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  1. eCQM Issue Tracker
  2. CQM-4862

Add a grace period for documenting the follow-up after a positive depression screening

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Details

    • EP/EC eCQMs
    • Status: Open
    • Moderate
    • Resolution: Unresolved
    • None

    Description

      Brief Description of Measure:

      CMS2: Preventive Care and Screening: Screening for Depression and Follow-Up Plan:
      Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

      Description of Issue:

      ​The measure currently requires that if a patient screens positive for depression, the follow-up plan must be documented on the date of the encounter. However, one stakeholder commented that this requirement does not follow provider workflow. The stakeholder recommended that a grace period of 1 to 3 days after the encounter be allowed for providers to get caught up with paperwork. In August 2021, the measure developer reviewed this issue with the expert work group who affirmed that there are typically delays with documentation of follow-up plans due to clinical workflows. Consensus was reached that a grace period of two days (48 hours) after the date of the encounter to document the follow-up plan is appropriate.

      Proposed Solution:

      We propose to add logic to the "Most Recent Adolescent Depression Screening Positive and Follow Up Provided" and "Most Recent Adult Depression Screening Positive and Follow Up Provided" definitions that will allow providers to document a follow-up plan on the day of or no more than two (2) days after the qualifying encounter:
      Most Recent Adolescent Depression Screening Positive and Follow Up Provided
      from
         "Most Recent Adolescent Depression Screening" LastAdolescentScreen,  
         "Follow Up Intervention For Positive Adolescent Depression Screening" FollowUpPositiveScreen,
         "Qualifying Encounter During Measurement Period" QualifyingEncounter  
          where Global."NormalizeInterval" ( LastAdolescentScreen.relevantDatetime, LastAdolescentScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
           and LastAdolescentScreen.result ~ "Depression screening positive (finding)"
           and ( FollowUpPositiveScreen.authorDatetime same day as end of QualifyingEncounter.relevantPeriod
               or start of Global."NormalizeInterval" ( FollowUpPositiveScreen.relevantDatetime, FollowUpPositiveScreen.relevantPeriod ) same day as
                end of QualifyingEncounter.relevantPeriod
               or FollowUpPositiveScreen.authorDatetime 2 days or less after end of QualifyingEncounter.relevantPeriod
               or start of Global."NormalizeInterval" ( FollowUpPositiveScreen.relevantDatetime, FollowUpPositiveScreen.relevantPeriod ) 2 days or less after end of QualifyingEncounter.relevantPeriod
      Most Recent Adult Depression Screening Positive and Follow Up Provided
      from
         "Most Recent Adult Depression Screening" LastAdultScreen,
         "Follow Up Intervention for Positive Adult Depression Screening" FollowUpPositiveAdultScreen,
         "Qualifying Encounter During Measurement Period" QualifyingEncounter
         where Global."NormalizeInterval" ( LastAdultScreen.relevantDatetime, LastAdultScreen.relevantPeriod ) 14 days or less on or before day of start of QualifyingEncounter.relevantPeriod
           and LastAdultScreen.result ~ "Depression screening positive (finding)"
           and ( FollowUpPositiveAdultScreen.authorDatetime same day as end of QualifyingEncounter.relevantPeriod
               or start of Global."NormalizeInterval" ( FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod ) same day as
                end of QualifyingEncounter.relevantPeriod
               or FollowUpPositiveAdultScreen.authorDatetime2 days or less after end of QualifyingEncounter.relevantPeriod
               or start of Global."NormalizeInterval" ( FollowUpPositiveAdultScreen.relevantDatetime, FollowUpPositiveAdultScreen.relevantPeriod )2 days or less after end of QualifyingEncounter.relevantPeriod
       
      ​If the proposed change as noted above is deemed appropriate, the header will also be updated to align with the revised logic.

      Rationale for Change:

      An EHR software may capture the date that the order for the follow-up plan was signed, which may be signed by the provider the day after the encounter (not the day of). In order to ensure that clinicians are not penalized for delays in documentation, clinical experts explained that allowing a grace period of two days (48 hours) is clinically-appropriate. The proposed revision will not change the intent of the measure.

       

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            khancock Mathematica EC eCQM Team
            sgearhart Mathematica EH eCQM Team
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            Dates

              Created:
              Updated: