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  1. eCQM Issue Tracker
  2. CQM-5457

Issues with EGA date/time before Admit date/time

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
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    • Carol Houlihan
    • 7173508211
    • Penn State Health
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      ​
      Thank you for your inquiry. For PC05 and PC06 eCQM, the EGA will need to be evaluated after the newborn is delivered (LOINC Code Gestational age – at birth). The EGA can be assessed anytime during the inpatient encounter (not the time EGA value is entered in the EHR system). In regards to timing of admission, all newborn information including EGA should be entered into the inpatient record during the inpatient encounter. The newborn should be in inpatient immediately after birth and not when the admit order is placed. We recommend assessing the correct workflow and consult with your EHR vendor to find a solution on how to capture or map the information correctly. For additional information, according to the eCQM, if there are missing EGA, the logic will evaluate if newborn has a birth weight of 3000 grams or more. For the 33% cases that are missing from the eCQM denominator, can you please clarify if those cases also have birth weight timing issues or is there no birth weight value available in the EHR.
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      ​ Thank you for your inquiry. For PC05 and PC06 eCQM, the EGA will need to be evaluated after the newborn is delivered (LOINC Code Gestational age – at birth). The EGA can be assessed anytime during the inpatient encounter (not the time EGA value is entered in the EHR system). In regards to timing of admission, all newborn information including EGA should be entered into the inpatient record during the inpatient encounter. The newborn should be in inpatient immediately after birth and not when the admit order is placed. We recommend assessing the correct workflow and consult with your EHR vendor to find a solution on how to capture or map the information correctly. For additional information, according to the eCQM, if there are missing EGA, the logic will evaluate if newborn has a birth weight of 3000 grams or more. For the 33% cases that are missing from the eCQM denominator, can you please clarify if those cases also have birth weight timing issues or is there no birth weight value available in the EHR.
    • CMS0009v11
    • Denominator for ePC5 and ePC6

      In comparing our 2022 ePC05 and ePC06 denominators to our chart abstracted denominators for Joint Commission we identified that 33% of our babies were missing from the eCQM denominator.  Upon investigation we learned it was because the estimated gestational age (EGA) date/time was documented before the admit date/time.  Its our understanding CMS does not permit retrospective orders (https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/R234BP.pdf).

      In practice the nurse will document the EGA but a provider must enter the admit order.  Coordinating their entries into the EMR is difficult, especially when minutes count (we have cases were the EGA was entered 1 minute before the admit time and were thus missed in the denominator).  We would like to propose an allowance of up to 1 shift (8 hrs) for the EGA to be entered into the patient electronic medical record before the admit order time.

        1. CMS Guidelines on Admit Order Timing.docx
          320 kB

            JLeflore Mathematica EH eCQM Team
            choulihan Carol Houlihan
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