Regarding the parallel logic statements: The intent of eCQM logic statements “Medication, Order Not Done: Medical Reason” and “Medication, Administered Not Done: Medical Reason” is to allow for documentation of a medical reason or a patient refusal to occur in two different clinical workflows: ordering, and medication administration. Recognizing that some acceptable reasons for not providing pharmacotherapy are difficult to capture as structured data, members of the eMeasures Issues Group (eMIG) reached the decision to use these parallel statements consistently throughout the eCQMs. As the intent of the statements are two address two separate processes (ordering and administration) that may occur at different points in time, and only one of the statements needs to be met in order to meet the exclusion criteria, we agree that presenting both to the physician is unnecessary. Regarding alignment with the chart abstracted measure: For this measure specifically, the logic is intended to align with the manually abstracted data element, Reason for Not Initiating IV Thrombolytic. This data element is a denominator exclusion, which lists valid reasons for which a patient would not receive IV Thrombolytic. As you noted, the manually abstracted data element states that other reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA or pharmacist- with the exception of nursing documentation of a telemedicine/teleneurology reason for not initiating IV thrombolytic therapy. In addition, several stand-alone reasons, such as patient refusal and an NIHSS score of zero are acceptable. In the eCQM, the “Medication, Administered Not Done: Medical Reason” logic provides a way to capture documentation at the point of administration for those stand-alone reasons as well as telemedicine reason, which are not explicitly modeled. We understand your concern that nursing staff documentation of other reasons for not administering should not be accepted for this data element, and will consider your feedback for the next annual update. Finally, your ticket references the December 2012 version of the eCQM (CMS91v1). Please note, the April 2014 version of this measure includes logic to support capture of standalone reasons for not administering IV thrombolytic, such as a documentation of an NIHSS score of zero. We encourage you to refer to the latest eCQM specifications (2014 CQM Eligible Hospitals, April 2014 Update) for this and other measures, as they have been updated to include new codes, logic corrections and clarifications. You can find the technical eCQM specifications for all versions of the eCQMs in CMS's eCQM library: http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html

Workflow burden by requiring a physician to answer an extra question that should not be needed. Administration of medication done or not done can be captured in the background. Requiring to distinguish ordered vs administered requires a physician to make a choice.