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  2. CQM-5785

STK-2 (CMS104) is patient class at the date/time of encounter discharge relevant for initial population

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
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    • Margaret A Venditti
    • 5864318687
    • Beaumont Health Services
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      ​STK-2 looks for an ["Encounter, Performed": "Non-Elective Inpatient Encounter"] whose relevantPeriod ends during the “Measurement Period” (please see TJC.”Non Elective Inpatient Encounter”). The QDM reference (https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf, page 9) defines relevantPeriod as administrative start/stop times, i.e. the admission and discharge times.

      However, many places in STK-2 then extend this inpatient encounter to the entire hospitalization using Global.”HospitalizationWithObservation”. Global.”HospitalizationWithObservation” groups ED, observation and inpatient encounters into a hospitalization. It looks for an observation that ends within one hour of the start of an inpatient encounter. It then looks for an ED visit that ends within one hour of the start of the observation visit.

      If the patient was discharged from an “Non-Elective Inpatient Encounter” during the measurement period then it will be considered by STK-2. Please let us know if this does not answer your question and follow-up with more detail.
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      ​STK-2 looks for an ["Encounter, Performed": "Non-Elective Inpatient Encounter"] whose relevantPeriod ends during the “Measurement Period” (please see TJC.”Non Elective Inpatient Encounter”). The QDM reference ( https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf, page 9) defines relevantPeriod as administrative start/stop times, i.e. the admission and discharge times. However, many places in STK-2 then extend this inpatient encounter to the entire hospitalization using Global.”HospitalizationWithObservation”. Global.”HospitalizationWithObservation” groups ED, observation and inpatient encounters into a hospitalization. It looks for an observation that ends within one hour of the start of an inpatient encounter. It then looks for an ED visit that ends within one hour of the start of the observation visit. If the patient was discharged from an “Non-Elective Inpatient Encounter” during the measurement period then it will be considered by STK-2. Please let us know if this does not answer your question and follow-up with more detail.
    • CMS0104v10
    • Initial population may include cases that are not eligible

      STK-2 (CMS 104) Initial Population is defined “Inpatient hospitalizations for patients age 18 and older, discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during the measurement period.  Does “discharged from inpatient care” include only those patients who are registered as an inpatient at the date/time of the encounter discharge?  Does this exclude patients meeting all other criteria that were admitted as an inpatient during an encounter, but at the time of discharge, were no longer an inpatient, i.e., patient class at time of discharge had been changed to observation?

            JLeflore Joelencia Leflore
            margaret.venditti@corewellhealth.org Margaret Venditti
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