Venous Thromboembolism Discharge Instructions

Last updated: July 12, 2017

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
Previous Version: Venous Thromboembolism Discharge Instructions
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 hospitals participating in the Medicare & Medicaid EHR Incentive Programs consider selecting alternative electronic clinical quality measures (eCQMs) to meet program requirements for meaningful use. If suitable alternatives are unavailable, CMS will accept a 0 denominator submission for the eCQM 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).

Addendum 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 EHR vs. Elements defined in the eCQM logic.

    Section: Guidance

    Source: JIRA (CQM-1693)

  • Removed unit of measurement language from Guidance. HQMF 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 numerator statement to better align with logic.

    Section: Numerator

    Source: JIRA (CQM-1693)

Logic

  • Added missing Occurrence A for $EncounterInpatient variable.

    Section: Denominator

    Source: Measure Lead

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

    Section: Initial Population

    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 Set

  • 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