download chevron-down chevron-right chevron-with-circle-down chevron-with-circle-up check circle-with-minus circle-with-plus export help-with-circle inbox link mail old-phone star-outlined star user v-card close close close Back to top
Top

Performance/Reporting Period
2019
Description:

Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke

Data Elements contained within the eCQM

Communication From Provider To Patient: Activation of Emergency Medical System Education

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent patients who receive emergency medical system education.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive education on the activation of emergency medical system.
Inclusion Criteria: Includes only relevant concepts associated with only SNOMED CT codes representing emergency medical system education.
Exclusion Criteria: No exclusions.

Constrained to codes in the Communication From Provider To Patient: Activation of Emergency Medical System Education value set (2.16.840.1.113883.3.117.1.7.1.377)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Communication From Provider To Patient: Instructions for Follow Up After Discharge

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent follow-up care after discharge or follow-up care planned and scheduled.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive instructions for follow up after discharge or have follow-up plans scheduled.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing instructions for follow up after discharge or follow-up care planned and scheduled.
Exclusion Criteria: Excludes codes that do not meet the inclusion criteria.

Constrained to codes in the Communication From Provider To Patient: Instructions for Follow Up After Discharge value set (2.16.840.1.113883.3.117.1.7.1.378)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Communication From Provider To Patient: Prescribed Medications Education

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent patients who receive prescribed medications education.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive education on the medications they were prescribed to take.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing prescribed medications education.
Exclusion Criteria: No exclusions.

Constrained to codes in the Communication From Provider To Patient: Prescribed Medications Education value set (2.16.840.1.113883.3.117.1.7.1.379)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Communication From Provider To Patient: Risk Factors Education

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent patients who receive risk factor education.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive education on risk factors.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing risk factor education.
Exclusion Criteria: No exclusions.

Constrained to codes in the Communication From Provider To Patient: Risk Factors Education value set (2.16.840.1.113883.3.117.1.7.1.380)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Communication From Provider To Patient: Warning Signs and Symptoms Education

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent patients who receive education for stroke warning signs and symptoms.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive education on stroke warnings signs and symptoms.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing education on warning signs and symptoms.
Exclusion Criteria: No exclusions.

Constrained to codes in the Communication From Provider To Patient: Warning Signs and Symptoms Education value set (2.16.840.1.113883.3.117.1.7.1.381)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Communication From Provider To Patient: Written Information Given

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent qualifiers used to represent patients who receive written information.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Communication. The intent of this data element is to identify patients who receive written information.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing written information given.
Exclusion Criteria: No exclusions.

Constrained to codes in the Communication From Provider To Patient: Written Information Given value set (2.16.840.1.113883.3.117.1.7.1.415)

QDM Datatype and Definition (QDM Version 5.3)
Communication From Provider To Patient

To meet criteria using this datatype, the communication indicated by the Communication QDM category and its corresponding value set must be communicated from a provider to a patient.

Timing: The time the communication occurs, or is sent; Author dateTime.

Discharge Disposition: Discharge To Home Or Police Custody

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent the discharge of a patient to home or police custody.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who were discharged to home or police custody.
Inclusion Criteria: Includes only relevant concepts associated with identifying a patient's discharge destination as either a home setting or police custody.
Exclusion Criteria: Excludes discharge concepts that identify a patient's discharge status as to anywhere else other than home or police custody.

Constrained to codes in the Discharge Disposition: Discharge To Home Or Police Custody value set (2.16.840.1.113883.3.117.1.7.1.82)

QDM Attribute and Definition (QDM Version 5.3)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Encounter, Performed: Emergency Department Visit

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures representing an emergency department encounter.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an emergency department encounter.
Inclusion Criteria: Includes only relevant concepts associated with an emergency department visit encounter using the SNOMED CT code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Emergency Department Visit value set (2.16.840.1.113883.3.117.1.7.1.292)

QDM Datatype and Definition (QDM Version 5.3)
Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Encounter, Performed: Non-Elective Inpatient Encounter

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures for non-elective inpatient encounters.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify non-elective inpatient encounters.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing non-elective inpatient encounters.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Non-Elective Inpatient Encounter value set (2.16.840.1.113883.3.117.1.7.1.424)

QDM Datatype and Definition (QDM Version 5.3)
Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Intervention, Order: Comfort Measures

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent care regimes used to define comfort measure care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention. The intent of this data element is to identify patients receiving comfort measure care.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT regime and therapy codes for comfort measures, terminal care, dying care and hospice care.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Order: Comfort Measures value set (1.3.6.1.4.1.33895.1.3.0.45)

QDM Datatype and Definition (QDM Version 5.3)
Intervention, Order

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime

Intervention, Performed: Comfort Measures

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent care regimes used to define comfort measure care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention. The intent of this data element is to identify patients receiving comfort measure care.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT regime and therapy codes for comfort measures, terminal care, dying care and hospice care.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intervention, Performed: Comfort Measures value set (1.3.6.1.4.1.33895.1.3.0.45)

QDM Datatype and Definition (QDM Version 5.3)
Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Negation Rationale: Patient Refusal

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent situations representing a patient's refusal for treatment.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Reason. The intent of this data element is to identify reasons a patient refuses treatment.
Inclusion Criteria: Includes only relevant concepts associated with identifying refusal of any intervention (including procedures, treatment, medication, counseling, screening).​
Exclusion Criteria: No exclusions.

Constrained to codes in the Negation Rationale: Patient Refusal value set (2.16.840.1.113883.3.117.1.7.1.93)

QDM Attribute and Definition (QDM Version 5.3)
Negation Rationale
The QDM attribute, negation rationale indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the 'negation rationale' attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes that any information expected will be in a clinical record. The situation is different when something that normally would be expected to be done is specifically not done because of a valid clinical reason (such as the patient is allergic, they are suffering from a complication, or some other rationale. In this case, the 'thing not done' is rarely documented, especially as a code, in the patient record. To express such lack of evidence, an eCQM author should use a CQL 'not exists' expression noted in the examples, and they must also capture the Negation rationale to capture a reason for the absence, i.e., the reason must be included to qualify as a negation rationale type expression. The syntax in the human readable HQMF is described in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, 'Procedure, Performed not done.' QDM 5.5 uses the syntax, 'Procedure, not Performed' and this is then associated with either a DRC or a value set used to identify 'the expected thing,' that in this case was not done. Negation Rationale attribute value indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing.

Patient Characteristic Ethnicity: Ethnicity

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.3)
Patient Characteristic Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Patient Characteristic Payer: Payer

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.3)
Patient Characteristic Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Patient Characteristic Race: Race

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.3)
Patient Characteristic Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Patient Characteristic Sex: ONC Administrative Sex

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.3)
Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Principal Diagnosis: Hemorrhagic Stroke

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent patients who have had a hemorrhagic stroke, or stroke caused by hemorrhage.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Principal Diagnosis. The intent of this data element is to identify patients who have a diagnosis of hemorrhagic stroke, or stroke caused by a hemorrhage.
Inclusion Criteria: Includes only relevant concepts associated with a diagnosis of hemorrhagic stroke, or stroke caused by hemorrhage. This is a grouping of ICD-10-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Hemorrhagic Stroke value set (2.16.840.1.113883.3.117.1.7.1.212)

QDM Attribute and Definition (QDM Version 5.3)
Principal Diagnosis
The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

Principal Diagnosis: Ischemic Stroke

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent patients who have had a stroke caused by ischemia, where the blood supply is restricted to an area of the brain by something like thrombosis or an embolism.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Diagnosis. The intent of this data element is to identify patients who have a diagnosis of ischemic stroke, or stroke caused by ischemia.
Inclusion Criteria: Includes only relevant concepts associated with a diagnosis of ischemic stroke, or stroke caused by ischemia. This is a grouping of ICD-10-CM and SNOMED CT codes and concepts.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Ischemic Stroke value set (2.16.840.1.113883.3.117.1.7.1.247)

QDM Attribute and Definition (QDM Version 5.3)
Principal Diagnosis
The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Includes Unions: