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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Resolved
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Minor
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None
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CMS171v1/NQF0527, CMS172v1/NQF0528
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Numerator for CMS171 may not be achievable
The SCIP-INF-1 measure contains the following (or similar) in all numerators:
OR: "Medication, Administered: IV quinolones (route: 'Hospital measures-Route IV')" <= 120 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"
OR: "Medication, Administered: Hospital measures-IV Vancomycin (route: 'Hospital measures-Route IV')" <= 120 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"
OR: "Medication, Administered: IV Antimicrobial medication (route: 'Hospital measures-Route IV')" <= 60 minute(s) starts before start of "Occurrence A of Procedure, Performed: General or Neuraxial Anesthesia (incision datetime)"
The issue here is that the codes in the General or Neuraxial Anesthesia valueset (unsurprisingly) do not refer to a procedure which involves an incision, it refers to the anesthesia. Instead, the valueset used here should be the actual surgery being performed - CABG, or other Cardiac, etc.
It is clear what the intent of the measure author is in this case; that the incision time of the principal surgical procedure be used. However, that is not what the logic formally suggests. With a literal reading of the logic, patients cannot pass the measure in this fashion, as there should not be an incision time associated with the anesthesia event, only with the surgery.