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CMS Measure ID: CMS645v4    Performance/Reporting Period: 2021    Version: 4    NQF Number: Not Applicable
Description:

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent prostate cancer diagnosis.
Data Element Scope: This value set may use Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with prostate cancer diagnoses.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Prostate Cancer value set (2.16.840.1.113883.3.526.3.319)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

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 prevalencePeriod 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 bone density x-ray studies.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnostic Study or Order. The intent of this data element is to identify patients with low bone mineral density.
Inclusion Criteria: Includes only relevant concepts associated with Dual-energy X-ray absorptiometry (DXA, DEXA) with 1 or more axial sites, axial skeleton (hips, pelvis, spine) or 1 or more appendicular skeleton sites (radius, wrist, heel).
Exclusion Criteria: No Exclusions.

Constrained to codes in the Diagnostic Study, Order: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care value set (2.16.840.1.113762.1.4.1151.38)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Diagnostic Study, Order

Data elements that meet criteria using this datatype should document a request by a clinician or appropriately licensed care provider to an appropriate provider or organization to perform the diagnostic study indicated by the QDM category and its corresponding value set. The request may be in the form of a consultation or a direct order to the organization that performs the diagnostic study. Diagnostic studies are those that are not performed in the clinical laboratory. Such studies include, but are not limited to, imaging studies, cardiology studies (electrocardiogram, treadmill stress testing), pulmonary function testing, and vascular laboratory testing.

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

Note: negation rationale 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 and must not use relevantPeriod.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent bone density x-ray studies.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnostic Study or Order. The intent of this data element is to identify patients with low bone mineral density.
Inclusion Criteria: Includes only relevant concepts associated with Dual-energy X-ray absorptiometry (DXA, DEXA) with 1 or more axial sites, axial skeleton (hips, pelvis, spine) or 1 or more appendicular skeleton sites (radius, wrist, heel).
Exclusion Criteria: No Exclusions.

Constrained to codes in the Diagnostic Study, Performed: DEXA Dual Energy Xray Absorptiometry, Bone Density for Urology Care value set (2.16.840.1.113762.1.4.1151.38)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Diagnostic Study, Performed

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

Timing:

  • relevant dateTime references the time the diagnostic study is performed if it occurs at a single point in time.
  • relevantPeriod references a start and stop time for an assessment that occurs over a time interval:
    • startTime - when the diagnostic study is initiated.
    • stopTime - when the diagnostic study is completed.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Examples using relevantPeriod:

  • Initiation of a treadmill stress test to the time the treadmill stress test has completed
  • Initiation of the ultrasound study until completion of the ultrasound study

Note: negation rationale 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 and must not use relevantPeriod.

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had an office or other outpatient visit.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive history, evaluation, and management of a patient in an office or outpatient facility. Patient can be presenting with problems that are minor to high severity. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Office Visit value set (2.16.840.1.113883.3.464.1003.101.12.1001)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

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.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

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

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • negation rationale 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 and must not use relevantPeriod.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent androgen deprivation therapy as identified for urology care.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Medication. This data element is to list androgen deprivation therapy for urology care for prostate cancer.
Inclusion Criteria: Includes only relevant concepts associated with androgen deprivation therapy medications.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Active: Androgen deprivation therapy for Urology Care value set (2.16.840.1.113762.1.4.1151.48)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Medication, Active

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set is being taken by the patient. Keep in mind that when this datatype is used with timing relationships, the criterion is looking for a medication being taken for the time frame indicated by the timing relationships.

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

Timing:

  • relevant dateTime references the time the medication is active on the medication record if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for an active medication on the medication record that is given or taken over a time interval:
  • The relevantPeriod addresses:
    • startTime - when the medication is first known to be used (generally the time of entry on the medication list).
    • stopTime - when the medication is no longer active.

In the original QDM 5.5 publication, stopTime stated: when the medication is discontinued (generally, the time discontinuation is recorded on the medication list). See Appendix 6.3 for clarification regarding definition of "Medication, Active" relevantPeriod stopTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a reason for patient refusal.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Negation Rationale.
Inclusion Criteria: Includes only relevant concepts associated with identifying a patient's reason for refusing treatment.
Exclusion Criteria: No exclusions.

Constrained to codes in the Negation Rationale: Patient Declined value set (2.16.840.1.113883.3.600.791)

QDM Attribute and Definition (QDM Version 5.5 Guidance Update)

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 a world view that absence of evidence indicates information does not exist or an action did not happen. To express such lack of evidence, an eCQM author should use the CQL expression not exists with reference to the data element rather than the QDM data model. negation rationale in QDM signifies only a reason for such absence, i.e., the reason must be present to qualify for negation rationale. The syntax in the human readable HQMF is addressed in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, "Procedure, Performed not done." QDM versions starting with 5.3 use the syntax, "Procedure, not Performed." Section A-5 provides examples for expressing negation rationale in CQL.

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

Note: negation rationale 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 and must not use relevantPeriod.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

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 5.5 Guidance Update)

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: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

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 5.5 Guidance Update)

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 relevantPeriod 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: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

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 5.5 Guidance Update)

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: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: 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 5.5 Guidance Update)

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.

Direct Reference Code

Constrained to 'Injection of leuprolide acetate for twelve month period (regime/therapy)' SNOMEDCT code

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

Procedure, Order

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

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

Notes: negation rationale 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 and must not use relevantPeriod.