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  1. eCQM Issue Tracker
  2. CQM-970

Medications “not done” require an unnecessary level of specificity for the medication that was not given.

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      Please note: the approach to medications and other activities that are "not done" has changed from the 2014 measure update to the 2015 measure update. See the correct measure publication guidance to ensure you are using the version's approach correctly.

      2015 measure publication:
      Between the 2014 and 2015 measure publication, updates were made to the approach and the QRDA standard to support the expression of "not done" using the null flavor for the code, where the use of null indicates that none of the codes in the value set were done or are applicable. Please see the Measure Logic Document (https://ecqi.healthit.gov/system/files/ecqm/2015/ecqm_logicguidance_v1_11_061915.pdf) and the CMS 2016 IG (https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/QRDA_2016_CMS_IG.pdf) for the explicit guidance. To negate the device datatype, there is a workaround as the device datatype does not allow direct negation in CDA. Please refer to ticket
      https://jira.oncprojectracking.org/browse/QRDA-176 for that specific instance.

      2014 measure publication:
      Value sets associated with these medication "not done" clauses are being changed to be ingredient-type RxNorm concepts that align with the medications originally noted as expected for the patient population and will be corrected in the EH measure update to be published April 1, 2014 and the EP measure update to be published May 30, 2014. These new value sets will be included with the 2014 MU releases and generally have value set names that end in "ingredient specific".

      CMS and ONC are currently working on a more technically correct approach to the "not done" concept for medications and other data types. The proposed approach suggests the use of the "null flavor" "not applicable". The downstream effects of this approach are currently under investigation and CMS and ONC anticipate publishing guidance on the definitive solution to this problem when it has been tested and approved. In the interim, we welcome comments regarding the feasibility of this proposed solution.
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      Please note: the approach to medications and other activities that are "not done" has changed from the 2014 measure update to the 2015 measure update. See the correct measure publication guidance to ensure you are using the version's approach correctly. 2015 measure publication: Between the 2014 and 2015 measure publication, updates were made to the approach and the QRDA standard to support the expression of "not done" using the null flavor for the code, where the use of null indicates that none of the codes in the value set were done or are applicable. Please see the Measure Logic Document ( https://ecqi.healthit.gov/system/files/ecqm/2015/ecqm_logicguidance_v1_11_061915.pdf ) and the CMS 2016 IG ( https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/QRDA_2016_CMS_IG.pdf ) for the explicit guidance. To negate the device datatype, there is a workaround as the device datatype does not allow direct negation in CDA. Please refer to ticket https://jira.oncprojectracking.org/browse/QRDA-176 for that specific instance. 2014 measure publication: Value sets associated with these medication "not done" clauses are being changed to be ingredient-type RxNorm concepts that align with the medications originally noted as expected for the patient population and will be corrected in the EH measure update to be published April 1, 2014 and the EP measure update to be published May 30, 2014. These new value sets will be included with the 2014 MU releases and generally have value set names that end in "ingredient specific". CMS and ONC are currently working on a more technically correct approach to the "not done" concept for medications and other data types. The proposed approach suggests the use of the "null flavor" "not applicable". The downstream effects of this approach are currently under investigation and CMS and ONC anticipate publishing guidance on the definitive solution to this problem when it has been tested and approved. In the interim, we welcome comments regarding the feasibility of this proposed solution.

      We would like to request a change to the CQM data definitions when a measure requires a very specific RxNorm code for a medication element that was ‘not done.’ For example, in CMS100, NQF142, the QDM component "Medication, Order not done: Medical Reason" for "Hospital Measures-Aspirin RxNorm Value Set" requires that the Element Code come from a value set that only contains very specific medications, doses and dose forms.
      In practice, clinicians would NEVER capture that level of specificity for something not prescribed or not ordered, and forcing that specificity would imply a precision without clinical accuracy and in fact may cause clinical inaccuracy. We would request that instead we are provided “category level” codes (e.g. Aspirin) since that is all the measure should need and in fact is all the precision that is available in clinical practice.

      Similarly, in CMS100 “Medication, Discharge not done: Patient Reason" for "Hospital Measures-Aspirin RxNorm Value Set”, the CQM requires reasons why a medication was not prescribed at discharge. The logic of the measure and the workflow of most vendors’ software make it clear that the intent of documenting the reason not done is in the context of Aspirin. However, the measure requires us to provide an Element Code not just for an Aspirin category but for a specific aspirin formulary item e.g. ‘RxNorm 252380 Aspirin 80 MG Enteric Coated Tablet.’ Again, practice patterns do not support nor require that medications to the precision of the formulary be entered when choosing NOT to prescribe it. Recording that level of detail is not clinical practice, does not enhance patient safety, decreases efficiency, and may cause errors.

      There are a variety of examples of this, many of which have other Jira tickets, and this is a request for to address the concern holistically.

            rob.mcclure Rob McClure
            siemens Siemens (Inactive)
            Abt Associate (Inactive), eldred (Inactive)
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