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Stroke Education

Last updated: September 14, 2018

CMS Measure ID: CMS107v7
Version: 7
NQF Number: None
Measure Description:

Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke

Initial Patient Population:

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 the measurement period

Denominator Statement:

Ischemic stroke or hemorrhagic stroke patients discharged to home, home care, or court/law enforcement

Denominator Exclusions:

Patients with comfort measures documented

Numerator Statement:

Ischemic or hemorrhagic stroke patients with written documentation that they or their caregivers were given educational material addressing all of the following:

1. Activation of emergency medical system

2. Follow-up after discharge

3. Medications prescribed at discharge

4. Risk factors for stroke

5. Warning signs and symptoms of stroke

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Short Name: STK-08
Previous Version:
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

Written information given to the patient is required to address each and every one of the educational components. These components are modeled in the population criteria and data criteria as communication from provider to patient :activation of emergency medical system, follow-up after discharge, medications prescribed at discharge, risk factors and signs and symptoms, and are intended to be specific to stroke.

The Non-elective admissions value setinfo-icon 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 admissions include emergency, urgent and unplanned admissions.

Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

Logic

  • Replaced 'Discharge status' attribute with 'Discharge Disposition' attribute for 'Encounter, Performed' and 'Transfer From' with 'Admission Source for' 'Encounter, Performed' datatypes to align with QDMinfo-icon 5.3 changes.

    Measure Section: Denominatorinfo-icon

    Source of Change: Standards Update

  • Added 'AuthorDateTime' attribute to QDM datatypes that include negation rationale: ‘Communication: From Provider to Patient, Not Done' to conform with QDM 5.3 changes.

    Measure Section: Numeratorinfo-icon

    Source of Change: Standards Update

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQLinfo-icon logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)-based logic to Clinical Quality Language (CQL)-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Deleted 2 SNOMEDCT codes (183956002, 385648002).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 1 SNOMEDCT code (28837001).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 2 ICD10CM codes (I63.81, I63.89) and deleted 1 ICD10CM code (I63.8).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources