Hybrid Measures Validation Tools

The ENCOR for Hospital Electronic Measures contains a number of tools to help validated data for the Hybrid measures

Review Invalid Units

Summary:  Invalid units of measure (UOM) for the required laboratory test results and vital sign results may cause rejections. The Invalid Unit Report can help to assist in identifying invalid units prior to submission. 

Procedures/Steps:
1. Hospital > Reporting > Validation and Improvement Dashboard (VID) > Data Integrity

*If there are invalid units, the indicator will be red.  Click on the Data Integrity widget to review. 

2. The Invalid Units Report is located at the bottom of the report. The Invalid Units
column shows the unit of issue. This report does not filter by date range or measure. The
time range is the active period start date and forward.

Review Measure Errors

Patient and Measure errors can cause issues in eCQM submissions including rejections and
inaccurate data issues. It is important to review the patient and measure error reports to
identify any errors that need to be corrected.

Procedures/Steps:

1. Hospital > Reporting > Validation and Improvement Dashboard (VID) > Data Integrity
Widget. The Patient Errors and Measure Errors reports are located in the Data Integrity
widget. To view the errors, click on the Data Integrity Widget. 

2. To review, select the specific measure and specific quarter you want to view for measure errors.

3. The Patient Error report will indicate issues like Missing MBI (Medicare Beneficiary ID).

4. The Measure Error report will include errors that may cause a rejection in the eCQM submission.

5. The Encounter End Date Time Before Start Date Time is a specific error that often causes
rejections in the eCQM submission.

6. To view the patient detail screen, right click on the patient’s name and open in a new
tab.

Review Missing Core Clinical Data Elements (CCDEs) Report

Summary:  The hybrid measures require that 90% of vital signs for discharged patients and 90% of laboratory data elements for discharged patients with a Medicare claim be included in the QRDA. The missing CCDE report in ENCOR helps to identify patients who have 1 or more missing CCDEs. 

The required CCDE elements are noted below:

Vital Signs:

Labs:

Procedures/Steps:
1. Hospital > Reporting > eCQMs > Hybrid Measure Tab > Missing CCDE Summary Tab
2. Each missing CCDE will have a separate row with noted percentage missing.
3. To see the patients with the missing CCDE, click the + expansion sign to the left of the
linking variable.

4. To view the patient detail screen, right click on the patient's name an dopen in a new tab.

 

Hybrid Missing Linking Variable Report

Summary:  Hybrid measures require six linking variables to link the submitted ENCOR electronic file to the CMS claims file. If any of the linking variables are missing, the electronic file will not link properly to the claims file. 

The linking variables are:

• MBI
• DOB
• Gender
• Admission Date
• Discharge Date
• CCN

The CCN is present on the ENCOR Hospital Data page and will not be included in the Missing Linking Variable Report.

Other linking variables should be reviewed in ENCOR by using the Missing Linking Variable
Report prior to submission to confirm files are not missing required linking variables.

Procedures/Steps:
1. Hospital > Reporting > eCQMs > Hybrid Measure Tab > Missing Linking Variables Tab

a. Verify you have updated the calendar to show the current reporting year.

i. Ex. 07/01/2022 to 06/30/2023

2. If a linking variable is missing, there will be a row labeled with the linking variable. 

3. To see the patients with the missing linking variable, click the + expansion sign to the left
of the linking variable.

4. To review the patient detail screen, right click on the patient’s name and open in a new
tab.