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  1. eCQM Issue Tracker
  2. CQM-6765

CMS871v2 DENEX logic issue affecting overall result for multiple episodes of care

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Moderate Moderate
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    • None
    • Julia Dawson
    • 630-319-0192
    • The Joint Commission
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      Thank you for your inquiry and comments specific to CMS871v2 Hospital Harm – Severe Hyperglycemia. We are aware of the Denominator Exclusion logic issue you have described, and the details are posted on the ONC eCQM Known Issues Dashboard website here: https://oncprojectracking.healthit.gov/support/browse/EKI-18. This known issue was resolved in the 2024 Reporting Period version of the measure, CMS871v3 Hospital Harm – Severe Hyperglycemia, where the logic was revised to constrain the glucose evaluation to only the glucose results performed during the qualifying encounter within the 7-hour window. The specifications for CMS871v3 are posted in the eCQI Resource Center website here: https://ecqi.healthit.gov/ecqm?qt-tabs_measure=specifications-and-data-elements
      Show
      Thank you for your inquiry and comments specific to CMS871v2 Hospital Harm – Severe Hyperglycemia. We are aware of the Denominator Exclusion logic issue you have described, and the details are posted on the ONC eCQM Known Issues Dashboard website here: https://oncprojectracking.healthit.gov/support/browse/EKI-18 . This known issue was resolved in the 2024 Reporting Period version of the measure, CMS871v3 Hospital Harm – Severe Hyperglycemia, where the logic was revised to constrain the glucose evaluation to only the glucose results performed during the qualifying encounter within the 7-hour window. The specifications for CMS871v3 are posted in the eCQI Resource Center website here: https://ecqi.healthit.gov/ecqm?qt-tabs_measure=specifications-and-data-elements
    • CMS0871v2
    • The overall result for multiple episodes of care can be incorrect in specific cases and the logic as written does not match measure intent.

      The following logic is invoked for all encounters where it should be invoked one encounter at a time:
      _First Blood Glucose Within 1 Hour Prior To and 6 Hours After Encounter Start
      First(["Laboratory Test, Performed": "Glucose Lab Test Mass Per Volume"] FirstBloodGlucose
      with("Qualifying Encounter")InpatientEncounter
      such that FirstBloodGlucose.relevantDatetime during Interval[(start of Global."HospitalizationWithObservation"(InpatientEncounter)- 1 hour),(start of Global."HospitalizationWithObservation"(InpatientEncounter)+ 6 hours)]
      sort by relevantDatetime
      )_

      We saw a case with two encounters that each had BloodGlucose measurements in the time period between an hour before and 6 hours after the start of their hospitalizations.

      • The BloodGlucose value was less than 1000 during 1 hour before to 6 hours after the start of the first encounter.
      • The BloodGlucose was greater than 1000 during 1 hour before to 6 hours after the start of the second encounter.

      The FIRST of these BloodGlucose is selected by the above logic, that occurs during the first encounter, yet is applied to all of the encounters. The greater than 1000 BloodGlucose is never chosen because all encounters are considered. Encounter 2 should have had a final state of DENEX. This affects the Overall outcomes calculation.

      Denominator Exclusion logic for HH02 then uses the FIRST BloodGlucose value (<1000) to decide whether the first and second Encounter have a final state of DENEX:
      _Encounter With First Blood Glucose Greater Than or Equal to 1000
      "Qualifying Encounter" InpatientHospitalization
      with "First Blood Glucose Within 1 Hour Prior To and 6 Hours After Encounter Start" FirstGlucoseResult
      such that FirstGlucoseResult.result >= 1000 'mg/dL'_

      A possible solution would be to change First Blood Glucose Within 1 Hour Prior To and 6 Hours After Encounter Start to a function with argument "Encounter, Performed" so that only Labs starting between 1 hour before to 6 hours after the specific encounter are considered when FIRST is chosen.

            JLeflore Joelencia Leflore
            jdawson@jointcommission.org Julia Dawson
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              Created:
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