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Performance/Reporting Period
2020
Description:

Ischemic stroke patients who are prescribed or continuing to take statin medication at hospital discharge

Data Elements contained within the eCQM

Adverse Event: Statin Allergen

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent an allergy to statin medications.
Data Element Scope: This value set may use Quality Data Model (QDM) category related to Allergy/Intolerance.
Inclusion Criteria: Includes only relevant concepts associated with statins and statin allergens. This is a grouping value set of RXNORM and SNOMED codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Adverse Event: Statin Allergen value set (2.16.840.1.113762.1.4.1110.42)

QDM Datatype and Definition (QDM Version 5.4)
Adverse Event

Data elements that meet criteria using this datatype should document the Adverse Event and its corresponding value set.

Allergy, Intolerance: Statin Allergen

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent an allergy to statin medications.
Data Element Scope: This value set may use Quality Data Model (QDM) category related to Allergy/Intolerance.
Inclusion Criteria: Includes only relevant concepts associated with statins and statin allergens. This is a grouping value set of RXNORM and SNOMED codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Allergy, Intolerance: Statin Allergen value set (2.16.840.1.113762.1.4.1110.42)

QDM Datatype and Definition (QDM Version 5.4)
Allergy Intolerance

Data elements that meet criteria using this datatype should document the Allergy or intolerance and its corresponding value set.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Discharge Disposition: Discharge To Acute Care Facility

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the discharge of a patient to an acute care facility.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who were discharged to an acute care facility.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing short-term acute care hospitals, including specialty hospitals.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Discharge To Acute Care Facility value set (2.16.840.1.113883.3.117.1.7.1.87)

QDM Attribute and Definition (QDM Version 5.4)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Discharge Disposition: Discharged To Health Care Facility For Hospice Care

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent the discharge of a patient to a health care facility for hospice care.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who were discharged to a health care facility for hospice care.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing health care facilities.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Discharged To Health Care Facility For Hospice Care value set (2.16.840.1.113883.3.117.1.7.1.207)

QDM Attribute and Definition (QDM Version 5.4)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Discharge Disposition: Discharged To Home For Hospice Care

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to represent the discharge of a patient to home for hospice care.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who were discharged to home for hospice care.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing discharge to home for hospice care.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Discharged To Home For Hospice Care value set (2.16.840.1.113883.3.117.1.7.1.209)

QDM Attribute and Definition (QDM Version 5.4)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Discharge Disposition: Left Against Medical Advice

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a patient leaving against medical advice.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge disposition. The intent of this data element is to identify the final place or setting to which the patient was discharged on the day of discharge from a particular inpatient encounter. This particular value set intends to identify patients who left against medical advice.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing leaving against medical advice.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Left Against Medical Advice value set (2.16.840.1.113883.3.117.1.7.1.308)

QDM Attribute and Definition (QDM Version 5.4)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Discharge Disposition: Patient Expired

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a patient who has died in the hospital.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Discharge Disposition. The intent of this data element is to identify the discharge status of patient expired as an attribute of the inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with codes for a patient who had died in the hospital. Codes used are to be SNOMED CT codes only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge Disposition: Patient Expired value set (2.16.840.1.113883.3.117.1.7.1.309)

QDM Attribute and Definition (QDM Version 5.4)
Discharge Disposition
The disposition or location to which the patient is transferred at the time of hospital discharge.

Encounter, Performed: Emergency Department Visit 1

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 1 value set (2.16.840.1.113883.3.117.1.7.1.292)

QDM Datatype and Definition (QDM Version 5.4)
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

 

Encounter, Performed: Non-Elective Inpatient Encounter

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures for non-elective inpatient encounters.
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 non-elective inpatient encounters.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing non-elective inpatient encounters.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Non-Elective Inpatient Encounter value set (2.16.840.1.113883.3.117.1.7.1.424)

QDM Datatype and Definition (QDM Version 5.4)
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

 

Encounter, Performed: Observation Services

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent observation 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 observation 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: Observation Services value set (2.16.840.1.113762.1.4.1111.143)

QDM Datatype and Definition (QDM Version 5.4)
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

 

Intervention, Order: Comfort Measures

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: Palliative Care.

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 5.4)
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

Intervention, Performed: Comfort Measures

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: Palliative Care.

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 5.4)
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.

Laboratory Test, Performed: LDL-c

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent lab tests commonly used for low-density lipoproteins (LDL) cholesterol measurement.
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 patients who had a lab test on a source of serum or plasma.
Inclusion Criteria: Includes only relevant concepts associated with LDL-C tests using the source of serum or plasma based on a measurement scale of mass per volume.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: LDL-c value set (2.16.840.1.113883.3.117.1.7.1.215)

QDM Datatype and Definition (QDM Version 5.4)
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).

Medication, Discharge: Statin Grouper

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent statin medications that are prescribed for therapy at hospital discharge.
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 statin medications at discharge.
Inclusion Criteria: Includes only relevant concepts associated with single and multiple ingredient prescribable statin medications. Oral dose forms should be included. Generic only.
Exclusion Criteria: No exclusions.

Constrained to codes in the Medication, Discharge: Statin Grouper value set (2.16.840.1.113762.1.4.1110.19)

QDM Datatype and Definition (QDM Version 5.4)
Medication, Discharge

Data elements that meet criteria using this datatype should document that the medications indicated by the QDM category and its corresponding value set should be taken by or given to the patient after being discharged from an inpatient encounter.

Timing: The time the discharge medication list on the discharge instruction form is authored.

Negation Rationale: Medical Reason 1

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 1 value set (2.16.840.1.113883.3.117.1.7.1.473)

QDM Attribute and Definition (QDM Version 5.4)
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.

Negation Rationale: Patient Refusal

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 5.4)
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.

Patient Characteristic, Birthdate: Birth date

Direct Reference Code

Constrained to 'Birth date' LOINC code

QDM Datatype and Definition (QDM Version 5.4)
Patient Characteristic Birthdate

The Patient Characteristic Birthdate data element should document the patient’s date of birth. Timing: The Patient Characteristic, Birthdate is a single point in time representing the date and time of birth. It does not have a start and stop time. Note: Patient Characteristic Birthdate is fixed to LOINC code 21112-8 (Birth date) and therefore cannot be further qualified with a value set.

Patient Characteristic, Ethnicity: Ethnicity

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 5.4)
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.

Patient Characteristic, Payer: Payer

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 5.4)
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

 

Patient Characteristic, Race: Race

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 5.4)
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.

Patient Characteristic, Sex: ONC Administrative Sex

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 5.4)
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.

Principal Diagnosis: Hemorrhagic Stroke

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent patients who have had a hemorrhagic stroke, or stroke caused by hemorrhage.
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 who have a diagnosis of hemorrhagic stroke, or stroke caused by a hemorrhage.
Inclusion Criteria: Includes only relevant concepts associated with a diagnosis of hemorrhagic stroke, or stroke caused by hemorrhage. This is a grouping of ICD-10-CM and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Hemorrhagic Stroke value set (2.16.840.1.113883.3.117.1.7.1.212)

QDM Attribute and Definition (QDM Version 5.4)
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.

Principal Diagnosis: Ischemic Stroke

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent patients who have had a stroke caused by ischemia, where the blood supply is restricted to an area of the brain by something like thrombosis or an 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 diagnosis of ischemic stroke, or stroke caused by ischemia.
Inclusion Criteria: Includes only relevant concepts associated with a diagnosis of ischemic stroke, or stroke caused by ischemia. This is a grouping of ICD-10-CM and SNOMED CT codes and concepts.
Exclusion Criteria: No exclusions.

Constrained to codes in the Principal Diagnosis: Ischemic Stroke value set (2.16.840.1.113883.3.117.1.7.1.247)

QDM Attribute and Definition (QDM Version 5.4)
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.
Includes Unions: