Healthy Term Newborn

Last updated: May 17, 2016

CMS Measure ID: CMS185v3
Version: 3
NQF Number: 0716
Measure Description:

Percent of term singleton live births (excluding those with diagnoses originating in the fetal period) who DO NOT have significant complications during birth or the nursery care.

Initial Patient Population:

All patients who are single liveborn term newborns born in a hosptital.

Denominator Statement:

The denominator is composed of singleton, term (>=37 weeks), inborn, livebirths in their birth admission. The denominator further has eliminated fetal conditions likely to be present before labor. Maternal and obstetrical conditions (e.g. hypertension, prior cesarean, malpresentation) are not excluded unless evidence of fetal effect prior to labor (e.g. IUGR/SGA).

Denominator Exclusions:

Denominator exclusions: multiple gestations, preterm, congenital anomalies or fetuses affected by selected maternal conditions.

Numerator Statement:

The absence of conditions or procedures reflecting morbidity that happened during birth and nursery care to an otherwise normal infant.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: California Maternal Quality Care Collaborative (CMQCC)
Domain: Patient Safety
Next Version: Healthy Term Newborn
Measure Score: Proportion
Score Type: Process
Improvement Notation:

Increase In Rate

Guidance:

CMS suggests eligible hospitals participating in the Medicare & Medicaid EHR Incentive Programs not select CMS185/NQF0716: Healthy Term Newborn as one of their additional electronic clinical quality measures (eCQMs) for meaningful use. The measure will no longer be maintained since the measure steward has submitted a substantially changed measure to NQF for endorsement.

The very first step for this measure, identifying all term singleton infants can be surprisingly challenging. Some hospitals do not do a good job of using the proper v-codes or DRGs so that clinical information such as birthweight and gestational age need to be used in the first step.

The logic phrase AND: Occurrence A of Encounter, Performed: Inpatient Encounter (reason: 'Birth') intends to capture admission type of newborn for the encounter. Where this information is available in existing EHR structured fields (e.g. data that is fed to UB?04, field location 14), it can be used to map the criterion specified in the logic.

The logic phrase AND: Diagnosis, Active: Liveborn Born In Hospital starts during Occurrence A of Encounter, Performed: Inpatient Encounter intends to capture the point of origin for the inpatient admission. Where this information is available in existing EHR structured fields (e.g. data that is fed to UB-04, field location 15), it can be used to map the criterion specified in the logic.

Specifications

External Resources