MVP: Adopting Best Practices and Promoting Patient Safety within Emergency Medicine
Most applicable medical specialty: Emergency medicine
The Adopting Best Practices and Promoting Patient Safety within Emergency Medicine MVP focuses on important assessors of the care emergency clinicians provide to patients with undifferentiated high-risk conditions. By focusing on these specific measures and activities, emergency clinicians can reduce clinical variability, improve the quality of emergency care and potentially lower costs.
Quality
To fulfill quality requirements:
- You must select 4 quality measures from the list below
At least 1 measure must be an outcome measure - You must collect data for each measure for the 12-month performance period of the associated performance year
(e.g., January 1, 2024 – December 31, 2024). - If no outcome measures are available, you may report a high priority measure.
TIP: Make sure that you select measures that are appropriate to your patient population. Measures that don’t meet
case minimum or data completeness criteria will earn zero points.
Quality measures
| ID | Title | Specs |
|---|---|---|
| 065 | Appropriate Treatment for Upper Respiratory Infection (URI) | Details |
| 116 | Avoidance of Antibiotic Treatment for Acute Bronchitis/Bronchiolitis | Details |
| 254 | Ultrasound Determination of Pregnancy Location for Pregnant Patients with Abdominal Pain | Details |
| 321 | CAHPS for MIPS Clinician/Group Survey | Details |
| 331 | Adult Sinusitis: Antibiotic Prescribed for Acute Viral Sinusitis (Overuse) | Details |
| 415 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | Details |
| 416 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | Details |
| 487 | Screening for Social Drivers of Health | Details |
| ACEP50* | ED Median Time from ED arrival to ED departure for all Adult Patients | Not supported by MIPSpro* |
| ACEP52* | Appropriate Emergency Department Utilization of Lumbar Spine Imaging for Atraumatic Low Back Pain | Not supported by MIPSpro* |
| ECPR46 | Avoidance of Opiates for Low Back Pain or Migraines | Details |
| HCPR24 | Appropriate Utilization of Vancomycin for Cellulitis | Details |
Improvement Activities
1. Two medium weighted improvement activities from the list below, or
2. One high weighted improvement activity from the list below, or
3. The IA_PCMH activity (participation in a certified or recognized patient-centered medical home
or a comparable specialty practice).
Improvement activities
| ID | Title |
|---|---|
| IA_AHE_12 | Practice Improvements that Engage Community Resources to Address Drivers of Health |
| IA_BE_4 | Engagement of patients through implementation of improvements in patient portal |
| IA_BE_6 | Regularly Assess Patient Experience of Care and Follow Up on Findings |
| IA_BMH_12 | Promoting Clinician Well-Being |
| IA_CC_2 | Implementation of improvements that contribute to more timely communication of test results |
| IA_MVP | Practice-Wide Quality Improvement in MIPS Value Pathways |
| IA_PCMH | Electronic submission of Patient Centered Medical Home accreditation |
| IA_PSPA_1 | Participation in an AHRQ-listed patient safety organization. |
| IA_PSPA_7 | Use of QCDR data for ongoing practice assessment and improvements |
| IA_PSPA_15 | Implementation of an ASP |
Cost
Important information to consider:
- 1. You don’t have to submit any data for this performance category. We’ll use Medicare claims data to
calculate your cost measure performance.
(You don’t select cost measures during MVP registration. CMS will calculate your performance
on all the cost measures included in the MVP based on available Medicare claims data.)
2. You’ll only be scored on the cost measures in this MVP for which you meet or exceed the established
case minimum.
Cost measures
| ID | Title | Specs |
|---|---|---|
| COST_EDV_1 | Emergency Medicine | Details |
Foundational Layer – Promoting Interoperability
To fulfill Promoting Interoperability requirements:
- Submit the required Promoting Interoperability measures (the same as under traditional MIPS) listed below. Bonus points are available for reporting measures that aren’t required.
- If you’re reporting as a subgroup, you’ll submit your affiliated group’s data for the Promoting Interoperability performance category.
- Review if you qualify for automatic reweighting of the Promoting Interoperability performance category based on your clinician type, special status, or an approved Promoting Interoperability Performance Category Hardship Exception Application.
Clinician Types for Automatic Reweighting:
- Clinical social worker
- Special status for automatic reweighting:
- Ambulatory Surgical Center (ASC)-based
- Hospital-based
- Non-patient facing
- Small practice
Promoting Interoperability Performance Category Hardship Exception Qualifications:
- Decertified EHR technology
- Insufficient internet connectivity
- Experience extreme and uncontrollable circumstances (e.g., disaster, practice closure, severe financial distress, vendor issues)
- Lack control over availability of CEHRT (Certified Electronic Health Record Technology)
Note: Promoting Interoperability requirements are the same in MVPs as they are in traditional MIPS. Learn more about Promoting Interoperability requirements.
Promoting Interoperability measures (all MVPs)
| ID | Title |
|---|---|
| PI_EP_1 | e-prescribing |
| PI_EP_2 | Query of the Prescription Drug Monitoring Program (PDMP) |
| PI_EP_2_EX_1 | Query of the Prescription Drug Monitoring Program (PDMP) |
| PI_EP_2_EX_2 | Query of the Prescription Drug Monitoring Program (PDMP) Exclusion |
| PI_HEI_1 | Support Electronic Referral Loops By Sending Health Information |
| PI_HEI_4 | Support Electronic Referral Loops By Receiving and Reconciling Health Information |
| PI_HEI_5 | Health Information Exchange (HIE) Bi-Directional Exchange |
| PI_HEI_6 | Enabling Exchange Under TEFCA |
| PI_INFBLO_1 | Actions to Limit or Restrict the Compatibility of CEHRT |
| PI_LVITC_2 | Support Electronic Referral Loops By Receiving and Reconciling Health Information Exclusion |
| PI_LVOTC_1 | Support Electronic Referral Loops By Sending Health Information Exclusion |
| PI_LVPP_1 | e-Prescribing Exclusion |
| PI_ONCACB_1 | ONC-ACB Surveillance Attestation |
| PI_ONCDIR_1 | ONC Direct Review Attestation |
| PI_PEA_1 | Provide Patients Electronic Access to Their Health Information |
| PI_PHCDRR_1 | Immunization Registry Reporting |
| PI_PHCDRR_1_EX_1 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_2 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_EX_3 | Immunization Registry Reporting Exclusion |
| PI_PHCDRR_1_PRE | Immunization Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_1_PROD | Immunization Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_2 | Syndromic Surveillance Reporting |
| PI_PHCDRR_2_PRE | Syndromic Surveillance Reporting Active Engagement Level 1 |
| PI_PHCDRR_2_PROD | Syndromic Surveillance Reporting Active Engagement Level 2 |
| PI_PHCDRR_3 | Electronic Case Reporting |
| PI_PHCDRR_3_EX_1 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_2 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_EX_3 | Electronic Case Reporting Exclusion |
| PI_PHCDRR_3_PRE | Electronic Case Reporting Active Engagement Level 1 |
| PI_PHCDRR_3_PROD | Electronic Case Reporting Active Engagement Level 2 |
| PI_PHCDRR_4 | Public Health Registry Reporting |
| PI_PHCDRR_4_PRE | Public Health Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_4_PROD | Public Health Registry Reporting Active Engagement Level 2 |
| PI_PHCDRR_5 | Clinical Data Registry Reporting |
| PI_PHCDRR_5_PRE | Clinical Data Registry Reporting Active Engagement Level 1 |
| PI_PHCDRR_5_PROD | Clinical Data Registry Reporting Active Engagement Level 2 |
| PI_PPHI_1 | Security Risk Analysis |
| PI_PPHI_2 | High Priority Practices Guide of the Safety Assurance Factors for EHR Resilience (SAFER) Guides |
Foundational Layer – Population Health
You must select 1 population health measure at the time of MVP registration.
- You don’t have to submit any data for this measure, CMS will calculate the population health measures for you using administrative claims data.
- This measure will be excluded from scoring if the measure doesn’t have a benchmark or meet the case minimum.
- Population health isn’t a new performance category. The population health measure you select during MVP registration will be scored as part of the quality performance category provided you meet the case minimum.
- Subgroups will be evaluated at the affiliated group level.
Improvement activities (all MVPs)