• We are concerned by these measures having an inflated number of data elements required for collection. We anticipate utilizing these measures at the facility-level will impose administrative burden. In other words, the volume of data elements required to demonstrate that the measures were applied has potential to impede on clinical time because of the apparent time commitment associated with the measures’ data collection. For instance, if a facility’s EHR does not capture the necessary data elements required to report the electronic clinical quality measure (e-CQM) efforts are made to create a workaround by submitting proxy data. This takes additional time and effort and may unintentionally alter the level of quality demonstrated by the measure.

• There are unique characteristics to specialty hospital units and other facilities and patients admitted to facilities might be temporarily unable to cooperate with a physical or cognitive, but it shouldn’t be assumed that this patient would carry a diagnosis related to the temporary cognitive issue. Once determined as temporary, the cognitive symptoms might not resolve within the first day of admission. For instance, it is not uncommon for patients admitted to psychiatric inpatient facilities to behave in a bizarre, disorganized, psychotic, catatonic, agitated, state. However, the diagnosis they are eventually determined to have might not qualify as a cognitive disorder, and therefore and would not meet the exclusion criteria.

Unfortunately, due to the measures specified as being screened “within the first day of admission” is problematic because the length of time that temporary cognitive impairment lasts might exceed the time permitted in the denominator. Given that the facility could screen later during the patient stay, after the temporary cognitive impairment improved, the facility will still "fail” the measure, and appear to demonstrate poor care, when this has not been the case.

Cognitive abilities vary from patient to patient. It is probable that someone unimpaired is likely to go undocumented as such. In other words, the state of their cognition is implicit rather than explicitly stated. So, while it is something unintentionally skimmed over, if it were documented, the information would be included in documented in text section and not in a structured field suitable for electronic extraction from an EHR.
• Including timing parameters for “Diagnosis: Alcohol and Drug Dependence?” Is beyond the scope of what is captured in the EHR. There is an increased unlikelihood that patients with primary diagnoses unrelated to substance use are recorded for having an alcohol or substance use disorder, even when the diagnosis is current, active and severe. Efforts to investigate for lifetime diagnosis is problematic on multiple fronts. As EHRs are in longer use, it could cause a significant (negative) impact on system performance to have to search for a lifetime diagnosis recorded at any time (even if currently inactive).
• Capturing timing parameters within the EHR as it applies to this measure could prove difficult. The idea that a referral counts if it was within 3 days BEFORE admission would be very hard to capture in an EHR unless a custom data entry option was built and then it would have to be answered for each patient (creating added burden for unclear gain).
• Lab tests for drug/substance use recorded and/or updated in the EHR within a 3-day timeframe of the encounter/episode occurs inconsistently. And similar to the prior comment on this measure occurring up to 3 days before admission would be difficult to capture and prove burdensome. Also, when done, it would occur on admission or presentation to the emergency department (which is typically a part of the encounter).
• We further caution against the use of the word "episode." Individuals could experience multiple encounters related to a single illness episode. If someone was tested within the 3 days BEFORE the encounter, it would be uncommon for that information to have been entered into the EHR unless the outpatient physician was also part of the hospital system.
• The medications listed for inclusion of this measure are all FDA-approved for medical cessation of alcohol or other substances. We support all included, but think it is important to inform the developers that gabapentin and topiramate, while note approved for this indication, are suggested for use as treatments for alcohol use disorder in the 2018 American Psychiatric Association published, “Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder. This is an important detail to consider, because some patients may not wish to take the other medications included on the list. Additionally, buprenorphine implants have also been approved and should probably be listed separately since long acting naltrexone injection is listed separately.