Our hospital has been working to validate CMS 996/OP-40 and we are finding that our results are not as expected.

We are finding that we have cases in the population that are failing the measure when they have ultimately been ruled out as a STEMI as the patient did not require a PCI after being taken to the cath lab.

We are also finding that our STEMI cases that receive a PCI are being excluded as all our cath lab patients from the ED remain in an emergency patient class until after the procedure is performed. To include the correct patients in the measure we would need to alter our workflow of assigning patient class when the patient goes to the cath lab. Altering the patient class could pose compliance issues as well as impede getting the patient to the cath lab for PCI.

Current state our results per the measure logic are very low and this is not true of our actual performance.