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  1. eCQM Issue Tracker
  2. CQM-7722

eCQM STEMI

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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
    • None
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    • LaWanda Jones or Tiffany Furlan
    • 915-933-1671 ext 30208
    • Riverside Medical Center
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      Thank you for your inquiry regarding CMS966: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The intent of your question is to determine whether patients that are diagnosed with STEMI in the ED, but ultimately are found to not have a STEMI, are included in the measure calculation. In accordance with the measure’s current specifications, these cases are included in the denominator and fail the numerator since the PCI is not completed within 90 minutes. The issue of no STEMI found after a “cath lab” (exclusion of patients with no STEMI found after procedure) has previously been brought to CMS’s attention. The measure developer will consider further measure refinements to address this during an upcoming Annual Update.
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      Thank you for your inquiry regarding CMS966: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). The intent of your question is to determine whether patients that are diagnosed with STEMI in the ED, but ultimately are found to not have a STEMI, are included in the measure calculation. In accordance with the measure’s current specifications, these cases are included in the denominator and fail the numerator since the PCI is not completed within 90 minutes. The issue of no STEMI found after a “cath lab” (exclusion of patients with no STEMI found after procedure) has previously been brought to CMS’s attention. The measure developer will consider further measure refinements to address this during an upcoming Annual Update.
    • CMS0002v14
    • CMS0002v13
    • Inaccurate patients pulling to report for eCQM, false STEMI patients found during CCL procedure. OP40

      Good Afternoon,

      I am looking for some guidance and clarification on how to proceed. 

      During our review of patients for submission that had a diagnosis of STEMI in the ED, we have found that some patients went to the cath lab that were ruled out as a STEMI and found to have another reason for the ST Elevation are populating. EPIC pulls these patients based off mapping guidelines that are provided for the measure but in reality there are no balloon/PCI times to determine it was less than 90 minutes and these patients should be excluded. These patients that are ruled out during the CCL procedure do not have the defined exclusions listed for the measure during our reviews. 

      Some questions and guidance needed

      1. Since we do not have door to balloon times as we did not do any intervention does CMS exclude them from our data if sent over?
      2. Does your team have any tips on how to map these patients to not include patients that were ruled out as a STEMI? 
      3. Does CMS need to update exclusions to ruled out STEMI patients also?

       

      Thank you for your help

            aweber Mathematica EH eCQM Team
            tiffany5435 Tiffany Furlan
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