Thank you for your inquiry for CMS996v4/v5: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We have confirmed our understanding of your inquiries and recommendations and have included responded to each below. 1. Our understanding is that the intent of your recommendation is to exclude cases from measure calculation in which a patient is initially diagnosed with a STEMI during the ED encounter, but ultimately does not receive PCI due to clinically valid reasons. This issue has previously been brought to CMS’s attention. The measure developer will consider further measure refinements during the Annual Update. 2. Our understanding is that you’re describing a prior STEMI or denominator exclusion diagnoses identified through the problem list, and suggest using claims data instead, to ensure accurate information. First, the Quality Data Model does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. As such, accurate EHR documentation is crucial. Second, the measure intends to capture STEMI diagnosis during the ED encounter and denominator exclusions in the specified lookback window. To differentiate between active and historic diagnoses in the problem list, it’s important for that both the onset and abatement times are populated in the EHR. Historic STEMI diagnosis should not be captured in the measure because: a) this runs contrary to the measure intent; and b) there is no ED encounter to link to. If a prior STEMI is documented as an active diagnosis or on the problem list within the EHR, it may erroneously count towards the measure population. We recommend working with your EHR vendor or internal IT staff to remove erroneous diagnoses. Further details on the measure specifications can be found here: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v5.html 3. Our understanding is that your recommendation is to use Hospital Access Records (HARs) as a data source for this measure. Per CMS guidelines, eCQMs are measures specified in a standard electronic format that use data electronically extracted from electronic health records, not HARs. 4. Similar to #2 above, it seems you’re describing a scenario in which the STEMI diagnoses and denominator exclusions are retrieved from diagnoses problem list and the information above hopefully clarifies. As stated above, onset and abatement should be captured in the EHR to document diagnoses that are active versus historic, based on clinical determination. Providers can validate eCQMs through internal processes, including collaborations between the EHR vendor and internal IT and QA teams to ensure clinical documentation is accurately captured in the EHR and that measure cases reflect measure specifications. Lastly, we want to acknowledge that these issues have previously been brought to CMS’s attention, and the measure developer will continue to identify future educational resources to support providers.