Top Tips: Succeeding with the STEMI eCQM (OP-40)
It’s a bit ironic: of all the measures in CMS’s Outpatient Quality Reporting (OQR) program, the Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) eCQM (OP-40)–aka the “STEMI eCQM”–is the one that’s probably making your blood pressure soar.
The irony is that, at face value, this should be a relatively easy measure to track. After all, measuring STEMI treatment times has been a nationwide best practice for more than two decades. What’s more, we’ve been tracking a version of this measure for some time now with the OQR program’s Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival (OP-2) chart-abstracted measure, which is set to be retired in 2025 now that the STEMI eCQM is in full swing.
Treat the STEMI eCQM like a work-in-progress
So, the trouble isn’t with the concept of the measure itself. Instead, the crux of the problem seems to be in our collective attempts to transition to an electronic version of the measure. There are multiple gaps in the STEMI eCQM logic that can lead to inaccurate (and unfair) representation of your hospital’s care. As we’ll see in several of the challenges below, it’s all too easy for a patient to end up in an area of the measure where they don’t belong.
The saving grace is that CMS has wisely chosen a gradual approach to the STEMI eCQM roll-out. In 2024, hospitals will only be required to submit one quarter of data. From there, CMS will increase the requirement by one additional quarter per year over the next three years. This gives both hospitals and CMS time to work out the measure’s kinks and ensure that the data being collected is both accurate and meaningful.
Ways to improve your STEMI eCQM score early
Our best advice is this: use the measure’s gradual roll-out to develop and field-test your process improvements now. To get you started, we’ve assembled six of the most common challenges that we see hospitals struggle with, and the matching solutions you can put in place to turn things around. If you’re still feeling relatively new to the STEMI eCQM, be sure to read our guide to setting up the measure as well as the latest measure specs from CMS before diving in.
Challenge #1: Getting an accurate initial population & denominator
In order for patients to qualify for the STEMI eCQM’s IP and denominator (which are the same in this measure), they must have a STEMI diagnosis during the ED encounter. “During the ED encounter” means not only do you need a qualifying code from the STEMI diagnosis value set, but you also need to capture the date & time of diagnosis AND link it directly to the ED encounter only. This is the make-or-break detail to capturing your IP and denominator correctly.
The trouble is that the two primary methods of documenting the diagnosis and diagnosis date/time — the problem list and/or coding — can lead to patients qualifying for the IP/denominator when they shouldn’t.
Let’s start with the problem list. The problem list documentation process can be complex and time-consuming, making it difficult for providers to maintain given their other priorities. As a result, the problem list may not be up to date. If you have a patient with a STEMI diagnosis from a previous encounter still lingering on their problem list in an unresolved status or without updated start/end date/time, the patient may end up in your IP/denominator if/when they enter your ED again — even if it’s for a totally unrelated issue.
If the problem list can include outdated information, coding on the other hand, may not have enough information. Let’s say a patient enters your ED with chest congestion and is subsequently admitted inpatient with a diagnosis of pneumonia. Later, several hours into the inpatient stay, the patient has a STEMI. The STEMI coding for the encounter will most likely qualify the patient for the measure, even though the STEMI did not occur during the ED encounter. This occurs because there is no way to distinguish when or where in the patient’s journey the STEMI diagnosis took place. In most EHRs, diagnoses entered during the coding process are associated with the entire encounter (both the ED and inpatient stay), and not linked specifically to the inpatient encounter.
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Recommendation: Add a “Patient Arrived With Active STEMI” field to your ED’s clinical documentation and train your ED staff to use it on every patient encounter. Map this documentation to the appropriate codes and a simple yes/no question will immediately filter out all the noise and make it easy for your clinicians and your quality team to keep your IP/denominator accurate. |
Challenge #2: Tracking your PCI times
The STEMI eCQM specifications dictate that patients must follow one of three paths for treatment: they must be administered fibrinolysis within 30 minutes, transferred to a receiving hospital within 45 minutes, or receive a completed PCI in your cath lab within 90 minutes. (All three paths consider the patient’s ED arrival time as the official start time.)
If your hospital has a cath lab, chances are it runs on a completely separate EHR than your hospital and/or ED. So, while your cath lab might be doing a great job of tracking PCI treatment times in their EHR, how can you be sure that data is making its way into your hospital’s EHR and your STEMI performance tracking?
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Recommendation: Work with your cath lab and your ED teams to establish a collaborative, consistent, and repeatable process to make sure the data gets transferred accurately and habitually. For some of the hospitals we work with, the patient’s post-cath-lab-recovery time has proven to be the ideal point in the workflow to make sure this exchange happens. Again, a simple clinical documentation field is your best friend. Make it as easy as possible for your cath lab or ED staff to record the PCI data in just a few clicks. |
Challenge #3: Meeting your transfer times consistently
Of the three treatment paths mentioned above, transferring patients to a receiving hospital within 45 minutes is the path that many hospitals struggle with the most. CMS defines the transfer window of time as from the moment the patient enters your ED to the moment they leave your ED.
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Recommendation: Set up a collaborative workgroup with your receiving hospital(s) and your EMS providers to refine your transfer process. Keep in mind that the STEMI patient is going to hit your receiving hospital’s IP/denominator, too, so it’s in their best interest to work with you. Quick case study: one transferring hospital we work with had an established process of calling its receiving hospital first, then notifying EMS second, whenever a STEMI transfer was initiated. By working with its partners to reduce the requirements that needed to be met for the receiving hospital to accept a STEMI transfer, the transfer hospital was able to reverse its notification process. Now EMS gets the first call, and the receiving hospital gets notified second. This has resulted in significantly lower transfer times and, most likely, more lives being saved. |
Challenge #4: Meeting your transfer times for “one-off” reasons
Even if you have the best workflow in place for transferring your STEMI patients, stuff happens. There could be weather issues, bottlenecks with your EMS system, and other issues that are unpredictable, out of your control, and make it utterly impossible for you to meet your CMS-mandated transfer window.
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Recommendation: CMS does not require you to meet a specific threshold for this measure. There will be some instances that you might not make the transfer timeline due to circumstances outside of your control. Our best-performing hospitals always emphasize the following: do what’s right for the patient first and document what was done. That way when you review your patient fall-outs you have a clear understanding of what happened. |
Challenge #5: Too many exclusions
There are nearly two dozen denominator exclusions in the STEMI eCQM, and each has its own specific timeline that must be met in order for a patient to qualify for an exclusion. An allergic reaction to alteplase, for example, must occur “at some point during ED encounter,” while a known structural cerebral vascular lesion must be present “before the start of ED encounter but does not end before ED encounter,” and a peptic ulcer should occur “90 days or less before start of ED encounter.” Once again, the trouble here is how you’re going to document these conditions and timelines accurately and link them to the appropriate “part” (ED or Inpatient) of the patient’s encounter.
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Recommendation: No surprise: we recommend using clinical documentation here, too. Create an easy way for your team to capture all the possible exclusions. If your hospital already has a STEMI checklist in place that maps out all the reasons why a patient should not receive treatment, then there’s a good chance you already have clinical documentation set up for most of these exclusions. You’ll just need to take it one step further and map them to the required codes. |
Challenge #6: Not enough exclusions
Despite the STEMI eCQM’s long list of denominator exclusions, there are still a lot of scenarios that are not currently included in the measure logic's exclusion list. These include patients who refuse treatment; patients who leave against medical advice; hospice patients, and patients who need to bypass the cath lab and go straight to open-heart surgery.
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Recommendation: Unfortunately, there isn’t a quick fix for this problem just yet. The good news is that CMS has received an influx of JIRA tickets surrounding this issue (including a few from us here at Medisolv), so stay tuned for updates. We also strongly encourage you to submit your own JIRA ticket. CMS has proven it’s willing to listen and change course if a suitable case for change is made. |
What’s next for the STEMI eCQM?
In addition to these tips for STEMI success, there are a few changes coming to the STEMI eCQM in 2025 that you should prepare for now:
- As noted above, you will be required to submit two quarters of data in 2025 — one more quarter than in 2024. This number will continue to increase by one quarter each year, with the full four quarters of data required in 2027.
- CMS has better defined the timeline for bleeding in your denominator exclusions. Whereas before bleeding needed to be present “at the start of ED encounter,” moving forward, it will count as an exclusion if it “starts before the start of ED encounter and does not end before ED encounter.” Clinical documentation can help you track this (refer back to Challenge #5).
- CMS is introducing the first and only denominator exception into the measure: any ED encounters where “the patient received fibrinolytic therapy at another facility within 24” If you’re wondering what a denominator exception even is, start here with CMS’s definition.
- CMS has changed the codes for a number of the STEMI eCQM value sets in 2025. Take time to review the updated measure specs and update your mapping accordingly.
- On a tangential note, The Joint Commission’s ORYX program continues to keep the STEMI eCQM (eOP-40) as one of the optional eCQMs you can choose from to meet your eCQM requirements. If you choose to report this measure in 2024, you are only required to submit one self-selected quarter of data, and it will still count as a complete measure toward meeting your requirements. Click here for a guide to your 2024 ORYX requirements.
Need more help with your OQR requirements?
For direct support with STEMI eCQM troubleshooting or any of your other OQR Program requirements, schedule a 1:1 conversation with us. You can also check out these Medisolv tools and resources and more in our free Education Center:
- Article: STEMI – The First OQR eCQM
- Guide: 2024 OQR Program Requirements
- FAQ: How Does the OQR Penalty Work?
Medisolv Can HelpAlong with award-winning software, each client receives a dedicated Clinical Quality Advisor that helps you with your technical and clinical needs. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-on-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.
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