Thank you for your question. In the eCQM, a value set which defines the concepts/codes for a medical reason for not removing the catheter is used. With our current tools we have today, we are unable to define the specific source for the provider who documents the medical reason. Therefore, the reasons listed in the value set for medical reason are what should be used in the query when the data is acquired using this eCQM. If documented, a reason that is consistent with these codes would be appropriate for mapping to the codes in the medical reason value set.

Our facility implemented a nursing protocol to address foley removal based on IQR specifications and now we are unsure if this counts with regards to MU/eCQMs. Per the eCQM/MU specifications the list of denominator exclusions include: Patients who had physician /APN/PA documentation of a reason for not removing the urinary catheter postoperatively. the SCIP-INF-9 specifications stated that if the physician ordered a facility approved foley removal protocol that nursing documentation of a reason for continuing the foley would be acceptable. However, the eCQM/MU specifications only mentions documentation by the physician/APN/PA.