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  2. CQM-6787

GMCS: Logic clarification

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your inquiry regarding CMS986v2, the Global Malnutrition Composite Score. The eligible denominator is always 4, with two exceptions :

      1. If a Malnutrition Risk Screening was performed with a Not At Risk Result in the absence of a Hospital Dietitian Referral Order, then the eligible denominator is 1.
      2. If a Nutrition Assessment was performed with a Not or Mildly Malnourished Result, then the eligible denominator is 2.

      Therefore, there will be scenarios in which the denominator is 4, despite performance for measure observations 2, 3 and/or 4. The performance for these measure observations will not be counted, particularly in the absence of a malnutrition risk screening and/or hospital dietitian referral.

      These scenarios may result in erroneous calculations, as described in the Known Issue for CMS986v2, ‘EKI-21’ (https://oncprojectracking.healthit.gov/support/browse/EKI-21). The measure observation logic in MO2, MO3, and MO4 is missing the requirement that the valid encounter contains a “Malnutrition Risk Screening At Risk Result” or an ordered “Hospital Dietitian Referral”. This may result in erroneously high-performance which is not aligned with measure intent. Please reference the ‘Desired Logic Pathway for GMCS’, which is attached to the Known Issue. The measure steward is evaluating potential logic changes and corresponding header updates to address the issue in a future Annual Update cycle.
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      Thank you for your inquiry regarding CMS986v2, the Global Malnutrition Composite Score. The eligible denominator is always 4, with two exceptions : 1. If a Malnutrition Risk Screening was performed with a Not At Risk Result in the absence of a Hospital Dietitian Referral Order, then the eligible denominator is 1. 2. If a Nutrition Assessment was performed with a Not or Mildly Malnourished Result, then the eligible denominator is 2. Therefore, there will be scenarios in which the denominator is 4, despite performance for measure observations 2, 3 and/or 4. The performance for these measure observations will not be counted, particularly in the absence of a malnutrition risk screening and/or hospital dietitian referral. These scenarios may result in erroneous calculations, as described in the Known Issue for CMS986v2, ‘ EKI-21 ’ ( https://oncprojectracking.healthit.gov/support/browse/EKI-21 ). The measure observation logic in MO2, MO3, and MO4 is missing the requirement that the valid encounter contains a “Malnutrition Risk Screening At Risk Result” or an ordered “Hospital Dietitian Referral”. This may result in erroneously high-performance which is not aligned with measure intent. Please reference the ‘Desired Logic Pathway for GMCS’, which is attached to the Known Issue. The measure steward is evaluating potential logic changes and corresponding header updates to address the issue in a future Annual Update cycle.
    • CMS0986v2
    • Lots of Eligible Denominators are showing up for those who meet the inital patient population, but have no data for Pop 1, 2, 3 and 4. Is this the intent?

      The logic in the guidance section is not within the actual Measure Logic.  

      • TotalMalnutritionCompositeScore Eligible Denominators(Encounter "Encounter, Performed") *


      • This is the guidance:

      The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:
      -If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed.
      -If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed.
      -If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.
      -If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

      So the above indicates you need some data for some population 1-4 , to be eligible denominators = 4.

      However, in the logic below, you don't need any data for any Population of 1-4. Is this the intent, to capture these cases as issues?

      if ( ( "Encounter with Malnutrition Risk Screening and Identified Result" contains Encounter
      and "Encounter with Malnutrition Screening Not At Risk Result" contains Encounter
      )
      and not ( "Encounter with Hospital Dietitian Referral" contains Encounter )
      ) then 1
      else if ( "Encounter with Nutrition Assessment and Identified Status" contains Encounter
      and "Encounter with Nutrition Assessment Status Not or Mildly Malnourished" contains Encounter
      ) then 2
      else 4 

            JLeflore Joelencia Leflore
            megbutler Margaret Butler
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