[CQM-1243] Clarification on Specific Occurrence Usage in Denominator Section of CMS53v3 Created: 07/25/14  Updated: 10/10/18  Resolved: 10/10/18

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals Priority: Minor
Reporter: Brian Thiessen (Inactive) Assignee: Yan Heras
Resolution: Done Votes: 0
Labels: Measure

Issue Links:
Relates
Solution: Thank you for bringing this to our attention. We plan to remove the redundant logic statements during the next regularly scheduled update of the eligible hospital measures.
Solution Posted On:
2015 Reporting Period EH eCQMs:
CMS53v3/NQF0163
Comment Posted On:

 Description   

I'd like to request clarification of the denominator logic for CMS53v3 in regards to the ANDing of "Occurrence A of Diagnostic Study, Result..." (DSR) so I'll do my best to make my questions as clear as I can.

The CMS implementation guide states regarding specific occurrence logic:

“When a specific occurrence of an event is specified in multiple clauses linked by AND logic, the logic is only satisfied if the ANDed logical statements evaluate to true using a specific (single) instance of the event.”

Considering the following logic branch:

  • AND: "Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'Hospital Measures-Acute or Evolving MI')"
  • AND NOT:
    • AND: "Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'Hospital Measures-Acute or Evolving MI')"
    • AND: "Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'NSTEMI')" // redundant logic
  • AND NOT: "Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG (result: 'NSTEMI')"
  • AND: FIRST:"Occurrence A of Diagnostic Study, Result: Hospital Measures-ECG" starts after start of "Occurrence A of Diagnostic Study, Performed: Hospital Measures-ECG"

The QRDA template for a DSR only allows for 1 value (Result). Since Occurrence A may only refer to one DSR across the ANDed logic, Occurrence A may not have multiple results (unless multiple DSR entries may be linked together to form a composite DSR - in which case how should that linking be done?) If we cannot reliably link multiple DSR templates in the QRDA document, how do we account for the logic that says Occurrence A of DSR (result: Acute or Evolving MI) AND NOT Occurrence A of DSR(result: NSTEMI)? Since a specific occurrence may only have a single result, it would seem that the AND NOT logic should be removed or the "Occurrence A" restriction should be removed from the "AND NOT DSR (result: NSTEMI)" statement.

I apologize in advance for the confusing question. Please let me know if I need to clarify.



 Comments   
Comment by Julia Skapik (Inactive) [ 11/17/14 ]

A link between CQM-1243 and CAU-275 has been created

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