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  2. CQM-1333

Misalignment with parallel Core Measure

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Done
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      The Joint Commission Perinatal Care Technical Advisory Panel (TAP) evaluated explicit logic modeling options for maternal medical conditions in the EHR. The TAP asked Joint Commission staff to analyze the number of cases excluded due to the Reasons for Not Exclusively Feeding Breast Milk data element in the manually abstracted cases reported to The Joint Commission. The analysis revealed that approximately 2% of all cases were excluded due to a maternal medical condition. As maternal medical conditions appeared to cause very few exclusions, we did not seek to model explicit reasons for this data element.

      We will reevaluate the exclusion rate as well as potential modeling options during the 2015 annual update cycle.
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      The Joint Commission Perinatal Care Technical Advisory Panel (TAP) evaluated explicit logic modeling options for maternal medical conditions in the EHR. The TAP asked Joint Commission staff to analyze the number of cases excluded due to the Reasons for Not Exclusively Feeding Breast Milk data element in the manually abstracted cases reported to The Joint Commission. The analysis revealed that approximately 2% of all cases were excluded due to a maternal medical condition. As maternal medical conditions appeared to cause very few exclusions, we did not seek to model explicit reasons for this data element. We will reevaluate the exclusion rate as well as potential modeling options during the 2015 annual update cycle.
    • CMS9v3/NQF0480

      CQM-443 identified missing maternal reasons for not exclusively breast feeding an infant. The solution that was provided discussed resolution of the discrepancy with the next release. However, the following were not addressed in the update.

      • Previous Breast Surgery (e.g. Mastectomy, implants or previous
      breast surgery resulting in inability to produce breast milk)
      • Adoption or foster home placement of the newborn

      Please consider the addition of these maternal reasons to ensure alignment of the measures.

            JLeflore Joelencia Leflore
            bodinekm Kimberly M. Bodine (Inactive)
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