Welcome to ACEP’s Clinical Emergency Data Registry
CEDR (Clinical Emergency Data Registry) is the first Emergency Medicine (EM) specialty-wide registry developed by ACEP.
CEDR has the capability and functionality to do the following:
- Measure EM outcomes
- Identify practice patterns and trends
- Improve the quality of acute care
- Meet and exceed QPP/MIPs quality reporting
- Eliminate penalty and/or increase payer revenue
In addition, the CEDR registry ensures that emergency physicians, rather than other parties, are identifying practices that work best for them.
CEDR currently offers 10 ACEP measures (EM specific) and 18 QPP measures that span across 5 domains of care:
- Efficiency and Cost Reduction
- Community/ Population Health
- Effective Clinical Care
- Patient Experience of Care
- Patient Safety
Take a Closer Look – Dr. Stephen Epstein
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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 developed under a sophisticated information technology infrastructure with ongoing development to support emerging quality needs of both ACEP members and nonmembers. This will be implemented in a phased-in manner over the next few years in terms of the number of participating EDs, scope and functionality.
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.
Advantages: CEDR - An Enhancement to Traditional Claims-Based Reporting
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.
Approved by CMS
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 CMS’ Quality Payment Program (QPP) / Merit-Based Incentive Payment Program reporting and regional and national certification requirements.
Evidence-Based Decision Making
National and comparative data generated by the CEDR registry will support evidence-based shared decision making and guideline-informed physician practices.
Comparative Quality Benchmarking
CEDR 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.
For government policy-makers, the CEDR registry will provide further understanding around clinical effectiveness, patient safety, care coordination, patient experience, efficiency and system effectiveness.
- CMS defines a Qualified Clinical Data Registry (QCDR) as a CMS approved entity that strives to improve healthcare quality.
- A QCDR collates data that can be utilized for fulfilling Merit-Based Incentive Payment Plan (MIPS), which is one of the two CMS Quality Payment Program (QPP) tracks.
- QCDRs were constructed for specialty providers to create specialty-specific measures, to promote interoperability, and to reduce reporting burden.
CEDR as a QCDR
- CEDR is a QCDR developed by the American College of Emergency Physicians for Emergency Physicians.
- CEDR collects clinical and/ or billing data for groups and individual MIPS eligible and non-eligible clinicians, research groups, and academic institutions.
- CEDR as a QCDR can be utilized to electronically submit Quality Performance data, Promoting Interoperability (PI) data , and Improvement activities (IA) directly to CMS.
- A QCDR measure is a registry specific metric created to fulfill group, ED, and individual quality outcomes
- A QCDR measure is not a replica of measures in the annual MIPS Measures list published by CMS.
- QCDR measures are approved each year by CMS after being self-nominated by the QCDR vendor.
- CMS allows QCDRs to customize CAHPS, and CMS allows the QCDR measure version of CAHPS to include non-Medicare beneficiaries.
A ‘Qualified Registry’ vs. a ‘QCDR’
QCDRs collate and transfer CMS developed measures and specialty- specific measures that can influence strategic care coordination and Medicare Part B reimbursement. Conversely, A Qualified Registry collates and transfers CMS only developed measures that can influence strategic care coordination and Medicare Part B reimbursement.
Frequently Asked Questions
What is CEDR?
Developed by ACEP, the Clinical Emergency Data Registry (CEDR) is the first Emergency Medicine specialty-wide registry to measure acute care quality, outcomes, practice patterns, and trends in emergency care. The CEDR registry ensures that emergency physicians, rather than other parties, are identifying what practices work best for them.
What are the benefits of participating in CEDR?
- Protection of revenue and ability to gain a bonus.
- MACRA/MIPS compliance.
- Establish national benchmarks for EM-specific quality measures.
- Assists you with easily fulfilling ABEM MOC Part IV (American Board of Emergency Medicine Maintenance of Certification) requirements.
- Facilitate appropriate emergency care research.
How do I access my Dashboard?
- Click Your CEDR Dashboard at the top of this page ↑ to proceed.
- After you click on the CEDR Dashboard Icon it will take you to the login page where you can login with your ACEP ID and Password.
How are the performance categories scores?
What is Quality Performance Category Scoring?
For the 2019 performance period:
- The weight of the Quality performance category is 45% of your MIPS final score.
- Quality measures that can be scored against a benchmark will receive between 3 and 10 points as measure achievement points.
- Quality measures that are not benchmarked by CMS, or do not meet the case minimum (e.g., a denominator of 20), will receive 3 points if data completes is ≥ 60% and if all payers for the reporting period are captured.
What does the onboarding and implementation process for CEDR look like?
- Download and complete the CEDR Interest Form
- Once contacted by a CEDR Specialist, an onboarding form will be sent to gather additional preliminary information.
- Initiate the Contracting Process (this includes a Business Agreement, Clinical Participation Agreement, Billing Vendor Agreement and/or Hospital Contract Agreement).
- Proceed to technical implementation and meet with your CEDR Account Lead. Your CEDR account lead will guide you through the selection of a data extraction method (Pull, Push, or FHIR) and data communication and mapping process.
- Review sample data and provide feedback.
- Run Query on Quality Payment Program Measures for extracted data.
- Dashboard delivery and review.
- Ongoing refresh and review of dashboard enhancements.
What is the cost of CEDR participation?
- A standard Data Processing Fee is applied, which is relative to the annual visit volume for each particular ED.
- Annual Clinician Fee is incurred for each participating clinician (including advanced practice/ midlevel clinicians). This fee is waived if a clinician is or becomes an ACEP member, a clinician group qualifies for 100% club membership, or if advanced practice/midlevel clinicians are members of associated organizations (i.e.: SEMPA) for advanced practice/midlevel providers.
- Additional information regarding the cost of CEDR participation will be provided during the onboarding process, however to learn more, please feel free to EMAIL US TODAY.
CEDR Sign Up Demo
Past Webinars and Educational Resources
With the CEDR Qualified Clinical Data Registry (QCDR) option in 2019, clinicians may choose to report the following QCDR Measures, MIPS Measures, and eCQMs to receive credit for MIPS quality reporting. Quality Improvement (QI) measures and E-QUAL measures are not eligible to be reported for MIPS Quality Reporting through CEDR.
QCDR Measures Supported
|ACEP19||Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older||Efficiency & Cost Reduction||Process||Yes|
|ACEP20||Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years||Efficiency & Cost Reduction||Process||Yes|
|ACEP21||Coagulation Studies in Patients Presenting with Chest Pain with No Coagulopathy or Bleeding||Efficiency & Cost Reduction||Process||Yes|
|ACEP22||Appropriate Emergency Department Utilization of CT for Pulmonary Embolism||Efficiency & Cost Reduction||Process||Yes|
|ACEP25||Tobacco Screening and Cessation Intervention for ED Patients with Cardiovascular and/or Pulmonary Conditions||Community -Population Health||Process||No|
|ACEP30||Sepsis Management: Septic Shock: Lactate Clearance Rate ≥ 10%||Effective Clinical Care||Outcome||Yes|
|ACEP31||Appropriate Foley Catheter Use in the Emergency Department||Patient Safety||Process||Yes|
|ACEP48||Sepsis Management: Septic Shock: Lactate Level Measurement, Antibiotics Ordered, and Fluid Resuscitation||Effective Clinical Care||Process||No|
|ACEP50||ED Median Time from ED arrival to ED departure for discharged ED patients for Adult Patients||Patient Experience of Care||Outcome||Yes|
|ACEP51||ED Median Time from ED arrival to ED departure for discharged ED patients for Pediatric Patients||Patient Experience of Care||Outcome||Yes|
MIPS Measures Supported
|ID||Description||NQS Domain||Type||High Priority|
|QPP65||Appropriate Treatment for Children with Upper Respiratory Infection (URI)||Efficiency & Cost Reduction||Process||Yes|
|QPP66||Appropriate Testing for Children with Pharyngitis||Efficiency & Cost Reduction||Process||Yes|
|QPP76||Prevention of Central Venous Catheter (CVC) - Related Bloodstream Infections||Patient Safety||Process||Yes|
|QPP91||Acute Otitis Externa (AOE): Topical Therapy||Effective Clinical Care||Process||Yes|
|QPP93||Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy Avoidance of Inappropriate Use||Efficiency & Cost Reduction||Process||Yes|
|QPP116||Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis||Efficiency & Cost Reduction||Process||Yes|
|QPP130||Documentation of Current Medications in the Medical Record||Patient Safety||Process||Yes|
|QPP187||Stroke and Stroke Rehabilitation: Thrombolytic Therapy (tPA)||Effective Clinical Care||Process||No|
|QPP254||Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain||Effective Clinical Care||Process||No|
|QPP255||Rh Immunoglobulin (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure||Effective Clinical Care||Process||No|
|QPP317||Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented||Community/Population Health||Process||No|
|QPP326||Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy||Effective Clinical Care||Process||No|
|QPP331||Adult Sinusitis: Antibiotic Prescribed for Acute Sinusitis (Overuse)||Efficiency and Cost Reduction||Process||Yes|
|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||Yes|
|QPP333||Adult Sinusitis: Computerized Tomography for Acute Sinusitis (Overuse)||Efficiency and Cost Reduction||Process||Yes|
|QPP415||Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older||Efficiency & Cost Reduction||Efficiency||Yes|
|QPP416||Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years||Efficiency & Cost Reduction||Efficiency||Yes|
|QPP419||Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination||Efficiency & Cost Reduction||Process||Yes|
ECQMs Measures Supported
|ECQM66||Appropriate testing for children with pharyngitis||Efficiency & Cost Reduction||Process|
|ECQM107||Adult Major Depressive Disorder (MDD): Suicide Risk Assessment||Effective Clinical Care||Process|
|ECQM317||Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented||Community/Population Health||Process|
QI Measures Supported
|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|
|ACEP29||Sepsis Management: Septic Shock: Repeat Lactate Level Measurement||Effective Clinical Care||QI/Process|
*QI measures are not eligible for 2018 MIPS Quality Reporting through CEDR
EQUAL Measures Supported
|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|
For more information on the EQUAL program, visit the Equal Website
*EQUAL measures are not eligible for 2018 MIPS Quality Reporting through CEDR.
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.
- 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.
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.
- 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.
Internship at American College of Emergency Physicians (ACEP)
ACEP is looking to engage Graduate/Senior level college students for a semester of management and IT trainee/internship. The ACEP Internship is one option for experiential learning and is available to selected students enrolled at a participating University in a degree-granting program or have recently completed one.
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.