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Venous Thromboembolism Discharge Instructions

Last updated: May 3, 2018

CMS Measure ID: CMS110v5
Version: 5
NQF Number: None
Measure Description:

This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions/interactions.

Initial Patient Population:

Patients age 18 and older discharged from hospital inpatient acute care during the measurement period with a length of stay less than or equal to 120 days and a diagnosis of venous thromboembolism (VTE)

Denominator Statement:

Patients with VTE confirmed through a diagnostic test and discharged to home or court/law enforcement on warfarin therapy

Denominator Exclusions:

None

Numerator Statement:

Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all of the following:

1. compliance issues, including compliance with taking the medication and INR monitoring

2. dietary advice, including vitamin K dietary management and recommendation not to change diet

3. follow-up monitoring

4. potential for adverse drug reactions and interactions

Patients who refuse written discharge instructions or other educational material about warfarin.

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: The Joint Commission
Domain: Person and Caregiver-Centered Experience Outcomes
Short Name: VTE5
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

CMS recognizes the difficulty in capturing the VTE confirmed concept required in this measure and suggests eligible hospitalsinfo-icon participating in the Medicare & Medicaid EHRinfo-icon Incentive Programs consider selecting alternative electronic clinical quality measuresinfo-icon (eCQMsinfo-icon) to meet program requirements for meaningful use. If suitable alternatives are unavailable, CMS will accept a 0 denominatorinfo-icon submission for the eCQMinfo-icon version only for this measure.

Written information given to the patient is required to address all educational components modeled in the logic as communication from provider to patient. However, implementers may map a single reference to the educational materials in the EHR to each of the educational components for reporting purposes, as long as:

1. the materials address each and every one of the warfarin education components specified in the eCQM logic;

2. EHR documentation shows that the patient was given a copy of the materials satisfying all the education components (written instructions, as opposed to verbal education).

Notes: Removed from Hospital Quality Reporting

Specifications

Release Notes

Header

  • Updated Copyright.

    Section: Copyright

    Source: Annual Update

  • Incremented eMeasure Version number.

    Section: eMeasure Version number

    Source: Measure Lead

  • Added guidance regarding granularity of data capture in the EHRinfo-icon vs. Elements defined in the eCQMinfo-icon logic.

    Section: Guidance

    Source: JIRAinfo-icon (CQMinfo-icon-1693)

  • Removed unit of measurement language from Guidance. HQMFinfo-icon now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Section: Guidance

    Source: Measure Lead

  • Revised numeratorinfo-icon statement to better align with logic.

    Section: Numerator

    Source: JIRA (CQM-1693)

Logic

  • Added missing Occurrence A for $EncounterInpatient variable.

    Section: Denominatorinfo-icon

    Source: Measure Lead

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDMinfo-icon 4.2 changes and provide more accurate logic.

    Section: Initial Populationinfo-icon

    Source: QDM Standards

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Section: Initial Population

    Source: Measure Lead

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: Initial Population

    Source: QDM Standards

  • Added new attribute 'diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Data Elements

    Source: QDM Standards

  • Replaced datatypes 'Diagnosis, Active; with the re-specified 'Diagnosis' datatype to conform to QDM 4.2 changes.

    Section: QDM Variables

    Source: QDM Standards

Value Setinfo-icon

  • Value set VTE Diagnostic Test (2.16.840.1.113883.3.117.1.7.1.276): Deleted 12 LOINC codes.

    Section: None

    Source: None

External Resources