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  1. eCQM Issue Tracker
  2. CQM-6277

VTE-1 EHR Programming Logic

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
    • Icon: Moderate Moderate
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    • Matt Shellhammer
    • 717-848-4800 ext 6810
    • OSS Orthopaedic Hospital d/b/a OSS Health
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      Hello and thank you for your inquiry. Unfortunately, this ticket is out of scope for the eCQM Issue Tracker. Please contact the Hospital Inpatient Support Team at https://cmsqualitysupport.servicenowservices.com/qnet_qa.
      Show
      Hello and thank you for your inquiry. Unfortunately, this ticket is out of scope for the eCQM Issue Tracker. Please contact the Hospital Inpatient Support Team at https://cmsqualitysupport.servicenowservices.com/qnet_qa .
    • CMS0108v11
    • Hide
      Our EHR vendor waited until late July to release a necessary update to track the performance rate of CMS108v11. As a result, our performance rate is drastically lower than our historical reporting rate. The vendor's logic does not match the numerator criteria of CMS108v11. Additional information regarding the impact of the issue is noted under "description."
      Show
      Our EHR vendor waited until late July to release a necessary update to track the performance rate of CMS108v11. As a result, our performance rate is drastically lower than our historical reporting rate. The vendor's logic does not match the numerator criteria of CMS108v11. Additional information regarding the impact of the issue is noted under "description."

      I am writing to inform you that our current EHR vendor, Evident/CPSI, is utilizing logic that is inconsistent with the specification for eCQM CMS108v11 (VTE-1). Evident/CPSI launched an update in late July that included the necessary logic for the 2023 reporting period, prior to this we had no way of tracking our performance rate based on the logic Evident/CPSI built. As a result, our true performance rate does not match the current reporting rate reflected in the Evident/CPSI data. Evident/CPSI states that Mechanical VTE Prophylaxis needs to be documented the day after admission for it to count positively in our data set.  

       

      The construction of this logic does not align with the numerator criteria for this measure: “Inpatient hospitalizations for patients who received VTE prophylaxis: 

      • between the day of arrival and the day after hospital admission 
      • the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission).”  

       

      What can be done since Evident/CPSI is unwilling to correct the logic in place for data collection purposes? Historically, we’ve achieved high VTE-1 performance rates and this year our reported performance is below 40%.  Can we be excluded from reporting this measure in 2023 because of the inconsistencies in Evident/CPSI’s logic build? 

       

      Thank you, 

      Matt Shellhammer 

      Clinical Analyst Coordinator 

      OSS Health 

      1861 Powder Mill Road 

      York, PA 17402 

      717-848-4800 ext 6810 

       

            JLeflore Mathematica EH eCQM Team
            mshellhammer@osshealth.com Matt Shellhammer
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