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  2. CQM-5606

CRP: Change prioritization of cumulative medication duration attributes

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    • Resolution: Unresolved
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      Brief description of measure:
      CMS128: Anti-depressant Medication Management
      Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

      ​​CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD)
      Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.

      CMS156: Use of High-Risk Medications in Older Adults
      Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported.1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses. 3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators).

      Description of issue:
      ​The current function in the CumulativeMedicationDuration library, “MedicationOrderPeriod”, calculates the medication period for a single “Medication, Order” using the following data elements and approach: if ‘relevantPeriod’ is present and completely specified (i.e., with start and end date), it is used directly. Otherwise, if ‘daysSupplied’ is present, the duration is ‘daysSupplied * (1+refills)’, else ‘daysSupplied’ is derived using ‘(supply/(dosage*frequency))*(1+refills)’; the result is then the interval from ‘relevantPeriod.start’ to ‘relevantPeriod.start + daysSupplied’, or ‘authorDatetime’ to ‘authorDatetime + daysSupplied’ if ‘relevantPeriod.start’ is not present.
        
      As currently specified, the function prioritizes ‘relevantPeriod’ over supply quantity for calculating medication period when all data are present. The QDM standards team cautioned this order of priority, specifically the prioritization of ‘relevantPeriod’, as using ‘relevantPeriod’ may potentially inadvertentlyover-count the medication duration, e.g., relevantPeriod with no end date, or relevantPeriod end date representing the stop/reorder date of the medication. The suggestion would be to reverse the order of priority for a more precise calculation. See illustration below.
       
      The function currently places the priority as follows:
         Highest: Interval[relevantPeriod.low or authorDatetime, end of relevantPeriod]
         Intermediate: daysSupplied
         Lowest: calculation using supply quantity, dosage, frequency and refills
       
      Proposed solution to reverse the order of priority to:
         Highest: calculation using supply quantity, dosage, frequency and refills
         Intermediate: daysSupplied
         Lowest: Interval[relevantPeriod.low or authorDatetime, end of relevantPeriod]

      For reference, QDM v5.6 (https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf) defines the “Medication, Order” elements as such:
        - relevantPeriod: relevantPeriod addresses the time referenced in the dosage instruction indicating when the medication administration should start and end.
        - author dateTime: references the date and time the medication order (prescription) is authored.
        - daysSupplied: Number of days of medication supplied per dispense.
        - supply: The quantity (amount) of therapeutic agent provided to a patient per dispensing event (i.e., number of doses, number of tablets or pills, volume of medication) indicated to be given during a procedure, diagnostic test, or medication, or substance administration.
        - dosage: Quantity (e.g., mg, mL) of medication per unit.
        - frequency: Number of units per time period the medication or substance should be taken by the patient or administered to the patient (c).
        - refills: The number of refills allowed by the prescription.

      Goal of review:
      Obtain clinical and technical feedback
      Show
      Brief description of measure: CMS128: Anti-depressant Medication Management Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks).b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months). ​​CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD) Percentage of children 6-12 years of age and newly prescribed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase. b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended. CMS156: Use of High-Risk Medications in Older Adults Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported.1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. 2. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses. 3. Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators). Description of issue: ​The current function in the CumulativeMedicationDuration library, “MedicationOrderPeriod”, calculates the medication period for a single “Medication, Order” using the following data elements and approach: if ‘relevantPeriod’ is present and completely specified (i.e., with start and end date), it is used directly. Otherwise, if ‘daysSupplied’ is present, the duration is ‘daysSupplied * (1+refills)’, else ‘daysSupplied’ is derived using ‘(supply/(dosage*frequency))*(1+refills)’; the result is then the interval from ‘relevantPeriod.start’ to ‘relevantPeriod.start + daysSupplied’, or ‘authorDatetime’ to ‘authorDatetime + daysSupplied’ if ‘relevantPeriod.start’ is not present.    As currently specified, the function prioritizes ‘relevantPeriod’ over supply quantity for calculating medication period when all data are present. The QDM standards team cautioned this order of priority, specifically the prioritization of ‘relevantPeriod’, as using ‘relevantPeriod’ may potentially inadvertentlyover-count the medication duration, e.g., relevantPeriod with no end date, or relevantPeriod end date representing the stop/reorder date of the medication. The suggestion would be to reverse the order of priority for a more precise calculation. See illustration below.   The function currently places the priority as follows:    Highest: Interval[relevantPeriod.low or authorDatetime, end of relevantPeriod]    Intermediate: daysSupplied    Lowest: calculation using supply quantity, dosage, frequency and refills   Proposed solution to reverse the order of priority to:    Highest: calculation using supply quantity, dosage, frequency and refills    Intermediate: daysSupplied    Lowest: Interval[relevantPeriod.low or authorDatetime, end of relevantPeriod] For reference, QDM v5.6 ( https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf ) defines the “Medication, Order” elements as such:   - relevantPeriod: relevantPeriod addresses the time referenced in the dosage instruction indicating when the medication administration should start and end.   - author dateTime: references the date and time the medication order (prescription) is authored.   - daysSupplied: Number of days of medication supplied per dispense.   - supply: The quantity (amount) of therapeutic agent provided to a patient per dispensing event (i.e., number of doses, number of tablets or pills, volume of medication) indicated to be given during a procedure, diagnostic test, or medication, or substance administration.   - dosage: Quantity (e.g., mg, mL) of medication per unit.   - frequency: Number of units per time period the medication or substance should be taken by the patient or administered to the patient (c).   - refills: The number of refills allowed by the prescription. Goal of review: Obtain clinical and technical feedback
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      Proposed solution:
      ​​//Before

      /*@description: Calculates the Medication Period for a single Medication, Order
      @comment: This function calculates the expected period of a medication order using the following approach: If the `relevantPeriod` element is present and completely specified, it is used directly. If the `daysSupplied` element is present, the duration is `daysSupplied * (1 + refills)`. Otherwise, `daysSupplied` is calculated using `(supply / (dosage * frequency)) * (1 + refills)`. The result is then the interval from `authorDatetime` to `authorDatetime + daysSupplied`.
      Note that the supply and dosage Quantity values on the order are assumed to be in terms of the same unit, typically a tablet or mL.
      @seealso: [CumulativeMedicationDuration](https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/blob/master/Source/Libraries)
      Note that relevantPeriod.low represents the interval's lower boundary and relevantPeriod.high represents the interval's higher boundary.*/

      define function "MedicationOrderPeriod"(Order "Medication, Order"):
        if Order.relevantPeriod.low is null
          and Order.authorDatetime is null then null
          else if Order.relevantPeriod.high is not null then Interval[date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime), date from end of Order.relevantPeriod]
          else ( Coalesce(Order.daysSupplied, Order.supply.value /(Order.dosage.value * ToDaily(Order.frequency))) * ( 1 + Coalesce(Order.refills, 0) ) ) totalDaysSupplied
          let startDate: date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime)
          return if totalDaysSupplied is not null then Interval[startDate, startDate + Quantity { value: totalDaysSupplied - 1, unit: 'day' }]
            else null

      //After
      [...]
      define function "MedicationOrderPeriod"(MedOrder "Medication, Order"):
        MedOrder Order
          let startDate: date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime),
          totalDaysSupplied: Coalesce(Order.supply.value /(Order.dosage.value * ToDaily(Order.frequency)), Order.daysSupplied) * ( 1 + Coalesce(Order.refills, 0) )
          return if startDate is null then null
            else if totalDaysSupplied is not null then Interval[startDate, startDate + Quantity { value: totalDaysSupplied - 1, unit: 'day' }]
            else if Order.relevantPeriod.high is not null then Interval[startDate, date from end of Order.relevantPeriod]
            else null

      Rationale for change:
      The Measure Developer would like to know if and how implementers are documenting Medication Order ‘relevantPeriod’ and how this information is represented in the EHR. For example, are Medication Order relevantPeriod stop dates automatically calculated in the EHR based on the prescription date and the supply quantity? This information will inform the Measure Developer of the need and potential impact of the proposed change.
      Show
      Proposed solution: ​​//Before /*@description: Calculates the Medication Period for a single Medication, Order @comment: This function calculates the expected period of a medication order using the following approach: If the `relevantPeriod` element is present and completely specified, it is used directly. If the `daysSupplied` element is present, the duration is `daysSupplied * (1 + refills)`. Otherwise, `daysSupplied` is calculated using `(supply / (dosage * frequency)) * (1 + refills)`. The result is then the interval from `authorDatetime` to `authorDatetime + daysSupplied`. Note that the supply and dosage Quantity values on the order are assumed to be in terms of the same unit, typically a tablet or mL. @seealso: [CumulativeMedicationDuration]( https://github.com/cqframework/CQL-Formatting-and-Usage-Wiki/blob/master/Source/Libraries ) Note that relevantPeriod.low represents the interval's lower boundary and relevantPeriod.high represents the interval's higher boundary.*/ define function "MedicationOrderPeriod"(Order "Medication, Order"):   if Order.relevantPeriod.low is null     and Order.authorDatetime is null then null     else if Order.relevantPeriod.high is not null then Interval[date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime), date from end of Order.relevantPeriod]     else ( Coalesce(Order.daysSupplied, Order.supply.value /(Order.dosage.value * ToDaily(Order.frequency))) * ( 1 + Coalesce(Order.refills, 0) ) ) totalDaysSupplied     let startDate: date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime)     return if totalDaysSupplied is not null then Interval[startDate, startDate + Quantity { value: totalDaysSupplied - 1, unit: 'day' }]       else null //After [...] define function "MedicationOrderPeriod"(MedOrder "Medication, Order"):   MedOrder Order     let startDate: date from Coalesce(Order.relevantPeriod.low, Order.authorDatetime),     totalDaysSupplied: Coalesce(Order.supply.value /(Order.dosage.value * ToDaily(Order.frequency)), Order.daysSupplied) * ( 1 + Coalesce(Order.refills, 0) )     return if startDate is null then null       else if totalDaysSupplied is not null then Interval[startDate, startDate + Quantity { value: totalDaysSupplied - 1, unit: 'day' }]       else if Order.relevantPeriod.high is not null then Interval[startDate, date from end of Order.relevantPeriod]       else null Rationale for change: The Measure Developer would like to know if and how implementers are documenting Medication Order ‘relevantPeriod’ and how this information is represented in the EHR. For example, are Medication Order relevantPeriod stop dates automatically calculated in the EHR based on the prescription date and the supply quantity? This information will inform the Measure Developer of the need and potential impact of the proposed change.

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          edave Mathematica EC eCQM Team
          edave Mathematica EC eCQM Team
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