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CMS Measure ID:
Version:
7
NQF Number:
372
Performance/Reporting Period
2019
Description:

This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer)

Data Elements contained within the eCQM + Expand all

Direct Reference Code

Constrained to 'Risk for venous thromboembolism' LOINC code

QDM Datatype and Definition (QDM Version 5.3)

Assessment, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.  

Timing: The time the assessment is completed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent graduated compression stocking devices that are used to prevent VTEs in patients.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to identify patients who have a graduated compression stocking device applied. It may also be used to identify patients who did not have a graduated compression stocking device applied for VTE prophylaxis for an allowable reason when used with a negation rationale attribute.
Inclusion Criteria: Includes only relevant concepts associated with graduated compression stockings.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Applied: Graduated compression stockings (GCS) value set (2.16.840.1.113883.3.117.1.7.1.256)

QDM Datatype and Definition (QDM Version 5.3)

Device, Applied

Data elements that meet criteria using this datatype should document that the device indicated by the QDM category and its corresponding value set is in use, or impacts or alters the treatment, care plan, or encounter (e.g., an antithrombotic device has been placed on the patient's legs to prevent thromboembolism, or a cardiac pacemaker is in place).

Timing: The Relevant Period addresses:

  • startTime – when the device is inserted or first used
  • stopTime – when the device is removed or last used

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent intermittent pneumatic compression devices used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to represent the application of certain intermittent pneumatic compression devices.
Inclusion Criteria: Includes only relevant concepts associated with representing different types of intermittent pneumatic compression devices.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Applied: Intermittent pneumatic compression devices (IPC) value set (2.16.840.1.113883.3.117.1.7.1.214)

QDM Datatype and Definition (QDM Version 5.3)

Device, Applied

Data elements that meet criteria using this datatype should document that the device indicated by the QDM category and its corresponding value set is in use, or impacts or alters the treatment, care plan, or encounter (e.g., an antithrombotic device has been placed on the patient's legs to prevent thromboembolism, or a cardiac pacemaker is in place).

Timing: The Relevant Period addresses:

  • startTime – when the device is inserted or first used
  • stopTime – when the device is removed or last used

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a venous foot pump device applied for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to identify patients who have a venous foot pump device applied for VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with codes which represent venous foot pump devices which are used for VTE prophylaxis.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Applied: Venous foot pumps (VFP) value set (2.16.840.1.113883.3.117.1.7.1.230)

QDM Datatype and Definition (QDM Version 5.3)

Device, Applied

Data elements that meet criteria using this datatype should document that the device indicated by the QDM category and its corresponding value set is in use, or impacts or alters the treatment, care plan, or encounter (e.g., an antithrombotic device has been placed on the patient's legs to prevent thromboembolism, or a cardiac pacemaker is in place).

Timing: The Relevant Period addresses:

  • startTime – when the device is inserted or first used
  • stopTime – when the device is removed or last used

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent graduated compression stocking devices that are used to prevent VTEs in patients.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to identify patients who have a graduated compression stocking device applied. It may also be used to identify patients who did not have a graduated compression stocking device applied for VTE prophylaxis for an allowable reason when used with a negation rationale attribute.
Inclusion Criteria: Includes only relevant concepts associated with graduated compression stockings.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Order: Graduated compression stockings (GCS) value set (2.16.840.1.113883.3.117.1.7.1.256)

QDM Datatype and Definition (QDM Version 5.3)

Device, Order

Data elements that meet criteria using this datatype should document an order for the device indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent intermittent pneumatic compression devices used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to represent the application of certain intermittent pneumatic compression devices.
Inclusion Criteria: Includes only relevant concepts associated with representing different types of intermittent pneumatic compression devices.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Order: Intermittent pneumatic compression devices (IPC) value set (2.16.840.1.113883.3.117.1.7.1.214)

QDM Datatype and Definition (QDM Version 5.3)

Device, Order

Data elements that meet criteria using this datatype should document an order for the device indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a venous foot pump device applied for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Device. The intent of this data element is to identify patients who have a venous foot pump device applied for VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with codes which represent venous foot pump devices which are used for VTE prophylaxis.
Exclusion Criteria: No exclusions.

Constrained to codes in the Device, Order: Venous foot pumps (VFP) value set (2.16.840.1.113883.3.117.1.7.1.230)

QDM Datatype and Definition (QDM Version 5.3)

Device, Order

Data elements that meet criteria using this datatype should document an order for the device indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent diagnoses used to identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter.
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 with a diagnosis of atrial fibrillation or flutter.
Inclusion Criteria: Includes only relevant concepts associated with codes that identify patients with a history of atrial fibrillation/flutter or a current finding of atrial fibrillation/flutter. This is a grouping of ICD-10-CM, ICD-9-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Atrial Fibrillation/Flutter value set (2.16.840.1.113883.3.117.1.7.1.202)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

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 Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent a condition, problem, or diagnosis related to pregnancy or obstetrics.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis. The intent of this data element is to identify patients who have a condition, problem or diagnosis related to pregnancy or obstetrics.
Inclusion Criteria: Includes only relevant concepts associated with a condition, problem or diagnosis related to pregnancy or obstetrics.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Obstetrics value set (2.16.840.1.113883.3.117.1.7.1.263)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

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 Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a venous thromboembolism related to pregnancy or obstetrics.
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 a venous thromboembolism related to pregnancy or obstetrics.
Inclusion Criteria: Includes only relevant concepts associated with a venous thromboembolism related to pregnancy or obstetrics.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Obstetrics VTE value set (2.16.840.1.113883.3.117.1.7.1.264)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

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 Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a venous thromboembolism, including a pulmonary 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 venous thromboembolism, including those who have a pulmonary embolism.
Inclusion Criteria: Includes only relevant concepts associated with codes representing pulmonary embolism and proximal venous thromboembolisms, including specific proximal veins: popliteal vein, femoral/superficial femoral vein, deep femoral vein, ileofemoral vein, iliac vein and inferior vena cava.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Venous Thromboembolism value set (2.16.840.1.113883.3.117.1.7.1.279)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

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 Prevalence Period references the time from the onset date to the abatement date.

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

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
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 inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

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

 

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

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.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent codes for laboratory test for INR, or international normalized ratio.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Laboratory Test. The intent of this data element is to identify INR laboratory tests.
Inclusion Criteria: Includes only relevant concepts associated with a laboratory test of INR (International Normalized Ratio). These are LOINC codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: INR value set (2.16.840.1.113883.3.117.1.7.1.213)

QDM Datatype and Definition (QDM Version 5.3)

Laboratory Test, Performed

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing: The Relevant Period addresses:

  • startTime – when the laboratory test is initiated (i.e., the time the specimen collection begins)
  • stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends)

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection

Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent direct thrombin inhibitor medications.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on a direct thrombin inhibitor.
Inclusion Criteria: Includes only relevant concepts associated with representing direct thrombin inhibitors. These are RxNorm codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Direct Thrombin Inhibitor value set (2.16.840.1.113883.3.117.1.7.1.205)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent codes that identify glycoprotein Iib/IIIa inhibitors.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on a glycoprotein Iib/IIIa inhibitor.
Inclusion Criteria: Includes only relevant concepts associated with a glycoprotein Iib/IIIa inhibitor. These are RxNorm codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Glycoprotein IIb/IIIa Inhibitors value set (2.16.840.1.113762.1.4.1045.41)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent codes which identify injectable factor Xa inhibitors, which are used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on a select injectable factor Xa inhibitor as prophylaxis for VTE.
Inclusion Criteria: Includes only relevant concepts associated with injectable factor Xa inhibitor medications. These are RxNorm codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Injectable Factor Xa Inhibitor for VTE Prophylaxis value set (2.16.840.1.113883.3.117.1.7.1.211)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent unfractionated heparin medications with strengths that could reasonably be used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on low-dose unfractionated heparin as VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with injectable products that could reasonably be used to achieve a dose of at least 5000 units when administered subcutaneously.
Exclusion Criteria: Excludes concentrations less than 250 units/mL.

Constrained to codes in the Medication, Administered: Low Dose Unfractionated Heparin for VTE Prophylaxis value set (2.16.840.1.113762.1.4.1045.39)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent low molecular weight heparin medications used for Venous Thromboembolism (VTE) prophylaxis. The medications included in this value set are administered parenterally.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on low molecular weight heparin therapy as VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with RxNorm codes that specifically represent low molecular weight heparins that are administered parenterally.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Low Molecular Weight Heparin for VTE Prophylaxis value set (2.16.840.1.113883.3.117.1.7.1.219)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent oral factor Xa inhibitors indicated for venous thromboembolism (VTE) prophylaxis and treatment.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who receive oral factor Xa inhibitors for VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with oral forms of factor Xa inhibitors.
Exclusion Criteria: Excludes other dose forms of factor Xa inhibitors.

Constrained to codes in the Medication, Administered: Oral Factor Xa Inhibitor for VTE Prophylaxis or VTE Treatment value set (2.16.840.1.113883.3.117.1.7.1.134)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent heparin formulations that could reasonably be used to treat venous thromboembolism as a continuous infusion.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who receive unfractionated heparin as an intravenous infusion.
Inclusion Criteria: Includes only relevant concepts associated with injectable products that could reasonably be used for continuous infusion of heparin and achieve therapeutic levels.
Exclusion Criteria: Excludes concentrations < 250 UNT/ML (except those representing premixed heparin infusion bags, per inclusion criteria).

Constrained to codes in the Medication, Administered: Unfractionated Heparin value set (2.16.840.1.113883.3.117.1.7.1.218)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent warfarin medications that are administered to patients to reduce the risk of blood clot formation.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are prescribed warfarin therapy at discharge following acute myocardial infarction.
Inclusion Criteria: Includes only relevant concepts associated with drug forms that are consistent with oral administration, such as tablets. Only single ingredient.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Warfarin value set (2.16.840.1.113883.3.117.1.7.1.232)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Administered

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing: The Relevant Period addresses:

  • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion, or administering a pill or IM injection to a patient),
  • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion, or the administration of a pill or IM injection is completed - for pills and IM injections, the start and stop times are the same)

NOTE – Measure developers should address multiple administrations over a period of time using CQL logic.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent codes which identify injectable factor Xa inhibitors, which are used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on a select injectable factor Xa inhibitor as prophylaxis for VTE.
Inclusion Criteria: Includes only relevant concepts associated with injectable factor Xa inhibitor medications. These are RxNorm codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Order: Injectable Factor Xa Inhibitor for VTE Prophylaxis value set (2.16.840.1.113883.3.117.1.7.1.211)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

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

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent unfractionated heparin medications with strengths that could reasonably be used for venous thromboembolism (VTE) prophylaxis.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on low-dose unfractionated heparin as VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with injectable products that could reasonably be used to achieve a dose of at least 5000 units when administered subcutaneously.
Exclusion Criteria: Excludes concentrations less than 250 units/mL.

Constrained to codes in the Medication, Order: Low Dose Unfractionated Heparin for VTE Prophylaxis value set (2.16.840.1.113762.1.4.1045.39)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

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

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent low molecular weight heparin medications used for Venous Thromboembolism (VTE) prophylaxis. The medications included in this value set are administered parenterally.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are on low molecular weight heparin therapy as VTE prophylaxis.
Inclusion Criteria: Includes only relevant concepts associated with RxNorm codes that specifically represent low molecular weight heparins that are administered parenterally.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Order: Low Molecular Weight Heparin for VTE Prophylaxis value set (2.16.840.1.113883.3.117.1.7.1.219)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

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

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent warfarin medications that are administered to patients to reduce the risk of blood clot formation.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify patients who are prescribed warfarin therapy at discharge following acute myocardial infarction.
Inclusion Criteria: Includes only relevant concepts associated with drug forms that are consistent with oral administration, such as tablets. Only single ingredient.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Order: Warfarin value set (2.16.840.1.113883.3.117.1.7.1.232)

QDM Datatype and Definition (QDM Version 5.3)

Medication, Order

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

Timing: The Author dateTime is the time the order is signed.

Timing: The Relevant Period addresses:

  • startTime - when the first administration of the medication is expected. The first administration may be expected at the time of the order or at a specified future date (i.e., the active time for the order); such information should be identified in the medication order. If the startTime is not specified in the order, the startTime defaults to the Author dateTime (the time the order is signed).
  • stopTime - when the medication supply provided by the medication order is expected to be completed, including all fulfillments covered by the number of refills.

Note that when calculating cumulative medication duration, the stopTime may be present directly in the medication order. If the stopTime is not available, the duration in days is the difference between the Relevant Period start and stop times multiplied by (1 + the number of refills).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent situations that represent medical reasons for not providing treatment.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Negation Rationale or Reason. The intent of this data element is to identify medical reasons for not providing treatment.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing medical reasons for not providing treatment should be included.
Exclusion Criteria: No exclusions.

Constrained to codes in the Negation Rationale: Medical Reason value set (2.16.840.1.113883.3.117.1.7.1.473)

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.
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.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the qualifier value used to identify the term principal.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Ordinality.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes that define the principal qualifier value.
Exclusion Criteria: Excludes codes that do not meet the inclusion criteria.

Constrained to codes in the Ordinality: Principal value set (2.16.840.1.113883.3.117.1.7.1.14)

QDM Attribute and Definition (QDM Version 5.3)

Ordinality

The scale in which different procedures are ordered in terms of the qualitative value, as opposed to a ranking performed strictly numerically or quantitatively.
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.

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

 

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.

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.

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent a surgical procedure where a general and/or neuraxial anesthesia is used.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a surgical procedure where general and/or neuraxial anesthesia is used.
Inclusion Criteria: Includes only relevant concepts associated with representing general and/or neuraxial anesthesia. Codes used are to be ICD-10-PCS, ICD-9 or SNOMED CT codes only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: General or Neuraxial Anesthesia value set (2.16.840.1.113883.3.666.5.1743)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent a general surgery procedure. These surgical procedures are thoracic and abdominal procedures, except for cardiac procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have general surgery procedures.
Inclusion Criteria: Includes only relevant concepts associated with representing general surgery. These surgical procedures are thoracic and abdominal procedures, except for cardiac procedures.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: General Surgery value set (2.16.840.1.113883.3.117.1.7.1.255)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent procedures of gynecologic surgery.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a gynecologic surgery procedure.
Inclusion Criteria: Includes only relevant concepts associated with representing gynecologic surgery procedures.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Gynecological Surgery value set (2.16.840.1.113883.3.117.1.7.1.257)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent procedures of hip fracture surgery.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a hip fracture surgery procedure.
Inclusion Criteria: Includes only relevant concepts associated with representing hip fracture surgery.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Hip Fracture Surgery value set (2.16.840.1.113883.3.117.1.7.1.258)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent total hip replacement procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a total hip replacement procedure.
Inclusion Criteria: Includes only relevant concepts associated with representing the surgical procedure of a total hip replacement.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Hip Replacement Surgery value set (2.16.840.1.113883.3.117.1.7.1.259)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent procedures of intracranial neurosurgery.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have an intracranial neurosurgery procedure.
Inclusion Criteria: Includes only relevant concepts associated with representing intracranial neurosurgery.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Intracranial Neurosurgery value set (2.16.840.1.113883.3.117.1.7.1.260)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent total knee replacement procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a total knee replacement procedure.
Inclusion Criteria: Includes only relevant concepts associated with surgical procedure of a total knee replacement.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Knee Replacement Surgery value set (2.16.840.1.113883.3.117.1.7.1.261)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent urologic surgery procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who have a urologic surgery procedure.
Inclusion Criteria: Includes only relevant concepts associated with representing urologic surgery procedures.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Urological Surgery value set (2.16.840.1.113883.3.117.1.7.1.272)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

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

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the route by which a medication is administered, in this case an intravenous route.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Route. The intent of this data element is to identify the route by which a medication is administered, in this case an intravenous route.
Inclusion Criteria: Includes only relevant concepts associated with identifying an intravenous route for giving a medication. Codes used are to be SNOMED CT codes only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Route: Intravenous Route value set (2.16.840.1.113883.3.117.1.7.1.222)

QDM Attribute and Definition (QDM Version 5.3)

Route

Refers to the path by which the medication or substance should be taken into the body system, such as intradermally, intrathecally, intramuscularly, intranasally, intravenously, orally, rectally, subcutaneously, sublingually, topically, or vaginally.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the route by which a medication is administered, in this case a subcutaneous route.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. The intent of this data element is to identify the route by which a medication is administered, in this case a subcutaneous route.
Inclusion Criteria: Includes only relevant concepts associated with identifying a subcutaneous route for giving a medication. These are SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Route: Subcutaneous Route value set (2.16.840.1.113883.3.117.1.7.1.223)

QDM Attribute and Definition (QDM Version 5.3)

Route

Refers to the path by which the medication or substance should be taken into the body system, such as intradermally, intrathecally, intramuscularly, intranasally, intravenously, orally, rectally, subcutaneously, sublingually, topically, or vaginally.