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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Answered
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Moderate
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None
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None
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Lilit Ovanisyan
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5592231819
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CMS0072v11
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Qualifying patients fall into Denominator category instead of Denominator Exception.
For STK-5, we noticed that orders qualifying for "Medication Not Ordered: Antithrombotic Therapy> Medical Reason" counted in the Denominator Exception, only if the order was auto discontinued upon discharge. For orders that were entered within day of or day after hospitalization but discontinued during the encounter...those orders did not count patient in Denominator Exception.
Example - Denominator Exception
Admit 1/10/23, "Medical Reason" order entered 1/10/23. Patient discharged 1/17/23. Order auto discontinued.
Example - Denominator
Admit 1/10/23, "Medical Reason" order entered 1/10/23. Order discontinued 1/16/23. Patient discharged 1/17/23.
Seeking clarification whether this was the intent with the Denominator Exception logic.
"No Antithrombotic Ordered or Administered Day Of or Day After Hospital Arrival"
No Antithrombotic Ordered or Administered Day Of or Day After Hospital ArrivalTJC."Ischemic Stroke Encounter" IschemicStrokeEncounter
with "No Antithrombotic Ordered or Administered" NoAntithrombotic
such that NoAntithrombotic.authorDatetime during day of TJC."CalendarDayOfOrDayAfter" ( start of Global."HospitalizationWithObservation" ( IschemicStrokeEncounter ) )
No Antithrombotic Ordered or Administered"Reason for Not Ordering Antithrombotic"
union "Reason for Not Administering Antithrombotic"
Reason for Not Administering Antithrombotic["Medication, Not Administered": "Antithrombotic Therapy"] NoAntithromboticGiven
where NoAntithromboticGiven.negationRationale in "Medical Reason"
or NoAntithromboticGiven.negationRationale in "Patient Refusal"