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  1. eCQM Issue Tracker
  2. CQM-696

Cypress Testing Method overwhelming EHRs with unnecessary smoking codes

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    • Icon: Value Sets Value Sets
    • Resolution: Done
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      Thank you for your comments regarding smoking and tobacco codes. Multiple stakeholders have noted that the tobacco-related concepts in the EHR Incentive Program are confusing, conflicting, and not aligned across programs.

      Cypress, for its part, cannot use any content outside of what exists in the MU measures-- it imports the electronic specifications directly and cannot deviate. Therefore, the confusion with Cypress codes is actually based on a problem that was created in the eCQMs and that persists across multiple federal programs.

      The good news is that the EP MU2 update for 2014 will address whatever possible smoking codes in the measure update. The Value Set Authority Center is the location these will be republished on May 30, 2014. https://vsac.nlm.nih.gov/

      Across measures within the MU program we will look to reduce the total number of different codes and value sets. CMS is currently leading a federal interagency workgroup to harmonize across programs and agencies. Further expertise and funding for VS harmonization is expected in the future.
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      Thank you for your comments regarding smoking and tobacco codes. Multiple stakeholders have noted that the tobacco-related concepts in the EHR Incentive Program are confusing, conflicting, and not aligned across programs. Cypress, for its part, cannot use any content outside of what exists in the MU measures-- it imports the electronic specifications directly and cannot deviate. Therefore, the confusion with Cypress codes is actually based on a problem that was created in the eCQMs and that persists across multiple federal programs. The good news is that the EP MU2 update for 2014 will address whatever possible smoking codes in the measure update. The Value Set Authority Center is the location these will be republished on May 30, 2014. https://vsac.nlm.nih.gov/ Across measures within the MU program we will look to reduce the total number of different codes and value sets. CMS is currently leading a federal interagency workgroup to harmonize across programs and agencies. Further expertise and funding for VS harmonization is expected in the future.
    • Harmonization for tobacco measure in MU2 and MU3

      The requirement that EHRs store the QRDA data generated by Cypress in their database is a big problem and in my opinion going to negatively affect data exchange and standardization between EHRs. I have included this as a fine example.

      Meaningful Use defined 8 smoking statuses and although I might not have picked them, they can probably at least be mapped to the typical questions providers ask about when did you start, when did you stop and how many pack years did you smoke, etc. But, if you also have to store everything that the quality measures might present to you, you end up having to store all of these possible smoking statuses. In addition, there are dozens of additional codes that mention smoking status within other measures.

      I don't think EHRs should be storing all of these possible codes for their patients except if they are data received in a CCDA from another provider. Testing that EHRs can record this data in this format on their own patients only testing that the EHR had been made into an inferior product in order to pass the Quality Measure portion of the testing. This problem is only going to be compounded as there are more and more quality measures.

      Testing should be to show that QRDAs are correct in their format and content in that the content is included in the list of codes that are options, not that every single code in these lists is a specific option to be used to record patient data on a patient that walks in the door and you ask about smoking. I think that those who wrote the Meaningful Use criteria recognized it but if fell apart when the testing for Quality Measures was designed and then the requirement for hashing the actual test instance of the EHR was added to show that the test instance is the same as the EHR in use. Hopefully, I am misinterpreting the requirements and reason for the hashing and sanity can prevail in the production EHR product for recording smoking status.

      Meaningful Use SNOMED codes

      449868002 SNOMED Current every day smoker
      428041000124106 SNOMED Current some day smoker
      8517006 SNOMED Former smoker
      266919005 SNOMED Never smoker
      77176002 SNOMED Smoker, current status unknown
      266927001 SNOMED Unknown if ever smoked
      428071000124103 SNOMED Heavy Tobacco Smoker >=10 cigarettes, cigars or pipes
      428061000124105 SNOMED Light Tobacco Smoker <10 cigarettes,cigars or pipes

      ID 2.16.840.1.113883.3.526.3.1189
      displayName Tobacco Non-User
      version 20121025
      ConceptList
      Code System Description
      105539002 SNOMEDCT Non-smoker for personal reasons (finding)
      105540000 SNOMEDCT Non-smoker for religious reasons (finding)
      105541001 SNOMEDCT Non-smoker for medical reasons (finding)
      160618006 SNOMEDCT Current non-smoker (finding)
      160620009 SNOMEDCT Ex-pipe smoker (finding)
      160621008 SNOMEDCT Ex-cigar smoker (finding)
      228501004 SNOMEDCT Does not use moist powdered tobacco (finding)
      228502006 SNOMEDCT Never used moist powdered tobacco (finding)
      228503001 SNOMEDCT Ex-user of moist powdered tobacco (finding)
      228512004 SNOMEDCT Never chewed tobacco (finding)
      266919005 SNOMEDCT Never smoked tobacco (finding)
      266921000 SNOMEDCT Ex-trivial cigarette smoker (<1/day) (finding)
      266922007 SNOMEDCT Ex-light cigarette smoker (1-9/day) (finding)
      266923002 SNOMEDCT Ex-moderate cigarette smoker (10-19/day) (finding)
      266924008 SNOMEDCT Ex-heavy cigarette smoker (20-39/day) (finding)
      266925009 SNOMEDCT Ex-very heavy cigarette smoker (40+/day) (finding)
      266928006 SNOMEDCT Ex-cigarette smoker amount unknown (finding)
      281018007 SNOMEDCT Ex-cigarette smoker (finding)
      360890004 SNOMEDCT Intolerant ex-smoker (finding)
      360900008 SNOMEDCT Aggressive ex-smoker (finding)
      360918006 SNOMEDCT Aggressive non-smoker (finding)
      360929005 SNOMEDCT Intolerant non-smoker (finding)
      405746006 SNOMEDCT Current non smoker but past smoking history unknown (finding)
      53896009 SNOMEDCT Tolerant ex-smoker (finding)
      8392000 SNOMEDCT Non-smoker (finding)
      8517006 SNOMEDCT Ex-smoker (finding)
      87739003 SNOMEDCT Tolerant non-smoker (finding)

      ID 2.16.840.1.113883.3.526.3.1278
      displayName Tobacco Use Screening
      version 20121025
      ConceptList
      Code System Description
      11366-2 LOINC History of tobacco use Narrative
      68535-4 LOINC Have you used tobacco in the last 30 days SAMHSA
      68536-2 LOINC Have you used smokeless tobacco product in the last 30 days SAMHSA

      ID 2.16.840.1.113883.3.526.3.1170
      displayName Tobacco User
      version 20121025
      ConceptList
      Code System Description
      160603005 SNOMEDCT Light cigarette smoker (1-9 cigs/day) (finding)
      160604004 SNOMEDCT Moderate cigarette smoker (10-19 cigs/day) (finding)
      160605003 SNOMEDCT Heavy cigarette smoker (20-39 cigs/day) (finding)
      160606002 SNOMEDCT Very heavy cigarette smoker (40+ cigs/day) (finding)
      160619003 SNOMEDCT Rolls own cigarettes (finding)
      228494002 SNOMEDCT Snuff user (finding)
      228504007 SNOMEDCT User of moist powdered tobacco (finding)
      228514003 SNOMEDCT Chews plug tobacco (finding)
      228515002 SNOMEDCT Chews twist tobacco (finding)
      228516001 SNOMEDCT Chews loose leaf tobacco (finding)
      228517005 SNOMEDCT Chews fine cut tobacco (finding)
      228518000 SNOMEDCT Chews products containing tobacco (finding)
      230059006 SNOMEDCT Occasional cigarette smoker (finding)
      230060001 SNOMEDCT Light cigarette smoker (finding)
      230062009 SNOMEDCT Moderate cigarette smoker (finding)
      230063004 SNOMEDCT Heavy cigarette smoker (finding)
      230064005 SNOMEDCT Very heavy cigarette smoker (finding)
      230065006 SNOMEDCT Chain smoker (finding)
      266920004 SNOMEDCT Trivial cigarette smoker (less than one cigarette/day) (finding)
      428041000124106 SNOMEDCT Occasional tobacco smoker (finding)
      428061000124105 SNOMEDCT Light tobacco smoker (finding)
      428071000124103 SNOMEDCT Heavy tobacco smoker (finding)
      449868002 SNOMEDCT Smokes tobacco daily (finding)
      65568007 SNOMEDCT Cigarette smoker (finding)
      77176002 SNOMEDCT Smoker (finding)
      81703003 SNOMEDCT Chews tobacco (finding)
      82302008 SNOMEDCT Pipe smoker (finding)

      ID 2.16.840.1.113883.3.600.1559
      displayName Smoking
      version 20121025
      ConceptList
      Code System Description
      160603005 SNOMEDCT Light cigarette smoker (1-9 cigs/day) (finding)
      160604004 SNOMEDCT Moderate cigarette smoker (10-19 cigs/day) (finding)
      160605003 SNOMEDCT Heavy cigarette smoker (20-39 cigs/day) (finding)
      160606002 SNOMEDCT Very heavy cigarette smoker (40+ cigs/day) (finding)
      160619003 SNOMEDCT Rolls own cigarettes (finding)
      230059006 SNOMEDCT Occasional cigarette smoker (finding)
      230060001 SNOMEDCT Light cigarette smoker (finding)
      230062009 SNOMEDCT Moderate cigarette smoker (finding)
      230063004 SNOMEDCT Heavy cigarette smoker (finding)
      230064005 SNOMEDCT Very heavy cigarette smoker (finding)
      230065006 SNOMEDCT Chain smoker (finding)
      266920004 SNOMEDCT Trivial cigarette smoker (less than one cigarette/day) (finding)
      365981007 SNOMEDCT Finding of tobacco smoking behavior (finding)
      365982000 SNOMEDCT Finding of tobacco smoking consumption (finding)
      56578002 SNOMEDCT Moderate smoker (20 or less per day) (finding)
      56771006 SNOMEDCT Heavy smoker (over 20 per day) (finding)
      59978006 SNOMEDCT Cigar smoker (finding)
      65568007 SNOMEDCT Cigarette smoker (finding)
      77176002 SNOMEDCT Smoker (finding)
      82302008 SNOMEDCT Pipe smoker (finding)

            rob.mcclure Rob McClure (Inactive)
            Anthracite Nancy Anthracite (Inactive)
            Cindy Cullen, Kevin Larsen (Inactive), Maureen Madden (Inactive), Minet Javellana (Inactive), Rob McClure (Inactive), Saul Kravitz (Inactive), Steve Emrick (Inactive)
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