Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge
Inpatient hospitalizations for patients age 18 and older, discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during measurement period
Inpatient hospitalizations for patients with a principal diagnosis of ischemic stroke
Inpatient hospitalizations for patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations.
Inpatient hospitalizations for patients discharged to another hospital
Inpatient hospitalizations for patients who left against medical advice
Inpatient hospitalizations for patients who expired
Inpatient hospitalizations for patients discharged to home for hospice care
Inpatient hospitalizations for patients discharged to a health care facility for hospice care
Inpatient hospitalizations for patients with comfort measures documented
Inpatient hospitalizations for patients prescribed or continuing to take statin medication at hospital discharge
Not Applicable
Inpatient hospitalizations for patients with a reason for not prescribing statin medication at discharge
Inpatient hospitalizations for patients with a maximum LDL-c result of less than 70 mg/dL <= 30 days prior to arrival or any time during the hospital stay
Inpatient hospitalizations for patients with a statin allergy.
Improvement noted as an increase in rate
The "Non-elective Inpatient Encounter" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient Encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective Inpatient Encounters include emergency, urgent, and unplanned admissions.
The "Medication, Discharge" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use.
Data Element Repository
Release Notes
Header
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Updated eCQM version number.
Measure Section: eCQM Version number
Source of Change: Annual Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated references to align with American Psychological Association (APA) style.
Measure Section: Reference
Source of Change: Measure Lead
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Updated references.
Measure Section: Reference
Source of Change: Measure Lead
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Updated guidance statement to correct grammatical errors.
Measure Section: Guidance
Source of Change: Measure Lead
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Updated initial population statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.
Measure Section: Initial Population
Source of Change: Measure Lead
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Updated denominator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.
Measure Section: Denominator
Source of Change: Measure Lead
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Updated denominator exclusion statement to align with logic.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Updated denominator exclusions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.
Measure Section: Denominator Exclusions
Source of Change: Measure Lead
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Updated numerator statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.
Measure Section: Numerator
Source of Change: Measure Lead
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Added to denominator exceptions statin allergy to align with logic.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
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Updated denominator exceptions statement to begin with ‘Inpatient Hospitalizations for patients’ instead of ‘Patient with’ to align with measure intent since measure is encounter-based not patient-based.
Measure Section: Denominator Exceptions
Source of Change: Measure Lead
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Updated parenthetical citations to align with American Psychological Association (APA) style.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Replaced ‘Global.Hospitalization’ with new function ‘Global.Hospitalization with Observation’ to capture assessments performed during observation status prior to inpatient admission.
Measure Section: Denominator Exclusions
Source of Change: ONC Project Tracking System (JIRA): CQM-2835
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Replaced extensional Statin Allergen (OID 2.16.840.1.113883.3.117.1.7.1.423) with Statin Allergen grouping (OID 2.16.840.1.113762.1.4.1110.42) to align with terminology updates that capture medication class allergens.
Measure Section: Denominator Exceptions
Source of Change: ONC Project Tracking System (JIRA): CQM-1798
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Updated definition name from TJC.'Ischemic Stroke Encounters with Discharge Status' to TJC.'Ischemic Stroke Encounters with Discharge Disposition' to align with measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.
Measure Section: Definitions and Functions
Source of Change: Standards Update
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Updated TJC_Overall Library version number (TJC_Overall-3.6.000).
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.
Measure Section: Multiple Sections
Source of Change: Standards Update
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Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).
Measure Section: Multiple Sections
Source of Change: Standards Update
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
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Value set LDL-c (2.16.840.1.113883.3.117.1.7.1.215): Added 8 LOINC codes (90364-1, 91105-7, 91106-5, 91107-3, 91108-1, 91109-9, 91110-7, 91111-5).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Statin Grouper (2.16.840.1.113762.1.4.1110.19): Added 2 RxNorm codes (1790679, 1944264).
Measure Section: Terminology
Source of Change: Annual Update
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Value set Observation Services (2.16.840.1.113762.1.4.1111.143): Added Observation Services.
Measure Section: Terminology
Source of Change: Annual Update
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Value set Statin Allergen (2.16.840.1.113762.1.4.1110.42): Added new grouping value set with 7 RxNorm codes (extensional value set 2.16.840.1.113883.3.117.1.7.1.423) and 1 SNOMED CT code (extensional value set 2.16.840.1.113762.1.4.1110.41).
Measure Section: Terminology
Source of Change: ONC Project Tracking System (JIRA): CQM-1798
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Value set Comfort Measures (1.3.6.1.4.1.33895.1.3.0.45): Changed Exclusion Criteria description from ‘None’ to ‘Palliative Care’ for clarity and to align with chart-abstracted measures.
Measure Section: Terminology
Source of Change: ONC Project Tracking System (JIRA): CQM-3396
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Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.
Measure Section: Terminology
Source of Change: Annual Update
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Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.
Measure Section: Terminology
Source of Change: Measure Lead