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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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Matt Shellhammer
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717-848-4800 ext 6810
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OSS Orthopaedic Hospital d/b/a OSS Health
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CMS0108v11
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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