disposition among ED visits for chest pain -Discharges
EQUAL11b Disposition among ED visits for chest pain - Observation
EQUAL11c Disposition among ED visits for chest pain - Inpatient Admission
EQUAL11d Disposition among ED visits for chest pain – Transfers
EQUAL12a Stress testing and imaging among ED visits for chest pain - Stress ECG
EQUAL12b Stress testing and imaging among ED visits for chest pain - Stress Nuclear, SPECT
EQUAL12c Stress testing and imaging among ED visits for chest pain - Stress Nuclear, PET
EQUAL12d Stress testing and imaging among ED visits for chest pain - Stress Echocardiogram
EQUAL12e Stress testing and imaging among ED visits for chest pain - Coronary CT Angiography
EQUAL12f Stress testing and imaging among ED visits for chest pain - Stress Cardiac MR

Download EQUAL Measures PDF

For more information on the EQUAL program, visit the Equal Website

*EQUAL measures are not eligible for 2018 MIPS Quality Reporting through CEDR.

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News

Call for performance measure topics

ACEP’s Clinical Emergency Data Registry (CEDR) is soliciting new topics for performance measure development from March 28-April 27th. All ACEP members are invited to submit a topic relevant to emergency medicine. Submissions for consideration will be reviewed and prioritized based on strength of evidence, opportunity for quality improvement, and impact on the specialty.

Submit Performance Measure Topic

QMs Scoring Rubric PDF

How can I get more information about CEDR?

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Participate Steps

Participant Questionnaire

  • Your group provides CEDR with information on group size, number of hospital EDs served, annual ED census, number of emergency clinician providers and contact information for each ED.

CEDR Sign Up Portal

Participation Agreement and Business Associate Agreement

  • The Participation Agreement is a vehicle to create common understanding and agreement of participation and expectations. It also includes the Business Associate Agreement and the Data Use Agreement for HIPPA compliance.

Initial Data Capture

  • All data extract and upload activity is fully encrypted and complies with HIPAA guidelines. We have successfully mapped data from over 50 different EHR systems.

RCMS / EHR Mapping

  • This step involves Group Administrator participation. A Client Account Manager (CAM) will engage the group in discussion to ensure accurate data mapping.

Report Generation

  • The Client Account Manager will coordinate calls with the group to review performance reports and answer questions. Typically during this step, the group will get access to an interactive dashboard. The dashboard gives the group the ability to query their data, see measure performance across different measures for multiple locations and providers.

Installation of the Registry Practice Connector (RPC)

  • Our standard integration method involves the installation of a piece of software known as the Registry Practice Connector which runs as a Windows service. This service is integrated with the Revenue Cycle Management (RCM) system and/or Electronic Health Record (EHR) database using read-only credentials for the back end RDBMS (i.e. Microsoft SQL Server, etc.).
  • The Registry Practice Connector allows us a great deal of flexibility in mapping data elements required by the registry and usually requires no involvement of the RCM &/or EHR vendor beyond providing read-only credentials to the database in situations that require it.
  • Our goal is to have minimal impact and require little if any work effort on the part of the RCM / EHR vendor and/or the group IT staff.
  • In situations where RPC installation is not possible, the registry can accept data files from the participating site or the RCM / EMR vendor via the data push method. Files are typically transferred via secure file transport protocol (SFTP). However, we encourage participation thru the data pull method via the Registry Practice Connector to reduce the burden of data collection and reporting on the ED providers and RCM firms.

How can I get more information about CEDR?

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