For Perinatal Care newborn quality measures, we have found patients that may have multiple qualifying encounters due to clinical documentation of “Single Live Born Newborn Born in Hospital” in subsequent hospital encounters. For example, a baby is delivered in Hospital A and then transferred to a NICU at Hospital B. Both encounters may have an clinical documentation with an Encounter.diagnoses of “Single Live Born Newborn Born in Hospital.”

Hospital quality staff are concerned that Hospital B should not have the baby in populations such as those of PC-06, despite that encounter diagnosis. The PC-06 measure author, The Joint Commission (TJC), said they do not think this second encounter with Hospital B should be reported for PC-06 (or similar measures) because they think Encounter.diagnoses should exclusively look to billing diagnoses as a source.

There is conflicting guidance on where the Encounter.diagnoses attribute in the Quality Data Model (QDM) should be sourced from within the EHR. QDM v5.6 provides only a brief definition before proceeding with technical constraints:

                “Coded diagnoses/problems addressed during the encounter.”

Guidance does indicate that “all” diagnoses are intended to be included: “The "Encounter, Performed" diagnoses attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.” eCQI Resource Center - "Encounter, Performed"

This has led to two differing interpretations:

1. Encounter.diagnoses should be retrieved exclusively from billing information, or
2. The QDM does not prescribe a specific source for diagnosis data, consistent with the Diagnosis datatype definition (“The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR.” eCQI Resource Center - "Diagnosis"

Although Encounter.diagnoses includes components such as presentOnAdmissionIndicator and rank– which align with claims-based UB-04 concepts – EHRs may also support documenting “Present on Admission” or “Principal” designations through clinical workflows. eCQMs are also reported out of certified EHRs, which may or may not have access to the hospital’s billing system data.

Looking ahead to the transition to digital quality measures (dQM), measure developers could leverage newer data modeling to exclude diagnoses where Condition.category = problem-list-item.

Epic seeks updated guidance for measure developers and implementers on acceptable data sources for Encounter.diagnoses, without the overhead of requiring new technical attributes or components to the QDM specification. The goal is to ensure that quality measure reporting remains feasible and consistent across organizations, especially those with clinical and claims data housed in separate systems.