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Type:
Hosp Inpt eCQMs - Hospital Inpatient eCQMs
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Resolution: Answered
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Priority:
Moderate
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Component/s: None
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None
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CMS0819v3
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Affect measure outcome, potential false numerator when case had OR time within 12 hours.
We had a patient who went to the OR during ED encounter for emergent need and when had another case where their encounter started as "Same Day Surgery" an outpatient encounter. The measure did not show their OR start time since it occurred before the inpatient start time. According to the measure logic, the Operating room encounter location is during the inpatient encounter.
This logic has a potential of missing OR start & end times when occur outside the inpatient encounter when the measure looks for Narcan administration throughout the encounter (ED or SDS- observation -inpatient)
- "Qualifying Encounter" InpatientEncounter
with "Opioid Administration" OpioidGiven
such that Global."NormalizeInterval" ( OpioidGiven.relevantDatetime, OpioidGiven.relevantPeriod ) starts during Global."HospitalizationWithObservation" ( InpatientEncounter )
and not exists ( InpatientEncounter.facilityLocations EncounterLocation
where EncounterLocation.code ~ "Operating Room/Suite"
and Global."NormalizeInterval" ( OpioidGiven.relevantDatetime, OpioidGiven.relevantPeriod ) starts during EncounterLocation.locationPeriod
)
Desired outcome recovered from Solution field:
Suggest adding a global encounter time for operating room start & end times.