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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Done
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Moderate
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University of Maryland Medical System
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Thank you for your input. This issue/request was brought forward to us this past year and we are making this change during our annual updates for Reporting year 2018.
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CMS108v5/NQF0371
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A percentage of our patients is showing as denominator instead of numerator when they follow this workflow.
We have patients that come in for surgery and are not immediately admitted as inpatients. At some point either during surgery or during recovery, the provider determines that the patient will need to be admitted. They place admission orders and at the SAME TIME they identify the patient as Low Risk for VTE. When they click to sign their orders, the date/time first inpatient = date/time Low Risk is identified which is appropriate based on this patient's scenario. This patient is only being captured as denominator and not numerator.
Measure Logic:
- Reasons for no VTE prophylaxis
◾OR: Union of: ◾"Risk Category Assessment: VTE Risk Assessment (result: Low Risk)"
◾"Laboratory Test, Performed: INR (result > 3.0 )"
◾"Medication, Administered: Unfractionated Heparin (route: Intravenous route)"
◾"Medication, Administered: Direct Thrombin Inhibitor"
◾"Medication, Administered: Glycoprotein IIb/IIIa Inhibitors"
◾starts during ("Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient )
*◾OR: Union of: ◾"Risk Category Assessment: VTE Risk Assessment (result: Low Risk)"
◾"Laboratory Test, Performed: INR (result > 3.0 )"
◾"Medication, Administered: Unfractionated Heparin (route: Intravenous route)"
◾"Medication, Administered: Direct Thrombin Inhibitor"
◾"Medication, Administered: Glycoprotein IIb/IIIa Inhibitors"
◾<= 1 day(s) starts after start of Occurrence A of $EncounterInpatient *
Since the logic verbiage is that Low Risk must "start after start", the QRDA engine does not recognize this patient as being Low Risk during their inpatient encounter. Could the logic eventually be updated to reflect "starts after or concurrent with start of Occurence A of $EncounterInpatient"?
We use Epic and this seems to be a common workflow used by other sites for these types of patients. It seems to be the intent of the measure that this patient would be a Pass and not only a denominator based on the rest of the logic.