[CQM-1284] Stroke 4 Thrombolytic Therapy Contraindication Created: 08/20/14  Updated: 07/14/15  Resolved: 12/01/14

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

Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs Priority: Minor
Reporter: Joseph Kunisch (Inactive) Assignee: Joelencia Leflore
Resolution: Answered Votes: 2
Labels: Measure

Issue Links:
Supports
Is supported by QDM-31 Does "medication, administered not do... Resolved
Is supported by CQM-970 Medications “not done” require an unn... Closed
Is supported by CQM-225 Medication Ordered vs Administered, n... Closed
Solution: Regarding the parallel logic statements:

The intent of eCQM logic statements “Medication, Order Not Done: Medical Reason” and “Medication, Administered Not Done: Medical Reason” is to allow for documentation of a medical reason or a patient refusal to occur in two different clinical workflows: ordering, and medication administration. Recognizing that some acceptable reasons for not providing pharmacotherapy are difficult to capture as structured data, members of the eMeasures Issues Group (eMIG) reached the decision to use these parallel statements consistently throughout the eCQMs.

As the intent of the statements are two address two separate processes (ordering and administration) that may occur at different points in time, and only one of the statements needs to be met in order to meet the exclusion criteria, we agree that presenting both to the physician is unnecessary.

Regarding alignment with the chart abstracted measure:

For this measure specifically, the logic is intended to align with the manually abstracted data element, Reason for Not Initiating IV Thrombolytic. This data element is a denominator exclusion, which lists valid reasons for which a patient would not receive IV Thrombolytic. As you noted, the manually abstracted data element states that
other reasons for not initiating IV thrombolytic therapy must be documented by a physician/APN/PA or pharmacist- with the exception of nursing documentation of a telemedicine/teleneurology reason for not initiating IV thrombolytic therapy. In addition, several stand-alone reasons, such as patient refusal and an NIHSS score of zero are acceptable.

In the eCQM, the “Medication, Administered Not Done: Medical Reason” logic provides a way to capture documentation at the point of administration for those stand-alone reasons as well as telemedicine reason, which are not explicitly modeled. We understand your concern that nursing staff documentation of other reasons for not administering should not be accepted for this data element, and will consider your feedback for the next annual update.

Finally, your ticket references the December 2012 version of the eCQM (CMS91v1). Please note, the April 2014 version of this measure includes logic to support capture of standalone reasons for not administering IV thrombolytic, such as a documentation of an NIHSS score of zero. We encourage you to refer to the latest eCQM specifications (2014 CQM Eligible Hospitals, April 2014 Update) for this and other measures, as they have been updated to include new codes, logic corrections and clarifications. You can find the technical eCQM specifications for all versions of the eCQMs in CMS's eCQM library: http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html
Impact: Workflow burden by requiring a physician to answer an extra question that should not be needed. Administration of medication done or not done can be captured in the background. Requiring to distinguish ordered vs administered requires a physician to make a choice.
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Last Commented Date:

 Description   

In the STK-4 algorithm the code is written in a way that requires an EHR with the ability to capture a contraindication at the time of ordering a medication OR the time of administering a medication. From an interface perspective, it forces a physician to document a contraindication by checkbox as it relates to "Order not done" or "Administered not done". If the intent of the eMeasures is to be a reflection of the legacy inpatient quality reporting measures, this makes absolutely no sense. When a quality abstractor is determining if a medication measure was met or not met, they look for evidence of administration given. Whether it was ordered or not has no bearing on the outcome. In essence, at what point in time (order or administered) a contraindication is documented has no bearing on the outcome. Medication administered in this case is what matters. I believe the "Medication, order not done" should be completely removed from the algorithm unless someone can explain why these two actions need to be captured when only one really counts in the end. Thank you

• Denominator Exclusions =
o AND:
 OR: "Occurrence A of Encounter, Performed: Inpatient Encounter (reason: 'Carotid Intervention')"
 OR: "Risk Category Assessment: National Institute of Health Stroke Scale (result = 0 )" <= 180 minute(s) starts after start of
 OR: "Occurrence A of Symptom, Active: Neurologic Symptoms of Stroke (start datetime)"
 OR: "Occurrence A of Symptom, Active: Baseline State (stop datetime)"
 OR: "Medication, Administered: Thrombolytic (t-PA) Therapy" <= 2 day(s) starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location arrival datetime)"
 OR:
 OR: "Medication, Order not done: Medical Reason" for "Thrombolytic (t-PA) Therapy RxNorm Value Set"
 OR: "Medication, Order not done: Patient Refusal" for "Thrombolytic (t-PA) Therapy RxNorm Value Set"
 OR: "Medication, Administered not done: Medical Reason" for "Thrombolytic (t-PA) Therapy RxNorm Value Set"
 OR: "Medication, Administered not done: Patient Refusal" for "Thrombolytic (t-PA) Therapy RxNorm Value Set"
 <= 180 minute(s) starts after start of "Occurrence A of Symptom, Active: Baseline State (stop datetime)"

 Comments   
Comment by Rituparna Ganguly (Inactive) [ 01/20/15 ]

The Denominator Exceptions in the April 2014 version of this measure, CMS 91v4, include patient refusal and medical reasons for not ordering or administering Thombolytic Therapy. The medical reason or patient refusal must be documented <= 180 minutes after either the recorded time that patient's baseline state ended, or after the start of symptom onset. Medical reason documentation is represented using the "Medical Reason SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.473)," which can be viewed at https://vsac.nlm.nih.gov/

Refer to http://cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/eCQM_Library.html for the most recent version of the CMS91 (STK4) eCQM specification.

Comment by Rafaela Laran (Inactive) [ 01/17/15 ]

Is there a timeframe when the physcian or provider can document reason for not administering thrombolytic like the IQR quidelines

Comment by Joseph Kunisch (Inactive) [ 10/06/14 ]

In your scenario, the EHR has the intelligence to determine whether the contraindication is being documented at the time of the order or the time of administration. That has not been my experience, or the experience of my colleagues in the hospital setting. In our experience, both sets of contraindications are presented at the same time, and the provider must indicate whether it is being documented at time of ordering or time of administering by clicking on a check box. This occurs outside of the normal workflow patterns and requires providers to remember to do it. This occurs because the way the code is written, the EHR vendors has to provide the ability to capture both data elements in order to pass certification.
Additionally, I’m regularly asked by physicians and nurses what the value is of distinguishing these 2 points in time. Because this is not required by the current inpatient quality reporting (IQR) specifications, physicians and nurses want to have some assurance that additional documentation requirements really add value to current and future patient care. As a former bedside nurse, I’m not able to answer those questions because I haven’t been able to find any evidence-based practices or ongoing research to suggest that this information really is needed. If you are aware of any, please let me know.
Lastly, since Stroke 4 Thrombolytic Therapy is remaining as an IQR chart abstracted measure; the e-specification causes a conflict as IQR specification clearly states the contraindication has to be documented by a physician. In the hospital setting, 99% of the time it is the nursing staff that administers all medications. If for some small chance the contraindication isn’t discovered until the point of the medication being administered, then nurses will be the ones documenting the contraindication, which cannot be used for the chart-abstracted measure.
In order to obtain a contraindication documented by a physician instead of a nurse, hospitals are forced to customize the EHR to prompt the physician for this documentation “at time of ordering” and ignore at time of administering for these reasons;
1) The physician always documents the contraindication to meet IQR specifications
2) The interface does not disrupt the physician workflow by forcing them to answer a question that they find irrelevant to their clinical practice.
Thank you

Comment by Anne Coultas (Inactive) [ 10/03/14 ]

The way the logic is written does not place undo burden on the provider. Having both workflows available in the logic allows documentation why the therapy was either not ordered or not administered within the appropriate workflow.
The decision to not order thrombolytic therapy for a specific reason should be documented in the order workflow by the physician. If the order is created and the thrombolytic therapy is not administered for a specific reason, that reason should be documented in the medication administer workflow by the person not administering the thrombolytic therapy. Since the order not done and the administration not done are "OR" statements, only one workflow needs to be documented against. We believe both workflows should remain in the logic.

Comment by Chris Moesel [ 08/20/14 ]

If I understand this issue correctly, it seems like it is more likely an issue with the logic of the CMS 91 eCQM rather than a defect in the QDM. For that reason, I'm moving it to the CQM project.

If this is in error, please feel free to move it back to QDM and provide more comments regarding the change you would like to see in the QDM specification.

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