Clarification on handling delayed documentation for hospital-based eCQMs

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for your questions. Please find responses to your questions below.

      Question: Should eCQM logic rely on the clinical event/performed date-time or the documentation/recorded date-time when determining whether the event occurred within the inpatient encounter?
      Answer: Different measures will use different data types and timing attributes to align with the clinical intent. This will be specified within the logic using the data type and/or a specific timing attribute if it applies to the clinical intent. Common timing attributes include relevantperiod, relevant datetime, and author dateTime. The relevantPeriod is a default attribute that evaluates activities occurring over a time interval (i.e., during the encounter). The relevant dateTime attribute is to clearly differentiate activities occurring at a point in time. (i.e. FIRST resulted vital signs within 2 hours [120 minutes] after the start of the inpatient admission). The author dateTime attribute is used to indicate the time a data element is documented, i.e., a single point in time. (i.e. patient refusal documented by end of day 2)

      Question: If documentation is entered after discharge but clearly refers to an event that occurred during hospitalization, should that event be considered valid for the hospital-based eCQM?
      Answer: It depends on the measure intent and how the measure logic is designed to handle the timing documentation (ex. author dateTime). For most eCQMs, documentation outside of the encounter should not be considered for the measure due to the documentation timing restraints within the inpatient encounter. Some measures may look at documentation outside of the encounter and allow for documentation of a data element post discharge (ex. documentation of a post discharge follow up call 3 days).

      Question: If the EHR does not capture a distinct performed/event date-time and only documentation timestamps are available, what is the expected approach for measure calculation and compliance?
      Answer: In most cases, when the start dateTime of a period is not known, the retrieve should default to the author dateTime without having to specify author dateTime in the measure.

      Question: Are hospitals expected to account for delayed documentation in measure logic, or is it acceptable to exclude events documented outside the encounter timeframe?
      Answer: See our response to the 2nd question above.

      Comment: Clarification on the expected source of truth for timing in these scenarios would support consistent implementation.
      Response: Additional details regarding the data attributes and timing elements can be found in the QDM v5.6 (https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf).
      Show
      Thank you for your questions. Please find responses to your questions below. Question: Should eCQM logic rely on the clinical event/performed date-time or the documentation/recorded date-time when determining whether the event occurred within the inpatient encounter? Answer: Different measures will use different data types and timing attributes to align with the clinical intent. This will be specified within the logic using the data type and/or a specific timing attribute if it applies to the clinical intent. Common timing attributes include relevantperiod, relevant datetime, and author dateTime. The relevantPeriod is a default attribute that evaluates activities occurring over a time interval (i.e., during the encounter). The relevant dateTime attribute is to clearly differentiate activities occurring at a point in time. (i.e. FIRST resulted vital signs within 2 hours [120 minutes] after the start of the inpatient admission). The author dateTime attribute is used to indicate the time a data element is documented, i.e., a single point in time. (i.e. patient refusal documented by end of day 2) Question: If documentation is entered after discharge but clearly refers to an event that occurred during hospitalization, should that event be considered valid for the hospital-based eCQM? Answer: It depends on the measure intent and how the measure logic is designed to handle the timing documentation (ex. author dateTime). For most eCQMs, documentation outside of the encounter should not be considered for the measure due to the documentation timing restraints within the inpatient encounter. Some measures may look at documentation outside of the encounter and allow for documentation of a data element post discharge (ex. documentation of a post discharge follow up call 3 days). Question: If the EHR does not capture a distinct performed/event date-time and only documentation timestamps are available, what is the expected approach for measure calculation and compliance? Answer: In most cases, when the start dateTime of a period is not known, the retrieve should default to the author dateTime without having to specify author dateTime in the measure. Question: Are hospitals expected to account for delayed documentation in measure logic, or is it acceptable to exclude events documented outside the encounter timeframe? Answer: See our response to the 2nd question above. Comment: Clarification on the expected source of truth for timing in these scenarios would support consistent implementation. Response: Additional details regarding the data attributes and timing elements can be found in the QDM v5.6 ( https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf ).
    • cms0986v6, cms1061v1, cms1317v1
    • Not measure related
    • CMS0071v15, CMS0072v14, CMS0104v14, CMS0108v14, CMS0190v14, CMS0334v7, CMS0506v8, CMS0816v5, CMS0819v4, CMS0826v3, CMS0832v3, CMS0871v5, CMS0986v3, CMS0986v5, CMS1017v1, CMS1017v2, CMS1028v4, CMS1074v3, CMS1218v1, CMS1218v2
    • CMS0071v14, CMS0072v13, CMS0104v13, CMS0108v13, CMS0190v13, CMS0334v6, CMS0506v7, CMS0816v4, CMS0819v3, CMS0826v1, CMS0826v2, CMS0832v1, CMS0832v2, CMS0871v4, CMS0986v4, CMS1028v3, CMS1074v1, CMS1074v2
    • CMS0071v13, CMS0072v12, CMS0104v12, CMS0108v12, CMS0190v12, CMS0334v5, CMS0506v6, CMS0816v3, CMS0819v2, CMS0871v3, CMS0986v2, CMS1028v2
    • Hospital based eCQMs

      For hospital-based eCQMs, we request clarification on handling cases where a clinical event occurs during an inpatient hospitalization, but documentation is completed later.

      Specifically:

      • Should eCQM logic rely on the clinical event/performed date-time or the documentation/recorded date-time when determining whether the event occurred within the inpatient encounter?
      • If documentation is entered after discharge but clearly refers to an event that occurred during hospitalization, should that event be considered valid for the hospital-based eCQM?
      • If the EHR does not capture a distinct performed/event date-time and only documentation timestamps are available, what is the expected approach for measure calculation and compliance?
      • Are hospitals expected to account for delayed documentation in measure logic, or is it acceptable to exclude events documented outside the encounter timeframe?

      Clarification on the expected source of truth for timing in these scenarios would support consistent implementation.

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Sailesh
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              Created:
              Updated:
              Resolved:
              Solution Posted On: