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  2. CQM-1090

Insufficiently restricted timing for Comfort Measures in CMS100v3

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      Thank you for your feedback on the AMI-2 measure. With harmonization efforts, the solution for this ticket will also be reflected in the AMI-10 measure logic. While this ticket recommends that “occurrence” is not meaningful in the logic and recommends its removal, CQM-1090 documents an issue with the Comfort Measures element and the timing relationship utilized in the encounter, and recommends the continued use of “occurrence” in its proposed fix. The logic will be modified to add an additional logic statement to the encounter beginning in the ED that leads to an inpatient one:

      • AND: “Occurrence A of Encounter, Performed: Emergency Department Visit” <= 1 hour(s) ends before start of “Occurrence A of Encounter, Performed: Encounter Inpatient”
      • AND: “Occurrence A of Intervention, Performed: Comfort Measures” starts after start of “Occurrence A of Encounter, Performed: Emergency Department Visit”
      • AND: “Occurrence A of Intervention, Performed: Comfort Measures” starts before or during “Occurrence A of Encounter, Performed: Encounter Inpatient”

      This logic change compliments the fix proposed in ticket CQM-1090 and satisfies the scenarios for patients with an ED encounter. This leads to an inpatient encounter where Comfort Measure documentation may occur in the ED and inpatient setting, and patients with only an inpatient encounter where Comfort Measure documentation occurs during the inpatient encounter. This solution satisfies the questions raised in CQM-1089 and CQM-1090.

      The second OR clause in the denominator exclusion contains logic statements that capture Comfort Measures documentation starting during an inpatient encounter that does not include an ED encounter leading to an inpatient encounter. The patient’s encounter begins in the inpatient setting. The current logic using the “Occurrence A” qualifier to specify the Comfort Measures instance will be removed in the 2015 EH eCQM update. This solution should satisfy questions raised in CQM-1094 and CQM-1090.
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      Thank you for your feedback on the AMI-2 measure. With harmonization efforts, the solution for this ticket will also be reflected in the AMI-10 measure logic. While this ticket recommends that “occurrence” is not meaningful in the logic and recommends its removal, CQM-1090 documents an issue with the Comfort Measures element and the timing relationship utilized in the encounter, and recommends the continued use of “occurrence” in its proposed fix. The logic will be modified to add an additional logic statement to the encounter beginning in the ED that leads to an inpatient one: • AND: “Occurrence A of Encounter, Performed: Emergency Department Visit” <= 1 hour(s) ends before start of “Occurrence A of Encounter, Performed: Encounter Inpatient” • AND: “Occurrence A of Intervention, Performed: Comfort Measures” starts after start of “Occurrence A of Encounter, Performed: Emergency Department Visit” • AND: “Occurrence A of Intervention, Performed: Comfort Measures” starts before or during “Occurrence A of Encounter, Performed: Encounter Inpatient” This logic change compliments the fix proposed in ticket CQM-1090 and satisfies the scenarios for patients with an ED encounter. This leads to an inpatient encounter where Comfort Measure documentation may occur in the ED and inpatient setting, and patients with only an inpatient encounter where Comfort Measure documentation occurs during the inpatient encounter. This solution satisfies the questions raised in CQM-1089 and CQM-1090 . The second OR clause in the denominator exclusion contains logic statements that capture Comfort Measures documentation starting during an inpatient encounter that does not include an ED encounter leading to an inpatient encounter. The patient’s encounter begins in the inpatient setting. The current logic using the “Occurrence A” qualifier to specify the Comfort Measures instance will be removed in the 2015 EH eCQM update. This solution should satisfy questions raised in CQM-1094 and CQM-1090 .

      Consider the following excerpt from the Denominator Exclusions criteria of CMS100v3 (AMI-2):

      • AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
      • AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"

      In the second criterion, due to the use of "starts after start", comfort measures provided any time after the start of the ED encounter, even months later, unrelated to this episode of care, will exclude this inpatient encounter from the Denominator. This surely is not the desired behavior.

      Proposed fix: The comparison could simply be changed from "starts after start" to "starts during". That would yield consistency with a similar pair of criteria in the population which look for comfort measures provided during the inpatient encounter. But presumably, when the inpatient encounter is preceded by an ED encounter, the exclusion should be satisfied by comfort measures initiated any time during the episode of care, not just during the ED encounter. Thus this issue could be resolved by leaving "starts after start" intact and adding another criterion to cover the other boundary:

      • AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"

      Impact on other issues: CQM-1089 proposes the removal of "Occurrence A" from instances of Intervention Performed for this measure, while the fix for this issue requires "Occurrence A" for the criteria discussed herein, seemingly countering the argument in CQM-1089. However, the second instance of "Occurrence A of Intervention, Performed" in the measure, the one compared against the inpatient encounter, still does not need "Occurrence A", so the proposal in CQM-1089 to remove "Occurrence A" from that criterion stands.

            JLeflore Joelencia Leflore
            jon.salmon Jon Salmon (Inactive)
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