[CQM-7778] CMS 996v5 STEMI IPP Diagnosis Onset dateTime Created: 03/28/25  Updated: 05/09/25  Resolved: 04/10/25

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

Type: Hosp Outpt eCQMs - Hospital Outpatient eCQMs Priority: Moderate
Reporter: Becky Crellin Assignee: Augustine Weber
Resolution: Answered Votes: 0
Labels: None

Issue Links:
Cloners
clones CQM-7526 CMS 996v5 STEMI Numerator PCI Closed
Solution: Thank you for your inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). A patient with a STEMI diagnosis may be captured in the measure in two ways. First, a STEMI diagnosis can be pulled directly from the ED encounter if a STEMI diagnosis was coded during the encounter, as indicated by the measure logic definition below.

 

ED Encounter with Encounter Diagnosis of STEMI

“ED Encounter During MP” EDEncounter

  with EDEncounter.diagnoses EncounterDiagnosis

   such that EncounterDiagnosis.code in “STEMI”

 

Second, the patient can have a diagnosis pulled from a claim, problem list, or other source in the EHR as long as the prevalencePeriod of the STEMI diagnosis started during the ED encounter relevantPeriod. The definition describing this measure logic can be found below.

 

ED Encounter with a Diagnosis of STEMI

“ED Encounter During MP” EDEncounter

  with [“Diagnosis”: “STEMI”] DxSTEMI

   such that DxSTEMI.prevalencePeriod starts during EDEncounter.relevantPeriod

 

To answer your first question, if the STEMI diagnosis is being pulled from the encounter diagnosis as depicted by the ED Encounter with Encounter Diagnosis of STEMI definition, the onset dateTime of the prevalencePeriod is not relevant; the patient would automatically get included in the initial population. In response to the second and third questions, if the STEMI diagnosis is being pulled from a source other than the encounter diagnosis, as depicted by the ED Encounter with a Diagnosis of STEMI definition, we recommend working with your EHR vendor to accurately document the prevalencePeriod onset dateTime and the author dateTime in the EHR, especially if there is uncertainty regarding the prevalencePeriod onset dateTime. We highlight that the QDM allows the author dateTime attribute to be retrieved when the start dateTime of a period (such as the prevalencePeriod) is not known. For more information, please see section 3.2 within the QDM 5.6 PDF found on the following webpage: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf.

 

We emphasize that the measure assesses time from ED arrival to time of appropriate treatment as defined by three numerator criteria: fibrinolytic therapy within 30 minutes of ED arrival, PCI within 90 minutes of ED arrival, or discharge to a PCI-capable Acute Care Facility within 45 minutes of ED arrival. Therefore, the clock for inclusion in the measure numerator would begin at ED arrival time, regardless of what time this particular patient received the STEMI diagnosis. We highlight that the intent of the measure is to ensure timely treatment of patients with a STEMI diagnosis in accordance with the measure Clinical Recommendation Statement section found on the eCQI Resource Center on the following webpage: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v5.html.
Solution Posted On:
2025 Reporting Period Hosp Outpt eCQMs:
CMS0996v5
Last Commented Date:

 Description   

CMS 996v5: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED)

Regarding the IPP logic for "ED Encounter with STEMI Diagnosis" EDwSTEMI:

ED Encounter with Diagnosis of STEMI

  • "ED Encounter During MP" EDEncounter
    with ["Diagnosis": "STEMI"] DxSTEMI
    such that DxSTEMI.prevalencePeriod starts during EDEncounter.relevantPeriod

QDM DataType defines Diagnosis as:

Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy).

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. The preferred terminology for diagnoses is SNOMED CT, but diagnoses may also be encoded using ICD-9-CM (for historical data) and/or ICD-10-CM.

Where prevalence period as:
Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Questions:

  1. If patient gets admitted to the ED at 1/1/2025 at 1pm with present symptoms of STEMI and they indicate to have started at 10am, and the physician confirms the diagnosis of STEMI at 2pm would the prevalence period onset date and time be 1/1 at 2pm as that is what the definition of diagnosis states? If 2pm we would expect this patient to fall into the IPP for this measure correct? If this is not the expected outcome what would be and why?
  2. So typically onset of a problem or diagnosis would indicate when it started or when symptoms started or when the condition first became present for the patient. And many patients that qualify for this measures IPP will probably have a true "onset" of symptoms prior to admission to ED.  So does onset for this measure purpose prevalence period mean something slightly different? Should we look at onset as really the date/time the condition was confirmed or identified by the physician? 
  3. If we are supposed to be using the onset date/Time of symptoms, and using scenario as in #1, how would the physician know (or the patient remember) the specific timing of when the symptoms started?

 Comments   
Comment by Augustine Weber [ 05/09/25 ]

Thank you for your follow-up inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). Additional information about QDM datatype to FHIR QI Core Profile mappings for the diagnosis datatype can be found on the following webpage: https://build.fhir.org/ig/HL7/fhir-qi-core/qdm-to-qicore.html#diagnosis. We appreciate your feedback and will take it into consideration.

Comment by Becky Crellin [ 05/02/25 ]

It seems that the wording of "onset" for the purpose of this specification and measure is a little different than how it is used in other formats when referring to diagnosis?  USCDI and HL7 indicate that "diagnosis onset" date and time represents when symptoms for the condition first presented for the patient.  But in this case it seems to be when the physician confirms the diagnosis (asserted), correct?  Just want to confirm I am understanding all that was stated. If that is the case, is it possible to have that mentioned in the QDM? I did not see anything in there on how onset was defined and I think that would help provide more clarity and avoid future confusion. Appreciate your help and guidance.

Comment by Augustine Weber [ 04/18/25 ]

Thank you for your follow-up inquiry regarding CMS996v5, Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). Based on the ED Encounter with a Diagnosis of STEMI definition, for the patient to be captured within the initial patient population, the prevalencePeriod onset dateTime of the STEMI diagnosis must be within the ED Encounter relevantPeriod (or the time the encounter began – admission time to the time the encounter ended – discharge time). If the physician confirms that the STEMI diagnosis onset occurred at 2pm in the EHR documentation, then we agree that the prevalencePeriod onset dateTime would be 1/1 at 2pm, and the patient would fall into the initial patient population (as long as the ED encounter discharge time was after 2pm since the diagnosis prevalencePeriod onset dateTime must be within the ED encounter relevantPeriod). However, since the inpatient transfer and ED discharge did not occur within 45 minutes of ED arrival (1pm), the patient would not be captured in the measure numerator.

 

In relation to the example provided by the inquiry, we recommend working with your EHR vendor to ensure that the inquiry’s “concepts” are accurately mapped to the appropriate QDM datatype attribute. The “asserted date” should be mapped to the STEMI diagnosis prevalencePeriod onset dateTime attribute (2pm), and the “recorded date” should be mapped to the STEMI diagnosis author dateTime attribute (3pm). The author dateTime attribute indicates the time a data element is documented, and does not necessarily indicate the time an action occurs (such as the confirmed STEMI diagnosis). Since the STEMI measure does not use the Symptom QDM datatype, the 10am symptom onset time stamp that occurred prior to ED admission is not relevant in the measure logic. For more information regarding Diagnosis and Symptom QDM datatype attributes, please see the QDM 5.6: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf.  

Comment by Augustine Weber [ 04/11/25 ]

Thank you for the follow-up question. We will review your ticket and provide a response as soon as possible.

Comment by Becky Crellin [ 04/10/25 ]

With regards to question 1, that was if evaluating based on ED Encounter with a Diagnosis of STEMI (added bolded for clarification). 

  1. If patient gets admitted to the ED at 1/1/2025 at 1pm (and ultimately transferred to Inpatient 1/1/2025 2:45pm) with present symptoms of STEMI and they indicate to have started at 10am, and the physician confirms the diagnosis of STEMI at 2pm would the prevalence period onset date and time be 1/1 at 2pm as that is what the definition of diagnosis states? If 2pm we would expect this patient to fall into the IPP for this measure correct? If this is not the expected outcome what would be and why?

Can you also elaborate on the response to questions 2 and 3? I do not understand.  In order to calculate and understand the IPP we need to understand ED Encounter with a Diagnosis of STEMI. Timing of that diagnosis is crucial so understanding the time that should be used is needed to determine if within the ED timeframe or not.

Concepts:

  • Onset date = when symptoms for the condition first presented for the patient
  • Asserted date = when the provider first makes a determination of the diagnosis
  • Recorded date = when the condition was actually documented in the patient’s local record

Example from 1:

  • Onset date = 1/1 10am
  • Asserted date = 1/1 2pm
  • Recorded date = 1/1 whenever the physician documents lets just say not until 3pm
  • Should this patient fall into the IPP if evaluating based on ED Encounter with a Diagnosis of STEMI?
Comment by Augustine Weber [ 04/07/25 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Augustine Weber [ 03/31/25 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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