What are the ACEP Emergency Quality (E-QUAL) Network learning collaboratives?
The ACEP E-QUAL Network offers learning collaboratives in four key areas to demonstrate the value of emergency care:
Improving outcomes for patients with sepsis
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
Reducing opioid-associated harm through safer prescribing and the implementation of evidence-base interventions.
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 four 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 & Enrollmennt
Quality Readiness Assessment Survey
Learning Collaborative Participation Sign Up
Learning Period (6-9 months)
Introduction to tool kits, guidelines and other informational materials
Online E-QUAL Portal Activities
CME and MOC activities
Data and Summary Reports
Lessons Learned Evaluation
eCME & MOC credit
Meet CMS PQRS requirements
What methods of quality improvement will be incorporated across the four learning collaboratives?
Developing quality improvement toolkits for each learning collaborative
Maintenance of Certification (MOC) Assessment of Performance in Practice credit
Data collection and reporting for benchmarking
Aligning clinical quality activities and the CMS Quality Payment Program (QPP)
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)
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
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.
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?
Who should I contact with any questions about E-QUAL?
For more information on how to join the ACEP SAN please contact Nalani Tarrant, Senior 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 our homepage.
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 and can provide access to other points-of-contact. If you are part of a site enrolled into an E-QUAL learning collaborative, please contact your site Champion directly.
What is the anticipated timeline for the launch of the four 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. Enrollment for all 2018 collaboratives is closed until 2019.
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 collaborative hompages for additional information.
What is the process for accessing E-QUAL's eCME content?
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.
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.
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.
How does participation in E-QUAL affect our site's ability to avoid MIPS penalties and gain bonuses?
For 2018, downward adjustments (or a penalties) can be avoided by participating in the program and completing at least one IA (E-QUAL actually can earn you credit for more than one IA) 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 eligibility requirement for bonuses applies to both Quality and IA categories. While CMS has not provided any detailed description of bonus eligibility, we believe that clinicians that receive full IA 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 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.
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 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".
Is the Transforming Clinical Practice Initiative (TCPI) considered an Alternative Payment Model (APM) under QPP?
TCPI is designated an APM under QPP. This designation provides partial scoring credit toward the MIPS IA performance category for those MIPS eligible clinicians participating in TCPI. This assignment rewards MIPS eligible clinicians for implementing clinical practice improvement by participating in the model. Participation in TCPI does not exempt participants from MIPS, nor does it modify reporting requirements under MIPS. Rather, participating MIPS eligible clinicians automatically receive at least partial credit in the IA performance category. Participation in TCPI can only result in a higher overall MIPS score; it will never result in a lower score.
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
Does E-QUAL fulfill the high-weighted activity labeled “Participation in CAHPS or other supplemental questionnaire" that is listed on the QPP MIPS IA summary table?
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 IA/MIPS Requirement”
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.
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. Our team review each sites prortal activity and document submissions. On a montly basis, your site's Champion will receive a progress report depicting complete/incomplete Activities. Also, we will contact your site's Champion directly if an uploaded document is incorrect.
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.
What are the submission dates for Activities 2 & 8?
Activity 2 - March 8, 2019 | Activity 8 - July 12, 2019
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.
Are there specific reasons for the quarters given in Activities 2 & 8?
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.
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.
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.
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 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.
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 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 9 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.
Are transfer outs excluded in Sepsis Wave IV?
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.
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.
What are the submission dates for Activities 2 & 9?
Activity 2 - April 12, 2019 | Activity 9 - July 12, 2019
Can E-QUAL provide some benchmark values for the ideal number or ordered labs and/or radiology studies per patient?
No. 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.
For Activity 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 9 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 9, 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.
Are pediatric patients included in the Chest Pain or Avoidable Imaging IA? If not, are our PEM physicians excluded from this part of MIPS?
The remaining Activities do include pediatric emergency physicians, and activities regarding best practices are still relevant. Whether 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.
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 for Wave IV: Guide.
I 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 Head CTs 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.
Will this process suffice for the statement needed in Activity 2?
Yes, 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.
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?
Yes, 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.
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 impressions or diagnostic codes to identify head injury patients. The Wave IV 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 Head/Syncope CT? Should we include:
Patients coded with both syncope and stroke who received Head CTs in the workup for neurologic deficit, OR
Patients coded with syncope and who received Head CT for head trauma evaluation because of a resulting fall?
The goal of the Head/Syncope CT measure is to identify isolated syncope cases or cases in which syncope is the reason for ordering the CT.
The patients who received Head CTs 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.
Have either ACEP or E-QUAL published any specific literature regarding the ordering of Head CTs for patients diagnosed with syncope?
To date, 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 collaborative.
Would the CT Utilization numerator for Minor Head Trauma be calculated regardless of diagnosis code and patient age?
The numerator is calculated after the denominator, so it would only include patients getting an imaging study among those with the 21 diagnosis codes and with the age restriction.
Should the CPT code 70450 be included in the calculation for Head CT Yield numerator for Minor Head Trauma?
CPT code 70450 is first used to capture all patients getting a CT scan for the denominator. It is unlikely, however, a patient with a positive diagnosis (e.g. subdural hemorrhage) and not given a CT scan would not be included in this measure. The codes included as a positive for the numerator are a subset of the codes that include both positive and negative studies in the denominator.
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.
For Question 1 (Activity 2), which value should be included for Total Adult Visits: Total Back Pain visits or Total ED Visits?
We are looking for Total Annual ED Visits. After selecting a specific target metric, the activity will ask for that specific visit count.
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?
Our 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.
What are the submission dates for Activities 2 & 9?
Activity 2 - April 19, 2019 | Activity 9 - July 12, 2019
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 III 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 for Wave III: 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 October – December 2018. 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?
Many 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 page. All CME approved webinars are worth 1 credit, and are recorded and posted online every month.
What are the submission dates for Activities 2 & 8?
Activity 2 - May 17, 2019 | Activity 8 - November 15, 2019
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”.
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.
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-prescribing increases risk of overdose, irrespective of the indication for each.
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.
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.
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.
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.