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E-QUAL Network FAQ

General | Sepsis | Opioid | Stroke



What is the Emergency Quality Network (E-QUAL)?

Emergency Quality Network (E-QUAL) is a collaborative-driven, practice change network tailored to the unique environment of emergency medicine. It is designed to achieve higher quality patient outcomes at lower cost by creating and accumulating meaningful tools targeted at emergency clinicians and quality improvement leaders to advance local quality improvement efforts focused on high-impact areas that demonstrate the value of emergency care.

EDs participate in a virtual learning community by joining a learning collaborative offered annually focusing on a single clinical topic. Each learning collaborative has up to a 9-month learning period in which the ED champion interacts with the E-QUAL virtual portal to report on local quality improvement activities. Activities include completing the online portal activities, engaging eligible providers in the QI local project, utilizing the educational toolkits, webinars, podcasts, and submit benchmarking data.

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What is the mission of the ACEP E-QUAL Network?

To engage emergency clinicians and leverage emergency departments to improve clinical outcomes, coordination of care and to reduce costs.

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What resources and benefits will the learning collaboratives provide to participating sites?

  • Improvement Activity Credit for CMS' Quality Payment Program MIPS
  • eCME Modules
  • Maintenance of Certification (MOC) Assesment of Performance in Practice Credit
  • Benchmarking Performance Reports
  • Data Collection and Data Feedback
  • Access to Educational Toolkits
  • Access to Webinars and Podcasts
  • Office Hours

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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
  • 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

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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.

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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.

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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.

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How do you join the E-QUAL Network?

Visit the E-QUAL homepage and click on the green ‘E-QUAL Initiatives Portal’ button to begin the enrollment process. For questions on how to enroll contact equal@acep.org and a team member will be in touch withing 72 business hours.

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Where can I find more information on the ACEP E-QUAL Network?

For more information on the E-QUAL Network, visit the homepage or contact the E-QUAL team. A team member will be in touch withing 72 business hours.

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When do the E-QUAL Learning Collaboratives become active for participation?

E-QUAL will offer each learning collaborative once a year to maximize participation and to align our offerings with CMS programs, ACEP & ABEM offerings.

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How do we access the E-QUAL portal?

Champions of the participating sites will receive an e-mail invite from “Customer Service” to activate their E-QUAL portal account. For details on how to navigate the E-QUAL portal, please reference the E-QUAL Portal Access Guide.

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Who is responsible for completing the E-QUAL Portal Activities?

Each participating site is required to have at least one Champion (no more than three) who will be responsible for completing that site's E-QUAL portal Activities.

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What is the webinar schedule?

All webinars will be pre-recorded and posted on the E-QUAL website. Please visit the collaborative hompages for additional information.

Sepsis | Opioid | Stroke (Comming Soon)

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What is the process for accessing E-QUAL's eCME content?

Our eCME are accessed from each collaborative homepage: Sepsis | Opioid | Stroke (Comming Soon)

After clicking an eCME 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 eCME.

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Are other clinicians (e.g. 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.

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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 MIPS, CMS will base reimbursement only upon participation.Please note that the quality category is based on actual quality measure scores, and participation in ACEP's CEDR can support your quality reporting needs.

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How does participation in E-QUAL affect our site's ability to avoid MIPS penalties and gain bonuses?

By completing one of the E-QUAL Learning Collaboratives will meet the CMS IA credit requirement. E-QUAL participation does not meet any Quality category requirements. 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.

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Must our site perform a 90-day “best-practices” intervention aligned with CMS IA guidelines?

While the CMS MIPS program has a 90-day requirement per IA, no IA-specific time requirement exists for each E-QUAL learning collaborative. Because the total length of each E-QUAL's learning collaborative exceeds the 90-day requirement, participation is considered sufficient to fully meet all approved IA requirements.

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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.

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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 of Completion 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".

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Will our entire group receive eCME credit if only our clinical leaders listen to the webinar recordings?

No. Each provider that is interested in eCME credit will need to review the webinar and take the post quiz. Note that eCME credit is different from IA credit.

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Which IA can be earned through participation in the E-QUAL Network

Please refer to the linked IA Cross Maps for each collaborative: Sepsis | Opioid | Stroke

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Do our site's clinicians all need to be ACEP members to participate in E-QUAL?

No. Participation in E-QUAL is independent of ACEP membership.

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Does the E-QUAL team review the items we upload in the various Activities to make sure what we have submitted is appropriate and acceptable?

Yes. The E-QUAL team will review all data including uploads that are submitted through the E-QUAL portal. The E-QUAL team will be in contact with the champion if there are any questions or if an uploaded document is incorrect.

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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 unenroll from an E-QUAL collaborative without incurring penalties or inhibiting participation in other E-QUAL Waves or IA activities.

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Does E-QUAL have a non-disclosure agreement for hospital data?

No, we do not have a non-disclosure agreement. However, as stated in our Participation Agreement (available in Activity 1 "Kick-Off"), E-QUAL does not collect data with PHI. All analyses and publications are done with aggregated, de-identified data.

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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 diagnostic coding logic for these methods can be downloaded in Activity 2.

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Are there specific reasons for the quarters given in Activities 2 & 7?

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 2019 (ensuring MIPS IA 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 Sepsis Workgroup for discussion.

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After trying to construct an Electronic Health Record (EHR) query to identify septic shock cases, we are finding that several patients do not have neither sepsis nor 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 (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 should include important Boolean logic:

  • Septic Shock diagnostic code, OR
  • Combination of an Infection AND Hypotension (low blood pressure) diagnostic codes.

Please see the linked data submission guide for Wave IV: Guide.

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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.

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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.

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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 bottom of the 1st page of your site-specific SEP-1 report in the sepsis component compliance table. It should be noted that these recommendations are only conditional.

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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 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 cedr@acep.org.

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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 9 for performing a lactate?

Instead of "Zero", please enter the code "888" if your site does not have the information available.

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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.

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Are transfer outs excluded?

Transfer outs are not excluded as the Sepsis Initiative seeks to improve initial identification and sepsis care including initial lactate testing, IV fluids, and antibiotics.

In the future, please feel free to submit these cases and simply indicate that later care processes such as repeat lactate testing were not done. As you review your reports you can simply ignore the repeat lactate metrics if they do not apply well to your site or review them in comparison to other smaller EDs that may have similar transfer profiles.

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Where does our site submit the attestations for Activities 5?

You will be prompted within each activity to upload a screenshot.

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How many points in Activity 6 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.

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What are the submission dates for Activities 2 & 8?

Activity 2 - May 17, 2019 | Activity 8 - November 15, 2019

Data submission guides and ICD-10 codes sets are available from directly within the Activity.

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For determining is other treatments were administered before opioids, does a 2-5 minute difference between treatments qualify as occurring “prior to opioid therapy”?

As this is not likely reflecting a care pattern that is using an alternative to opioid, as opposed to adjunctive treatment with an opioid, we consider concurrent administration of an opioid with a non-opioid as not occurring “prior to opioid therapy.” In this case the visit should be considered as “No”.

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If more than one opioid treatment is administered, does our site only select the first one given?

Select the first or primary opioid given.:

  • If only two opioids are given, then select first.
  • If more than two doses of opioids are given select the opioid given the most number of times.

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For determining if a benzodiazepine (BDZ) is ordered, does ordering one on d/c, for alcohol withdrawal, qualify as a “Yes”?

Still indicate that a benzodiazepine was administered. Concurrent alcohol and opioid abuse is common. And while BDZ therapy may be indicated for treatment of alcohol withdrawal, such patients may be at higher risk of poor outcomes and should be tracked for quality improvement. Benzodiazapine and opioid co-prescsribing increases risk of overdose, irrespective of the indication for each.

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Should our site only consider falls from a certain height as trauma?

For the purposes of this quick review, any fall warranting evaluation for trauma or workup for possible trauma may be considered a fall.

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Does our site include patients who have been admitted?

For both the Safe Prescribing and the Overdose chart review options, only discharged patients are to be included. This ensures that benchmarking results are easier to interpret between sites.

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Does our site exclude cases in which a patient’s code out and discharge diagnoses are different (e.g. low back pain v. UTI)?

Ideally, such cases should be excluded. We have developed denominator definitions using ICD-10 designed to identify cases with atraumatic low back pain as the primary presentation and need for ED care as opposed to alternative pathologies that may cause back pain. Searching by ICD-10 code should only yield charts with that diagnosis.

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Should our site include charts in which patients are coded for more than one type of pain (e.g. back pain and headache)?

Since sites can only select one target first included charts with only one type of pain. If your system can select charts by primary code, then use charts with multiple types of pain can be used.

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