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Hearing Screening Prior To Hospital Discharge

Last updated: September 14, 2018

CMS Measure ID: CMS31v7
Version: 7
NQF Number: 1354
Measure Description:

This measure assesses the proportioninfo-icon of births that have been screened for hearing loss before hospital discharge

Initial Patient Population:

Live birth encounters at a hospital or birthing facility where the newborn was discharged with hospital stays <= 120 days that ends during the measurement period

Denominator Statement:

Denominatorinfo-icon is equal to the Initial Populationinfo-icon

Denominator Exclusions:

A live birth encounter where the newborn expires prior to discharge and has not received a complete hearing screening

Numerator Statement:

A live birth encounter where a complete newborn hearing screening is performed prior to discharge or the newborn is not screened due to medical reasons

Numerator Exclusions:

Not applicable

Denominator Exceptions:

None

Measure Steward: CDC National Center on Birth Defects and Developmental Disabilities
Short Name: EHDI-1a
Previous Version:
Improvement Notation:

Improvement noted as an increase in rate

Guidance:

Complete hearing screening is defined as having both ears screened during the inpatient encounter.

The Medical Reasons value setinfo-icon (OID 2.16.840.1.114222.4.1.214079.1.1.7) includes SNOMED codes to capture medical contraindications, surgical contraindications, and not indicated because there is a reason to withhold a certain medical procedure/treatment because it could harm a patient. A comprehensive list of codes for these conditions is not available because the judgement is often subjective. This value set is not intended to be used for other reasons a screening was not performed, such as parent refusal, technical failure, or a missed procedure.

Meaningful Measure: Preventive Care

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Replaced the word 'None' with the standard copyright information.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Removed the measurement period/reporting period text because it is not needed.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Revised guidance to define and clarify what constitutes a Complete Hearing Screening: Complete hearing screening is defined as having both ears screened during the inpatient encounter.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Revised denominator exclusioninfo-icon statement by replacing text '...hearing screening for the left or right ear' with '...a complete hearing screening' to better align with logic and the measure intent.

    Measure Section: Denominator Exclusionsinfo-icon

    Source of Change: Measure Lead

  • Revised numeratorinfo-icon by replacing text 'Live birth encounters during the measurement period where a patient born at the facility is screened for hearing loss prior to discharge or...' with 'A live birth encounter where a complete newborn hearing screening is performed prior to discharge or the newborn is...' to better align with the measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

Logic

  • Added Author Datetime attribute to 'Diagnosis' datatype to align with QDMinfo-icon 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Replaced 'Discharge status' attribute with 'Discharge Disposition' attribute for 'Encounter, Performed' and 'Encounter, Active' datatypes to align with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Replaced the Newborn Hearing Screen Right and Newborn Hearing Screen Left with Complete Hearing Screening in logic to better align with intent of the measure.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Added 'code' attribute to all datatypes to conform with QDM 5.3 changes.

    Measure Section: Denominator Exclusions

    Source of Change: Standards Update

  • Added Author Datetime attribute to 'Diagnosis' datatype to align with QDM 5.3 changes.

    Measure Section: Numerator

    Source of Change: Standards Update

  • Added 'Component' attribute to 'Assessment, Performed', 'Diagnostic, Performed' and 'Laboratory Test, Performed' datatypes to conform with QDM 5.3 changes.

    Measure Section: Numerator

    Source of Change: Standards Update

  • Replaced the Newborn Hearing Screen Right and Newborn Hearing Screen Left with Complete Hearing Screening in logic to better align with intent of the measure.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added 'code' attribute to all datatypes to conform with QDM 5.3 changes.

    Measure Section: Numerator

    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 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 Live Birth Newborn Born in Hospital (2.16.840.1.113762.1.4.1046.6): Added 2 SNOMEDCT codes (17561000119102, 717803002).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Replaced the Patient Expired value set with a direct reference code. The value set is no longer used by the measure because the CQL expression uses the direct-referenced code rather than this single code value set. A direct referenced code is a single concept code that is used to describe a clinical element directly within the logic. The use of direct referenced codes replaces the need for single code value sets.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • 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

External Resources