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  1. eCQM Issue Tracker
  2. CQM-5380

Should CMS996v3 use Encounter.RelevantPeriod during Measurement Period or Encounter.RelevantPeriod "starts" during Measurement Period

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    • Icon: OQR eCQMs - Outpatient Quality Reporting OQR eCQMs - Outpatient Quality Reporting
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
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    • CMS0996v3
    • Some ED cases would inaccurately not be included in the population

      Outpatient eCQM is available here - https://ecqi.healthit.gov/eh-oqr-ecqms

      Should the Outpatient eCQM - CMS996v3 (Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)) use

      • Encounter.RelevantPeriod during Measurement Period OR
      • Encounter.RelevantPeriod "starts during" Measurement Period  

       

       

      This question is important because as it currently stands some ED encounters would not be included in the population.

      Example

      EDEncounter.RelevantPeriod is made of EDEncounter.StartDate and EDEncounter.EndDate

      EDEncounter.Start Date - Dec 31, 2023 11 PM

      EDEncounter.End Date - Jan 1, 2024 9 AM

      Assume the appropriate treatment was provided so that the case would meet the numerator if included in the population.

       

      This case does not meet the current IPP logic (see below) for CY2013 or CY2014 because the relevantPeriod (both start and end dates of encounter) are NOT during the CY2013 or CY2014 Period. Only the start date is in the CY2023 reporting period but not the end date.

      Current Logic

      EDEncounter.relevantPeriod during "Measurement Period

       

      However if the logic is changed as below to look for the start of the ED Encounter.relevantPeriod then the case would be included in the CY2023 population.

      Proposed LogicEDEncounter.relevantPeriod starts during "Measurement Period

       

      I'm assuming we do not want to exclude these cases completely, correct? Currently, they would not fall in any measurement period.

      Any guidance on this would be appreciated.

      Thanks!

            tamara.mohammed@yale.edu Tamara Mohammed (Inactive)
            mparekhji Manish Parekhji (Inactive)
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              Created:
              Updated:
              Resolved: