Measure Specifications eCQM 68 - Documentation of Review of Medications

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for inquiring about the Documentation of Current Medications in the Medical Record eCQM. To clarify, the measure is intended to be reported by any healthcare provider specified in the value set. The measure’s Rationale section includes the following statements: "Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's Physician's Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs.” In alignment with the rationale, primary care providers, specialists, and other non-primary care providers should confirm all medications the patient takes at each encounter. Review of the medications does not mean that the non-prescribing provider must modify the dose, frequency, etc., but rather that they have documented a list of current medications utilizing all immediate resources available on the day of the encounter. The measure’s Guidance section explicitly states, "This list must include all known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol (CBD) products AND must contain the medications' name, dosage, frequency, and route of administration."
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      Thank you for inquiring about the Documentation of Current Medications in the Medical Record eCQM. To clarify, the measure is intended to be reported by any healthcare provider specified in the value set. The measure’s Rationale section includes the following statements: "Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which is necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's Physician's Role in Medication Reconciliation, which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (2007). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs.” In alignment with the rationale, primary care providers, specialists, and other non-primary care providers should confirm all medications the patient takes at each encounter. Review of the medications does not mean that the non-prescribing provider must modify the dose, frequency, etc., but rather that they have documented a list of current medications utilizing all immediate resources available on the day of the encounter. The measure’s Guidance section explicitly states, "This list must include all known prescriptions, over-the-counter products, herbals, vitamins, minerals, dietary (nutritional) supplements, cannabis/cannabidiol (CBD) products AND must contain the medications' name, dosage, frequency, and route of administration."
    • CMS0068v14
    • CMS0068v13

      We would like to get clarifications on the specifications of the CMS 68 measure. The clinician types based on value set seem to include non-primary care providers, e.g. LCSW, nutritionist, medical specialist, etc. If all these provider types should be included in the denominator, does it mean that these non-primary care providers need to document the review of medications at every encounter? If yes, does it count in the numerator if they only documented the review of those medications related to their specialty but not all other medications the patient takes?

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Lixin Zhang
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