Uploaded image for project: 'eCQM Issue Tracker'
  1. eCQM Issue Tracker
  2. CQM-1307

Data capture and validation for CMS171

XMLWordPrintable

    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Minor Minor
    • Measure
    • None
    • Hide
      Thank you for your question. A patient may have more than one surgery during the surgical episode surrounding the principal procedure. The principal procedure may not always be performed first. The timing of antibiotics should be based on the first incision during the episode. This revised logic for the numerator address the need to use the first incision for the calculation that determines if the antibiotic was given within 2 hours of the start of the surgical episode.
      Show
      Thank you for your question. A patient may have more than one surgery during the surgical episode surrounding the principal procedure. The principal procedure may not always be performed first. The timing of antibiotics should be based on the first incision during the episode. This revised logic for the numerator address the need to use the first incision for the calculation that determines if the antibiotic was given within 2 hours of the start of the surgical episode.
    • CMS171v4/NQF0527
    • eMeasure 171 V4 population will be reduced

      The specification for eMeasure 171/V4 includes the incision date and time in the performance of General or Neuraxial Anesthesia. This statement is confusing in that the incision date and time would normally be associated with the Procedure Performed, as stated in eMeasure 171/V3.

      eMeasure 171/V4

      Numerator 1 =
      AND:
      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)"

      eMeasure 171/V3
      Numerator 1 =
      AND:
      OR: "Medication, Administered: Hospital measures-SCIP IV quinolones (route: 'Hospital measures-Route IV')" <= 120 minute(s) starts before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG (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: Hospital measures-CABG (incision datetime)"
      OR: "Medication, Administered: Hospital measures-IV Antimicrobial medication (route: 'Hospital measures-Route IV')" <= 60 minute(s) starts before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG (incision datetime)"

      This also varies from eMeasure 172/V3 andV4, which also includes the incision date and time with the actual surgical procedure performed, instead of General or Neuraxial Anesthesia

      1.)What development guidance can you offer to accurately capture the involved data?

            JLeflore Joelencia Leflore
            bodinekm Kimberly M. Bodine (Inactive)
            Votes:
            0 Vote for this issue
            Watchers:
            2 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: