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CMS Measure ID:
Version:
7
NQF Number:
None
Performance/Reporting Period
2019
Description:

Acute myocardial infarction (AMI) patients with a diagnostic ECG and ST-segment elevation, who receive a primary percutaneous coronary intervention (PCI) during their hospital stay, and the time from hospital arrival to PCI is 90 minutes or less

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients with a cardiopulmonary arrest.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Principal Diagnosis. The intent of this data element is to identify patients with a diagnosis of cardiopulmonary arrest.
Inclusion Criteria: Includes only relevant concepts associated with diagnosis codes that identify cardiac arrest.
Exclusion Criteria: Excludes codes that describe history of cardiac arrest.

Constrained to codes in the Diagnosis: Cardiopulmonary arrest value set (2.16.840.1.113883.3.666.5.748)

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 used to define electrocardiogram (ECG).
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnostic Study. The intent of this data element is to identify patients who had an electrocardiogram (ECG) diagnostic test.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients who had an electrocardiogram (ECG).
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Electrocardiogram (ECG) value set (2.16.840.1.113883.3.666.5.735)

QDM Datatype and Definition (QDM Version 5.3)

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: The Relevant Period addresses:

  • startTime – when the diagnostic study is initiated
  • stopTime – when the diagnostic study is completed

Examples:

  • 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

 

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 medications that are prescribed for fibrinolytic therapy in patients with an episode of acute myocardial infarction.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Medication, Administered. The intent of this data element is to identify patients who are prescribed fibrinolytic therapy during an episode of an acute myocardial infarction.
Inclusion Criteria: Includes only relevant concepts associated with generic and prescribable fibrinolytic agents. Only injectable dose forms should be included. Single ingredient.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Administered: Fibrinolytic Therapy value set (2.16.840.1.113883.3.666.5.736)

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 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 contains concepts that represent diagnoses used to identify patients with an acute or evolving myocardial infarction.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Result. The intent of this data element is to identify patients with an acute or evolving myocardial infarction.
Inclusion Criteria: Includes only relevant concepts associated with codes that identify patients with an acute or evolving myocardial infarction. This is a grouping of ICD-10-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Acute Or Evolving MI value set (2.16.840.1.113883.3.666.5.3022)

QDM Attribute and Definition (QDM Version 5.3)

Principal Diagnosis

The coded diagnosis/problem established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to identify aortic balloon pump insertion.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Performed. The intent of this data element is to identify patients with the procedure aortic balloon pump insertion.
Inclusion Criteria: Includes only relevant concepts associated with codes that describe insertion of the aortic balloon pump.
Exclusion Criteria: Excludes codes that describe complications and procedures for removing the device.

Constrained to codes in the Procedure, Performed: Aortic balloon pump insertion value set (2.16.840.1.113883.3.666.5.1151)

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 procedures used to define endotracheal intubation.
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 received endotracheal intubation as a medical procedure.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients who had endotracheal intubation. This is a grouping of ICD-10-PCS and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Endotracheal Intubation value set (2.16.840.1.113762.1.4.1045.69)

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 procedures used to define percutaneous coronary intervention (PCI).
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Performed. The intent of this data element is to identify patients who had percutaneous coronary intervention (PCI) during an episode of acute myocardial infarction.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients receiving percutaneous coronary intervention (PCI). This is a grouping of ICD-10-PCS and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: PCI value set (2.16.840.1.113762.1.4.1045.67)

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 procedures used to identify the placement of a ventricular assist device.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Performed. The intent of this data element is to identify procedures for ventricular assist device placement.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients with ventricular assist device placement. This is a grouping of ICD-10-PCS and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Ventricular Assist Device placement value set (2.16.840.1.113883.3.666.5.3015)

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.