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  1. eCQM Issue Tracker
  2. CQM-1691

Clarification regarding PC-05a

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
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    • Sandra Lynch
    • Novant Health
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      eCQM reporting requirements are defined by regulation. There have been no regulatory changes that have suggested any change to this eCQM or its reporting requirements.
      In your scenario, it is unclear whether feeding plan is recorded in the infant's record as well as the mother's record, or if the feeding plan is documented on the mother's record and appears on the newborn delivery record. In order to meet the eCQM, documentation for the mother's feeding plan must be present in the newborn's EHR record. The eCQM logic evaluates the newborn record, and excludes patients who do not have a documented feeding plan indicating an intention to breast feed, documented within 1 hour of birth.
      • Denominator Exclusions 2 =
      o AND:
       OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Neonatal Intensive Care Unit (NICU)')" during "Occurrence A of Encounter, Performed: Encounter Inpatient"
       OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Patient Expired')"
       OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Discharge To Another Hospital')"
      OR NOT: "Communication: From Patient to Provider: Feeding Intention-Breast" <= 1 hour(s) starts after start of "Patient Characteristic: Birth"
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      eCQM reporting requirements are defined by regulation. There have been no regulatory changes that have suggested any change to this eCQM or its reporting requirements. In your scenario, it is unclear whether feeding plan is recorded in the infant's record as well as the mother's record, or if the feeding plan is documented on the mother's record and appears on the newborn delivery record. In order to meet the eCQM, documentation for the mother's feeding plan must be present in the newborn's EHR record. The eCQM logic evaluates the newborn record, and excludes patients who do not have a documented feeding plan indicating an intention to breast feed, documented within 1 hour of birth. • Denominator Exclusions 2 = o AND:  OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Neonatal Intensive Care Unit (NICU)')" during "Occurrence A of Encounter, Performed: Encounter Inpatient"  OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Patient Expired')"  OR: "Occurrence A of Encounter, Performed: Encounter Inpatient (discharge status: 'Discharge To Another Hospital')" OR NOT: "Communication: From Patient to Provider: Feeding Intention-Breast" <= 1 hour(s) starts after start of "Patient Characteristic: Birth"
    • CMS9v4/NQF0480
    • Clarification needed regarding PC-05a

      As of October 1, 2015 discharges, The Joint Commission has retired PC-05a due to the challenge of capturing the mothers' preference in regards exlusively breast feeding. As the Joint Commission is the PC-05 MU measure steward, will this impact MU reporting of PC-05a data? This documentation occurs in the initial discussion with the mother and becomes a part of her record. The newborn EHR consists of the delivery summary report, which information from the mother's record is included; the feeding plan. Our team plans to incorporate the date and time of documentation of the mothers feeding plan in the newborn EHR delivery summary. Will this meet the requirement for MU as documentation of feeding plan?

            JLeflore Joelencia Leflore
            sml006 Sandra Lynch (Inactive)
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