eCQM Title

Median Time to Pain Medication for Patients with a Diagnosis of Sickle Cell Disease (SCD) with Vaso-Occlusive Episode (VOE)

CMS ID

1272

eCQM Version Number

1.2.000

CBE Number

Not Applicable

GUID

886627af-28eb-4335-9716-a55b6264a673

Measurement Period

January 1, 2026 through December 31, 2027

Measure Steward

American Society of Hematology

Measure Developer

Health Services Advisory Group

Endorsed By

None

Description

Median time (in minutes) from Emergency Department (ED) arrival to initial administration of pain medication for all patients, regardless of age, with a principal encounter diagnosis of sickle cell disease (SCD) with vaso-occlusive episode (VOE)

LOINC (R) copyright 2004-2024, Regenstrief Institute, Inc. SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2024, The International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2024 World Health Organization. All Rights Reserved.

The copyrights in the Current Procedural Terminology (“CPT”) codes are owned by the American Medical Association (“AMA”). Copyright 2024 American Medical Association. All rights are reserved by the AMA. You cannot, without express written permission from the AMA, copy, modify, distribute, display, or use CPT for any commercial purpose, including for productive use in a clinical setting. Any such use requires a separate license from the AMA.

(R) or [R] represents Registered Trademark, and (c) represents Copyright.

Disclaimer

This measure, including specifications (“Measure”), is not a clinical guideline, does not establish a standard of medical care, and has not been tested for all potential applications. The Measure is not intended to diagnose or treat disease or other conditions. The Measure is not a medical device and has not been evaluated by the Food and Drug Administration. Information provided through the Measure is not intended to direct or substitute for the independent assessment or judgment of a qualified healthcare professional. The American Society of Hematology (“ASH”) assumes no liability for use of the Measure, or data contained or not contained in the Measure.

ASH consents to the use, reproduction, and distribution of the Measure for non-commercial purposes only (e.g., for consideration by health care providers in a professional setting). You cannot, without the express written consent of ASH, use the Measure for any commercial purpose. Unauthorized commercial use of the Measure is expressly prohibited. Commercial use includes as the sale, license, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed, or distributed for commercial gain. These requirements apply to both you as an individual and to the corporate entity that you represent as an employee or agent, to the extent applicable.

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“This [publication, etc.] was prepared using clinical quality measures developed by the American Society of Hematology. The content reflects the views of [name of author(s)].”

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USE OF THE MEASURE (INCLUDING ANY CPT CODES) IS AT YOUR SOLE RISK. THE MEASURE IS PROVIDED “AS IS” WITHOUT EXPRESS OR IMPLIED WARRANTIES OF ANY KIND, INCLUDING IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NONINFRINGEMENT. ASH EXPRESSLY DISCLAIMS ANY AND ALL RESPONSIBILITY OR LIABILITY FOR DAMAGES OF ANY KIND ARISING OUT OF USE, REFERENCE TO, OR RELIANCE ON THE MEASURE.

Measure Scoring

Continuous Variable

Measure Type

Process

Stratification

Stratification 1: Pain medication administered via parenteral route

Stratification 2: Pain medication administered via non-parenteral route

Risk Adjustment

None

Rate Aggregation

Median

Rationale


 
  
 
 
  
   
    Sickle Cell Disease (SCD) is the most common inherited blood disorder and is estimated to affect approximately 100,000 individuals in the United States (Hassell, 2010). SCD is also most prominent among Black or African American patients—affecting 1 out of 365 Black or African American births (Hassell, 2010)—and the average life expectancy of publicly insured individuals with SCD is reported to be approximately 52.6 years of age (Jiao et al., 2023). Based on a 2022 systematic review, total annual costs (medical and non-medical) were estimated to range from $14,012 to $80,842 per patient per year (Baldwin et al., 2022).
    Evidence suggests that up to 60% of patients with SCD surveyed reported avoiding care in the ED (Crego et al., 2021). When they do seek emergency care due to an acute severe pain crisis, studies have shown patients wait an average of 90 minutes before analgesics are given (Tanabe, 2007; Lin, Strouse, Whiteman, Anders, & Stewart, 2016), and in another study across seven EDs found that half of all pediatric visits had a time to first opioid over one hour (Brousseau et al., 2020). Updated data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) show that from 1999 to 2020, of the 222,612 estimated yearly average number of ED visits by patients with a diagnosis of SCD, three-fourths were due to a complaint of pain (Attell et al., 2024). Compared with prior estimates (1999-2007), the overall volume of ED visits has increased by nearly 13% (Attell et al., 2024). Individuals with SCD face health inequities stemming from socioeconomic factors, including disease stigma, racial prejudice, and lack of access to specialized care (Haywood et al., 2014; Pokhrel, Olayemi, Ogbonda, Nair, & Wang, 2023; Telfair, Haque, Etienne, Tang, & Strasser, 2003; Wahab et al., 2024). These inequities were demonstrated in a study of adult patients with acute pain from SCD and renal colic in an ED. This study showed that despite higher arrival pain scores and triage acuity levels in patients with SCD, SCD patients experienced longer time to initial analgesia when compared with renal colic patients (Lazio et al., 2010).
    To promote rapid, effective, and safe analgesic management and resolution of VOE, the 2014 National Heart, Lung, and Blood Institute (NHLBI) Evidence-Based Management of Sickle Cell Disease Expert Panel Report recommends the use of an individualized prescribing and monitoring protocol or an SCD-specific protocol whenever possible (National Institutes of Health [NIH] & NHLBI, 2014). Individualized care plans, developed by the patient’s SCD clinician, are based on the patient’s home opioid consumption and effective dosing from previous ED visits. The plan is made available to ED clinicians via the electronic health record and provides direction on pain management. Individualized prescribing and monitoring protocols in patients with SCD have demonstrated decreased time to first opioid, shorter ED and hospital length of stay, and more rapid reduction in pain scores, when compared with weight-based dosing (Della-Moretta et al., 2020; Tanabe et al., 2023a; Tanabe et al., 2023b; Welch-Coltrane et al., 2021).
    The implementation of this eCQM targeting timing to administration of pain medication for adult and pediatric patients with SCD presenting to the ED may significantly improve pain management and other outcomes, including admission rates (Wachnik et al., 2022), hospital length of stay (Wachnik et al., 2022; Brandow et al., 2016; King, Albright, & Murry, 2023), length of ED stay (Lin et al., 2016; King et al., 2023; Mathias & McCavit, 2015), and patient satisfaction (Kim, Brathwaite, & Kim, 2017).

Clinical Recommendation Statement

This measure is supported by two evidence-based clinical practice guidelines. The clinical recommendation statements from the supporting guidelines are noted below and specifically recommend the rapid initiation of analgesic medications for patients presenting to the ED with acute pain associated with a diagnosis of SCD with VOE, which demonstrates a direct relationship to this measure:

The American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain (Brandow et al., 2020) Statement: Recommendation 1A - For adults and children with SCD presenting to an acute care setting with acute pain related to SCD, the ASH guideline panel recommends rapid (within 1 hour of emergency department [ED] arrival) assessment and administration of analgesia with frequent reassessments (every 30-60 minutes) to optimize pain control (strong recommendation based on low certainty in the evidence about effects).
The 2014 National Heart, Lung, and Blood Institute (NHLBI): Evidence-Based Management of Sickle Cell Disease Expert Panel Report (NIH & NHLBI, 2014) Statement: In adults and children with SCD and a vaso-occlusive crisis (VOC):

a) Rapidly initiate treatment with parenteral opioids associated with severe pain (Strong Recommendation, High-Quality Evidence) OR

b) Rapidly initiate analgesic therapy within 30 minutes of triage or within 60 minutes of registration. (Consensus–Panel Expertise – Expert Opinion).

Improvement Notation

Decreased score indicates improvement

Reference

Reference Type: Citation

Reference Text:

Attell, B. K., Barrett, P. M., Pace, B. S., McLemore, M. L., McGee, B. T., Oshe, R., . . . Snyder, A. B. (2024). Characteristics of emergency department visits made by individuals with sickle cell disease in the U.S., 1999-2020. AJPM Focus, 3(1), 100158. doi:10.1016/j.focus.2023.100158

Reference

Reference Type: Citation

Reference Text:

Baldwin, Z., Jiao, B., Basu, A., Roth, J., Bender, M. A., Elsisi, Z., . . . Devine, B. (2022). Medical and non-medical costs of sickle cell disease and treatments from a US perspective: A systematic review and landscape analysis. PharmacoEconomics Open, 6(4), 469-481. doi:10.1007/s41669-022-00330-w

Reference

Reference Type: Citation

Reference Text:

Brandow, A. M., Carroll, C. P., Creary, S., Edwards-Elliott, R., Glassberg, J., Hurley, R. W., . . . Lang, E. (2020). American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Advances, 4(12), 2656-2701. doi:10.1182/bloodadvances.2020001851

Reference

Reference Type: Citation

Reference Text:

Brandow, A. M., Nimmer, M., Simmons, T., Charles Casper, T., Cook, L. J., Chumpitazi, C. E., . . . Brousseau, D. C. (2016). Impact of emergency department care on outcomes of acute pain events in children with sickle cell disease. American Journal of Hematology, 91(12), 1175-1180. doi:10.1002/ajh.24534

Reference

Reference Type: Citation

Reference Text:

Brousseau, D. C., Alpern, E. R., Chamberlain, J. M., Ellison, A. M., Bajaj, L., Cohen, D. M., . . . Pediatric Emergency Care Applied Research Network. (2020). A multiyear cross-sectional study of guideline adherence for the timeliness of opioid administration in children with sickle cell pain crisis. Annals of Emergency Medicine, 76(3S), S6-S11. doi:10.1016/j.annemergmed.2020.08.006

Reference

Reference Type: Citation

Reference Text:

Crego, N., Masese, R., Bonnabeau, E., Douglas, C., Rains, G., Shah, N., & Tanabe, P. (2021). Patient perspectives of sickle cell management in the emergency department. Critical Care Nursing Quarterly, 44(2), 160-174. doi:10.1097/CNQ.0000000000000350

Reference

Reference Type: Citation

Reference Text:

Della-Moretta, S., Delatore, L., Purcell, M., Huang, Y., Heinlein, M., Adkins, E., & Desai, P. (2020). The effect of use of individualized pain plans in sickle cell patients presenting to the emergency department. Annals of Emergency Medicine, 76(3S), S21-S27. doi:10.1016/j.annemergmed.2020.08.008

Reference

Reference Type: Citation

Reference Text:

Hassell, K. L. (2010). Population estimates of sickle cell disease in the U.S. American Journal of Preventive Medicine, 38, S512–S521. doi:10.1016/j.amepre.2009.12.022

Reference

Reference Type: Citation

Reference Text:

Haywood, C., Jr., Diener-West, M., Strouse, J., Carroll, C. P., Bediako, S., Lanzkron, S., . . . IMPORT Investigators. (2014). Perceived discrimination in health care is associated with a greater burden of pain in sickle cell disease. Journal of Pain and Symptom Management, 48(5), 934-943. doi:10.1016/j.jpainsymman.2014.02.002

Reference

Reference Type: Citation

Reference Text:

Jiao, B., Johnson, K. M., Ramsey, S. D., Bender, M. A., Devine, B., & Basu, A. (2023). Long-term survival with sickle cell disease: a nationwide cohort study of Medicare and Medicaid beneficiaries. Blood Advances, 7(13), 3276-3283. doi:10.1182/bloodadvances.2022009202

Reference

Reference Type: Citation

Reference Text:

Kim, S., Brathwaite, R., & Kim, O. (2017). Evidence-based practice standard care for acute pain management in adults with sickle cell disease in an urgent care center. Quality Management in Health Care, 26(2), 108-115. doi:10.1097/QMH.0000000000000135

Reference

Reference Type: Citation

Reference Text:

King, H., Albright, A., & Murry, M. (2023). Delayed management of sickle cell disease vaso-occlusive episodes and the impact on prolonged hospitalizations at a single academic center. Blood, 142(Supplement 1), 7201. doi:10.1182/blood-2023-190385

Reference

Reference Type: Citation

Reference Text:

Lazio, M. P., Costello, H. H., Courtney, D. M., Martinovich, Z., Myers, R., Zosel, A., & Tanabe, P. (2010). A comparison of analgesic management for emergency department patients with sickle cell disease and renal colic. The Clinical Journal of Pain, 26(3), 199-205. doi:10.1097/AJP.0b013e3181bed10c

Reference

Reference Type: Citation

Reference Text:

Lin, S. M., Strouse, J. J., Whiteman, L. N., Anders, J., & Stewart, R. W. (2016). Improving quality of care for sickle cell patients in the pediatric emergency department. Pediatric Emergency Care, 32(1), 14-16. doi:10.1097/PEC.0000000000000369

Reference

Reference Type: Citation

Reference Text:

Mathias, M. D., & McCavit, T. L. (2015). Timing of opioid administration as a quality indicator for pain crises in sickle cell disease. Pediatrics, 135(3), 475-482. doi:10.1542/peds.2014-2874

Reference

Reference Type: Citation

Reference Text:

National Institutes of Health, & National Heart, Lung, and Blood Institute. (2014). Evidence-based Management of Sickle Cell Disease Expert Panel Report. Bethesda, MD. Retrieved from https://www.nhlbi.nih.gov/health-topics/evidence-based-management-sickle-cell-disease

Reference

Reference Type: Citation

Reference Text:

Pokhrel, A., Olayemi, A., Ogbonda, S., Nair, K., & Wang, J. C. (2023). Racial and ethnic differences in sickle cell disease within the United States: From demographics to outcomes. European Journal Haematology, 110(5), 554-563. doi:10.1111/ejh.13936

Reference

Reference Type: Citation

Reference Text:

Tanabe, P., Bosworth, H. B., Crawford, R. D., Glassberg, J., Miller, C. N., Paice, J. A., & Silva, S. (2023). Time to pain relief: A randomized controlled trial in the emergency department during vaso-occlusive episodes in sickle cell disease. European Journal of Haematology, 110(5), 518–526. doi:10.1111/ejh.13924

Reference

Reference Type: Citation

Reference Text:

Tanabe, P., Ibemere, S., Pierce, A. E., Freiermuth, C. E., Bosworth, H. B., Yang, H., . . . Barnhart, H. X. (2023). A comparison of the effect of patient-specific versus weight-based protocols to treat vaso-occlusive episodes in the emergency department. Academic Emergency Medicine, 30(12), 1210-1222. doi:10.1111/acem.14805

Reference

Reference Type: Citation

Reference Text:

Tanabe, P., Myers, R., Zosel, A., Brice, J., Ansari, A. H., Evans, J., . . . Paice, J. A. (2007). Emergency department management of acute pain episodes in sickle cell disease. Academic Emergency Medicine, 14(5), 419-425. doi:10.1197/j.aem.2006.11.033

Reference

Reference Type: Citation

Reference Text:

Telfair, J., Haque, A., Etienne, M., Tang, S., & Strasser, S. (2003). Rural/urban differences in access to and utilization of services among people in Alabama with sickle cell disease. Public Health Reports, 118(1), 27-36. doi:10.1093/phr/118.1.27

Reference

Reference Type: Citation

Reference Text:

Wachnik, A. A., Welch-Coltrane, J. L., Adams, M. C. B., Blumstein, H. A., Pariyadath, M., Robinson, S. G., . . . Hurley, R. W. (2022). A standardized emergency department order set decreases admission rates and in-patient length of stay for adults patients with sickle cell disease. Pain Medicine, 23(12), 2050-2060. doi:10.1093/pm/pnac096

Reference

Reference Type: Citation

Reference Text:

Wahab, S., Kelly, K., Klingler, M., Pirovic, A., Futch, K., Rennie, C., . . . Costin, J. M. (2024). Impact of race, socioeconomic status, and geography on healthcare outcomes for children with sickle cell disease in the United States: A scoping review. Cureus: Journal of Medical Science, 16(3), e56089. doi:10.7759/cureus.56089

Reference

Reference Type: Citation

Reference Text:

Welch-Coltrane, J. L., Wachnik, A. A., Adams, M. C. B., Avants, C. R., Blumstein, H. A., Brooks, A. K., . . . Hurley, R. W. (2021). Implementation of individualized pain care plans decreases length of stay and hospital admission rates for high utilizing adults with sickle cell disease. Pain Medicine (Malden, Mass.), 22(8), 1743–1752. doi:10.1093/pm/pnab092

Definition

A qualifying encounter is defined as an ED visit for a patient, regardless of age, for which the discharge time occurred during the two-year measurement period and the following criteria are met:

The ED visit requires a principal diagnosis of SCD with VOE, and
The ED visit requires at least one qualifying pain medication administered during the ED encounter

Guidance

This eCQM is an episode-based measure. An episode is defined as a qualifying emergency department encounter that ends during the measurement period.

The measure uses a two-year measurement period from January 1, XXXX through December 31, XXXX. This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Transmission Format

TBD

Initial Population

ED encounters with a discharge time during the two-year measurement period for all patients, regardless of age, who have a principal encounter diagnosis of SCD with VOE and who have at least one qualifying pain medication administered during the ED encounter

Measure Population

Equals Initial Population

Measure Population Exclusions

None

Measure Observations

Time (in minutes) from ED arrival to initial administration of pain medication

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

    "ED Encounter For SCD With VOE With Pain Medication Administered"

- Measure Population
  - "Initial Population"

- Measure Population Exclusions
  - None

Stratification 1

    "ED Encounters Where First Pain Medication Was Administered Via Parenteral Route"

Stratification 2

    "ED Encounters Where First Pain Medication Was Administered Via Non-Parenteral Route"

Measure Observation

Median (
    duration in minutes of Interval[
        Global."EmergencyDepartmentArrivalTime"(SCDwVOEEncounterWithPainMed), 
            Global."EarliestOf"(
                "FirstPainMedicationAdministration"(SCDwVOEEncounterWithPainMed).relevantDatetime, 
                "FirstPainMedicationAdministration"(SCDwVOEEncounterWithPainMed).relevantPeriod 
            )
    ]
)

Definitions

ED Encounter For SCD With VOE With Pain Medication Administered

    "ED Encounter With Principal Diagnosis Of SCD With VOE" SCDwVOEEncounter
        with "Pain Medications Administered During ED Encounter" PainMed
            such that Global."EarliestOf"(PainMed.relevantDatetime, PainMed.relevantPeriod) 
                during SCDwVOEEncounter.relevantPeriod

ED Encounter With Principal Diagnosis Of SCD With VOE

    ["Encounter, Performed": "Emergency Department Evaluation and Management Visit"] EDEncounter
        with EDEncounter.diagnoses EncounterDiagnosis
            such that EncounterDiagnosis.code in "Sickle Cell Disease with Vaso Occlusive Episode"
                and EncounterDiagnosis.rank = 1
                and EDEncounter.relevantPeriod ends during day of "Measurement Period"

ED Encounters Where First Pain Medication Was Administered Via Non-Parenteral Route

    from "ED Encounter For SCD With VOE With Pain Medication Administered" SCDwVOEEncounterWithPainMed
    let FirstParenteral: "FirstParenteralForEncounter"(SCDwVOEEncounterWithPainMed),
        FirstNonParenteral: "FirstNonParenteralForEncounter"(SCDwVOEEncounterWithPainMed)
    where
        Global."EarliestOf"(FirstParenteral.relevantDatetime, FirstParenteral.relevantPeriod) is null
        or (Global."EarliestOf"(FirstNonParenteral.relevantDatetime, FirstNonParenteral.relevantPeriod) 
            before Global."EarliestOf"(FirstParenteral.relevantDatetime, FirstParenteral.relevantPeriod))
    return SCDwVOEEncounterWithPainMed

ED Encounters Where First Pain Medication Was Administered Via Parenteral Route

    from "ED Encounter For SCD With VOE With Pain Medication Administered" SCDwVOEEncounterWithPainMed
    let FirstParenteral: "FirstParenteralForEncounter"(SCDwVOEEncounterWithPainMed),
        FirstNonParenteral: "FirstNonParenteralForEncounter"(SCDwVOEEncounterWithPainMed)
    where
        Global."EarliestOf"(FirstNonParenteral.relevantDatetime, FirstNonParenteral.relevantPeriod) is null
        or (Global."EarliestOf"(FirstParenteral.relevantDatetime, FirstParenteral.relevantPeriod) 
            on or before Global."EarliestOf"(FirstNonParenteral.relevantDatetime, FirstNonParenteral.relevantPeriod))
    return SCDwVOEEncounterWithPainMed

Initial Population

    "ED Encounter For SCD With VOE With Pain Medication Administered"

Measure Population
- - "Initial Population"

Non-Parenteral Pain Medications Administered During ED Encounter

    ["Medication, Administered": "Analgesics for Acute Pain (Non Parenteral Route)"] PainMed
        with "ED Encounter With Principal Diagnosis Of SCD With VOE" SCDwVOEEncounter
            such that Global."EarliestOf"(PainMed.relevantDatetime, PainMed.relevantPeriod) 
                during SCDwVOEEncounter.relevantPeriod

Pain Medications Administered During ED Encounter

    ["Medication, Administered": "Analgesics for Acute Pain"] PainMed
        with "ED Encounter With Principal Diagnosis Of SCD With VOE" SCDwVOEEncounter
            such that Global."EarliestOf"(PainMed.relevantDatetime, PainMed.relevantPeriod) 
                during SCDwVOEEncounter.relevantPeriod

Parenteral Pain Medications Administered During ED Encounter

    ["Medication, Administered": "Analgesics for Acute Pain (Parenteral Route)"] PainMed
        with "ED Encounter With Principal Diagnosis Of SCD With VOE" SCDwVOEEncounter
            such that Global."EarliestOf"(PainMed.relevantDatetime, PainMed.relevantPeriod) 
                during SCDwVOEEncounter.relevantPeriod

SDE Ethnicity

    ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

    ["Patient Characteristic Payer": "Payer Type"]

SDE Race

    ["Patient Characteristic Race": "Race"]

SDE Sex

    ["Patient Characteristic Sex": "Federal Administrative Sex"]

Stratification 1

    "ED Encounters Where First Pain Medication Was Administered Via Parenteral Route"

Stratification 2

    "ED Encounters Where First Pain Medication Was Administered Via Non-Parenteral Route"

Functions

FirstNonParenteralForEncounter(SCDwVOEEncounterWithPainMed "Encounter, Performed")

    First("Non-Parenteral Pain Medications Administered During ED Encounter" NonParenteralPainMed
        sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
    )

FirstPainMedicationAdministration(SCDwVOEEncounterWithPainMed "Encounter, Performed")

    First("Pain Medications Administered During ED Encounter" PainMed
        sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
    )

FirstParenteralForEncounter(SCDwVOEEncounterWithPainMed "Encounter, Performed")

    First("Parenteral Pain Medications Administered During ED Encounter" ParenteralPainMed
        sort by Global."EarliestOf"(relevantDatetime, relevantPeriod)
    )

Global.Earliest(period Interval<DateTime>)

  if ( HasStart(period)) then start of period 
    else 
  end of period

Global.EarliestOf(pointInTime DateTime, period Interval<DateTime>)
- - Earliest(NormalizeInterval(pointInTime, period))

Global.EmergencyDepartmentArrivalTime(Encounter "Encounter, Performed")

  start of First(("HospitalizationLocations"(Encounter))HospitalLocation
  		where HospitalLocation.code in "Emergency Department Visit"
  		sort by start of locationPeriod
  ).locationPeriod

Global.HasStart(period Interval<DateTime>)

  not ( start of period is null
      or start of period = minimum DateTime
  )

Global.HospitalizationLocations(Encounter "Encounter, Performed")

  Encounter Visit
  	let EDVisit: Last(["Encounter, Performed": "Emergency Department Visit"] LastED
  			where LastED.relevantPeriod ends 1 hour or less on or before start of Visit.relevantPeriod
  			sort by 
  			end of relevantPeriod
  	)
  	return if EDVisit is null then Visit.facilityLocations 
  		else flatten { EDVisit.facilityLocations, Visit.facilityLocations }

Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

  if pointInTime is not null then Interval[pointInTime, pointInTime]
    else if period is not null then period 
    else null as Interval<DateTime>

Measure Observation(SCDwVOEEncounterWithPainMed "Encounter, Performed")

    duration in minutes of Interval[
        Global."EmergencyDepartmentArrivalTime"(SCDwVOEEncounterWithPainMed), 
            Global."EarliestOf"(
                "FirstPainMedicationAdministration"(SCDwVOEEncounterWithPainMed).relevantDatetime, 
                "FirstPainMedicationAdministration"(SCDwVOEEncounterWithPainMed).relevantPeriod 
            )
    ]

Terminology

valueset "Analgesics for Acute Pain" (2.16.840.1.113762.1.4.1160.43)
valueset "Analgesics for Acute Pain (Non Parenteral Route)" (2.16.840.1.113762.1.4.1160.73)
valueset "Analgesics for Acute Pain (Parenteral Route)" (2.16.840.1.113762.1.4.1160.74)
valueset "Emergency Department Evaluation and Management Visit" (2.16.840.1.113883.3.464.1003.101.12.1010)
valueset "Emergency Department Visit" (2.16.840.1.113883.3.117.1.7.1.292)
valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
valueset "Federal Administrative Sex" (2.16.840.1.113762.1.4.1021.121)
valueset "Payer Type" (2.16.840.1.114222.4.11.3591)
valueset "Race" (2.16.840.1.114222.4.11.836)
valueset "Sickle Cell Disease with Vaso Occlusive Episode" (2.16.840.1.113762.1.4.1160.42)

Data Criteria (QDM Data Elements)

"Encounter, Performed: Emergency Department Evaluation and Management Visit" using "Emergency Department Evaluation and Management Visit (2.16.840.1.113883.3.464.1003.101.12.1010)"
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292)"
"Medication, Administered: Analgesics for Acute Pain (Non Parenteral Route)" using "Analgesics for Acute Pain (Non Parenteral Route) (2.16.840.1.113762.1.4.1160.73)"
"Medication, Administered: Analgesics for Acute Pain (Parenteral Route)" using "Analgesics for Acute Pain (Parenteral Route) (2.16.840.1.113762.1.4.1160.74)"
"Medication, Administered: Analgesics for Acute Pain" using "Analgesics for Acute Pain (2.16.840.1.113762.1.4.1160.43)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer Type" using "Payer Type (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: Federal Administrative Sex" using "Federal Administrative Sex (2.16.840.1.113762.1.4.1021.121)"

Supplemental Data Elements

SDE Ethnicity

    ["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

    ["Patient Characteristic Payer": "Payer Type"]

SDE Race

    ["Patient Characteristic Race": "Race"]

SDE Sex

    ["Patient Characteristic Sex": "Federal Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

None