❖ Data, Measures & Performance Improvement

✓ Measure Up: Why ED Throughput Matters

ED throughput is how quickly and efficiently patients move through the emergency department system. Efficient throughput improves patient outcomes, hospital capacity, staff workflow, and Hospital Efficiency Regulatory Reporting. Poor throughput can cause ED overcrowding, delayed treatment, and higher complication rates.

CMS Throughput Reporting

Electronic Health Records use timestamps to generate reports required for quality reporting programs, such as those of the Centers for Medicare & Medicaid Services. These measures rely heavily on accurate arrival and discharge timestamps.

• OP-18: Median time from ED arrival to ED departure for discharged patients
• OP-22: Median time from ED arrival to ED departure for admitted patients

Common EHR configuration mistakes can lead to incorrect ED discharge timestamps, which affect ED throughput metrics and quality reporting to CMS. Here are real-life ED workflow situations that commonly cause discharge time capture errors. These examples show how normal operational steps can lead to incorrect timestamps in EHR.

1. Provider places the DC order late

Real workflow scenario: Pt evaluated and treated → Provider verbally tells nurse, "Patient can go." → RN begins discharge instructions → Provider gets busy with another patient → Discharge Order entered later in EHR.

2. Nurse Completes Documentation After Patient Leaves

Real workflow scenario: Provider places discharge order → Nurse gives verbal instructions and removes the IV → Patient leaves quickly → Nurse documents discharge later when workload allows.

3. Waiting for Discharge Instructions or Prescriptions

Real workflow scenario: Provider decides to discharge → Nurse waits for printed instructions, electronic prescriptions, follow-up paperwork → Documentation may occur at different times.

Why these errors matter: Incorrect discharge times affect Throughput Quality Measures, including: ED Length of Stay (LOS), Door to Discharge time, CMS outpatient quality measures, ED Crowding Analysis, and Operational performance reporting.

✓ From Chart to Change

Here are recent scenarios regarding quality measure reporting and the importance of accurate documentation and re-abstraction.

Scenario 1: Cath Lab Documentation - NCDR Cath/PCI Registry Focus

Stress Test Documentation Requirements:

• Stress test performed before the procedure.
• Documented date of the stress test.
• Type of stress test noted (e.g., exercise stress, stress echo, stress nuclear, or Stress Image with CMR).
• Level of risk clearly documented (e.g., low, intermediate, or high risk).
• Results are described clearly and consistently with the risk assessment.

Scenario 2: Numerator Exclusion Trigger

Scenario: A chart initially met the numerator for a quality measure.
Change: Post-discharge documentation clarified a condition that triggered an exclusion.
Outcome: The chart required a re-review to ensure accurate and compliant reporting.

✓ Data to Difference

Objective: To ensure that abstraction decisions are defensible, repeatable, and fully aligned with current specifications.

Frequently encountered common challenges:

• Documentation Timeliness: We need to ensure documentation is completed promptly to accurately capture data fields that impact star ratings and outcome measures.
• Consistency in Interpretation: Inconsistent interpretation of exclusion logic across the abstraction team.
• Data Accessibility: Key details are frequently located in scanned documents rather than in structured fields or free-text notes, which complicates data retrieval.

❖ Compliance Corner

Consistency is the foundation of compliance. Even small differences in interpretation can lead to missed exclusions, inconsistent results, and increased audit risks.

Helpful Tips:

• Review internal timelines to allow for re-abstraction before final submission
• Ensure abstraction notes clearly justify inclusion or exclusion decisions
• Maintain a centralized reference for the interpretation of measures
• Define a process for handling late documentation

Deadline Watch

Hospital Quality Reporting Important Dates and Deadlines (All dates are subject to change.)

CMS Hospital IQR Program & HAC Reduction Programs

Validation Deadlines

eCQM Validation

FY 2027 APU

FY 2028 APU

Total Hip Arthroplasty / Total Knee Arthroplasty (THA/TKA) PRO-PM Reporting

¹ The HCAHPS deadline has been extended by one week due to the new survey being implemented beginning with CY 2025 discharges.
² Submission deadline falls on a weekend or holiday and is moved to the next business day.
³ Hospital Acquired Condition (HAC) Reduction Program Healthcare-Associated Infection (HAI) measures include CAUTI, CLABSI, SSI (Colon & Abdominal Hysterectomy), MRSA, and CDI.
⁴ Web-based structural measures include mandatory reporting of Maternal Morbidity, Age-friendly, and Patient Safety.

Hospital Quality Reporting: Important Dates and Deadlines

• Generally, data must be submitted no later than 11:59 PST on the submission deadline, except for HCAHPS, which must submit by 11:59 CST.
• Data for clinical measures, eCQMs, hybrid core clinical data elements, structural measures, population and sampling, DACA, and THA/TKA PRO-PM are transmitted within the HQR Secure Portal.
• HAI validation Template data are transmitted within the HQR Secure Portal via Unified File Management (UFM), Managed File Transfer (MFT).
• HAI, CAUTI-Onc, CLABSI-Onc, Influenza, and patient safety Structural measure data are submitted to the CDC through NHSN.

Data Submission Guidelines

Data Submissions must be timely, accurate, and complete.

Collect chart-abstracted clinical data for each quarter and submit these data by the deadline. For the CY 2028 payment determination, the applicable patient encounter quarters for chart-abstracted data are as follows:

Note: Hospitals with fewer claims per quarter for any measure (e.g., Stroke) will not be required to submit patient-level data for that measure for that quarter, though voluntary submission is allowed.

Web-Based Measures: Data submission opens Jan 1, 2027 through May 17, 2027 for CY 2026 encounters.

Patient Survey Measures (HCAHPS):

eCQMs: For CY 2028 payment determination, three self-selected quarters of data from CY 2026 reporting period are required. The submission deadline is May 17, 2027.

Hospital Outpatient Quality Reporting (OQR) Program Validation Efforts

Every year, CMS selects up to 500 hospitals for data validation of chart-abstracted measures through the Hospital OQR Program. Selection for CY 2027 payment determination was completed in August 2025.

CY 2027 OQR Estimated Medical Records Request Dates

Direct Difference serves as your abstraction partner for all clinical data and provides full validation support for both randomly selected and targeted facilities at no extra cost. Please follow this process each quarter upon receiving your selected patient list:

1. 1Post Case Selection: Immediately upload the case selection Excel file to the shared drive and notify your Account Manager and Clinical Liaison. Direct Difference will then conduct a second review of each case.
2. 2Share PDF Charts: Once your HIM team has the PDF charts ready, post them to the shared drive. This allows us to locate all data elements, identify chart nuances, verify EMS records, and ensure no inappropriate documentation is present.
3. 3Await Clearance: Direct Difference will review all PDF charts and notify your facility when the charts are ready for submission for that quarter.
4. 4Review Results Together: Post your validation results to the shared drive immediately. In the event of a mismatch, Direct Difference will investigate and, if validators are incorrect, prepare an educational review for submission before the 30-day deadline.

✓ CMS Compass

Updates and Clarifications: IQR / OQR Measure Retirement & Additions

CMS has updated the 2026 Hospital Inpatient Quality Reporting (IQR) Program. Key updates include:

• Removed Measures: COVID-19 vaccination coverage and health equity/SDOH measures are being removed.
• New Requirements: Two oncology-stratified Healthcare-Associated Infection (HAI) measures and additional hospital-harm eCQMs have been added.
• Hybrid Measures: Lowered reporting thresholds and provisions allowing limited missing data.
• Claims-Based Measures: Measures such as COMP-HIP-KNEE and MORT-30-STK now include Medicare Advantage patients and utilize a shorter 2-year performance window with ICD-10 coding.
• Future Adjustments: Removal of COVID-19 exclusions across measures starting FY 2028.

Office Hours: Your Questions Answered

This newsletter is one of the many ways Direct Difference supports our partners by sharing insights drawn from actual abstraction experience across hospitals nationwide. If there are specific topics you would like us to cover in a future issue, or if you have questions, please reach out to your Direct Difference contact or email us at ASKDD@directdifference.com.

✓ Common Client Question of the Month

The Difference Update

✓ Direct Difference New Service Capabilities — Message from CEO Debra Aruffo

"At the heart of Direct Difference, Inc. is a steadfast commitment to loyalty, integrity, and long-term partnership. We seek to cultivate enduring relationships with healthcare leaders—partnerships grounded in trust, transparency, and a shared responsibility to advance the quality of care.

As part of this commitment, we have strategically expanded our services to include abstraction of the Cancer Registry and the Trauma Registry. This expansion reflects our continued investment in supporting hospitals and health systems as they navigate increasing regulatory complexity, accreditation requirements, and quality improvement expectations.

High-quality cancer and trauma registry data are foundational to outcomes analysis, performance benchmarking, research advancement, and reimbursement integrity. Our expanded team brings deep expertise in registry standards, compliance frameworks, and rigorous clinical abstraction to ensure that data is accurate, reliable, and decision ready."