eCQMs for 2016 Reporting Period

Clinical Quality Measures and their electronic specifications as defined in the 2015 update for Eligible Hospitals.

Measure Namesort descending Short Name CMS eCQM ID Domain NQF ID Measure Steward USHIK Version Links
Anticoagulation Therapy for Atrial Fibrillation/Flutter Stroke3 CMS71v5 Effective Clinical Care 0436 The Joint Commission Version Detail
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Antithrombotic Therapy By End of Hospital Day 2 Stroke5 CMS72v4 Effective Clinical Care 0438 The Joint Commission Version Detail
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Aspirin Prescribed at Discharge AMI2 CMS100v4 Effective Clinical Care 0142 Centers for Medicare & Medicaid Services Version Detail
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Assessed for Rehabilitation Stroke10 CMS102v4 Communication and Care Coordination 0441 The Joint Commission Version Detail
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Discharged on Antithrombotic Therapy Stroke2 CMS104v4 Effective Clinical Care 0435 The Joint Commission Version Detail
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Discharged on Statin Medication Stroke6 CMS105v4 Effective Clinical Care 0439 The Joint Commission Version Detail
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Elective Delivery PC01 CMS113v4 Effective Clinical Care 0469 The Joint Commission Version Detail
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Exclusive Breast Milk Feeding BF CMS9v4 Effective Clinical Care 0480 The Joint Commission Version Detail
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Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival AMI7a CMS60v4 Effective Clinical Care 0164 Centers for Medicare & Medicaid Services Version Detail
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Healthy Term Newborn CMS185v4 Patient Safety 0716 Centers for Medicare & Medicaid Services Version Detail
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Hearing Screening Prior To Hospital Discharge EHDI_1a CMS31v4 Effective Clinical Care 1354 CDC National Center on Birth Defects and Developmental Disabilities Version Detail
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Home Management Plan of Care (HMPC) Document Given to Patient/Caregiver HMPC CMS26v3 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Incidence of Potentially-Preventable Venous Thromboembolism VTE6 CMS114v4 Patient Safety None The Joint Commission Version Detail
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Initial Antibiotic Selection for Community-Acquired Pneumonia (CAP) in Immunocompetent Patients PN6 CMS188v5 Efficiency and Cost Reduction Use of Healthcare Resources 0147 Centers for Medicare & Medicaid Services Version Detail
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Intensive Care Unit Venous Thromboembolism Prophylaxis VTE2 CMS190v4 Patient Safety 0372 The Joint Commission Version Detail
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Median Admit Decision Time to ED Departure Time for Admitted Patients ED2 CMS111v4 Person and Caregiver-Centered Experience Outcomes 0497 Centers for Medicare & Medicaid Services Version Detail
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Median Time from ED Arrival to ED Departure for Admitted ED Patients ED1 CMS55v4 Person and Caregiver-Centered Experience Outcomes 0495 Centers for Medicare & Medicaid Services Version Detail
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Median Time from ED Arrival to ED Departure for Discharged ED Patients ED3 CMS32v5 Communication and Care Coordination 0496 Centers for Medicare & Medicaid Services Version Detail
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Primary PCI Received Within 90 Minutes of Hospital Arrival AMI8a CMS53v4 Effective Clinical Care 0163 Centers for Medicare & Medicaid Services Version Detail
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Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision SCIPInf1 CMS171v5 Patient Safety 0527 Centers for Medicare & Medicaid Services Version Detail
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Prophylactic Antibiotic Selection for Surgical Patients SCIPInf2 CMS172v5 Efficiency and Cost Reduction Use of Healthcare Resources 0528 Centers for Medicare & Medicaid Services Version Detail
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Statin Prescribed at Discharge AMI10 CMS30v5 Effective Clinical Care 0639 Centers for Medicare & Medicaid Services Version Detail
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Stroke Education Stroke8 CMS107v4 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Thrombolytic Therapy Stroke4 CMS91v5 Effective Clinical Care 0437 The Joint Commission Version Detail
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Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero SCIPInf9 CMS178v5 Patient Safety 0453 Centers for Medicare & Medicaid Services Version Detail
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Venous Thromboembolism Discharge Instructions VTE5 CMS110v4 Person and Caregiver-Centered Experience Outcomes None The Joint Commission Version Detail
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Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages/Platelet Count Monitoring by Protocol or Nomogram VTE4 CMS109v4 Effective Clinical Care None The Joint Commission Version Detail
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Venous Thromboembolism Patients with Anticoagulation Overlap Therapy VTE3 CMS73v4 Effective Clinical Care 0373 The Joint Commission Version Detail
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Venous Thromboembolism Prophylaxis VTE1 CMS108v4 Patient Safety 0371 The Joint Commission Version Detail
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Recent Activity

Wednesday, March 22

Tuesday, March 21

Tuesday, May 17 2016

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    3:28pm EDT
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  • Your profile picture
    3:27pm EDT
    Changes to Release Notes
     
    of logical expressions and reduce redundancy/complexity.
     
    of logical expressions and reduce redundancy/complexity.
     
    * Removed Date Difference function from Numerator logic and replaced it with
     
    * Removed Date Difference function from Numerator logic and replaced it with
    -
    the expression of logic in the Numerator, -The line of logic 'AND:
    +
    the expression of logic in the Numerator, -The line of logic 'AND:
     
    Difference between dates >= 4 days of:” has been removed and replaced
     
    Difference between dates >= 4 days of:” has been removed and replaced
     
    with the timing relationship '>=4 day(s) starts before start of”. The
     
    with the timing relationship '>=4 day(s) starts before start of”. The
     
    'First” segment of logic is now the left-hand side of this clause, and
     
    'First” segment of logic is now the left-hand side of this clause, and
     
    the 'Most Recent” segment of logic is now the right-hand side of this
     
    the 'Most Recent” segment of logic is now the right-hand side of this
    -
    clause. -The line of logic 'AND: Difference between dates < 4 days of:”
    +
    clause. -The line of logic 'AND: Difference between dates < 4 days of:”
     
    has been removed and...
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  • Your profile picture
    3:25pm EDT
    Changes to Release Notes
     
    clinical trials that are specific to the measure.
     
    clinical trials that are specific to the measure.
     
    * Removed Denominator Exception: Medication, Administered not done: Medical
     
    * Removed Denominator Exception: Medication, Administered not done: Medical
    -
    Reason' for 'Fibrinolytic Therapy' and 'Medication, Administered not
    +
    Reason' for 'Fibrinolytic Therapy' and 'Medication, Administered not done:
    -
    done: Patient Refusal' for 'Fibrinolytic Therapy' to eliminate redundant
    +
    Patient Refusal' for 'Fibrinolytic Therapy' to eliminate redundant logic.
    -
    logic.
      
     
    * Replaced 'ends before start' with 'ends before or concurrent with start
     
    * Replaced 'ends before start' with 'ends before or concurrent with start
     
    of' to align across measures (when appropriate for measure intent).
     
    of' to align across measures (when appropriate for measure intent).
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    3:24pm EDT
    Changes to Guidance
     
    To identify the ECG closest to hospital arrival, the denominator will
     
    To identify the ECG closest to hospital arrival, the denominator will
     
    identify the most recent ECG performed that starts less than 1 hour prior to
     
    identify the most recent ECG performed that starts less than 1 hour prior to
    -
    the emergency department (ED) or inpatient encounter OR the first ECG
    +
    the emergency department (ED) or inpatient encounter OR the first ECG
     
    performed starts after the ED or inpatient encounter started.
     
    performed starts after the ED or inpatient encounter started.
     
     
     
    Numerator element guidance:
     
    Numerator element guidance:
     
     
    -
    This measure expects a PCI procedure within 90 minutes of hospital arrival.
    +
    This measure expects a PCI procedure within 90 minutes of hospital arrival.
     
    Those patients receiving PCI procedures greater than 90 minutes after arrival
     
    Those patients receiving PCI procedures greater than 90 minutes after arrival
     
    may be excluded from the denominator only if there is a documented reason for
     
    may be excluded from the denominator only if...
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    3:24pm EDT
    Changes to Guidance
    -
    This measure uses a continuous variable. The specification provides elements
    +
    This measure uses a continuous variable. The specification provides elements
     
    from the clinical electronic record required to calculate for each ED
     
    from the clinical electronic record required to calculate for each ED
     
    encounter, i.e., the length of time the patient was in the Emergency
     
    encounter, i.e., the length of time the patient was in the Emergency
     
    Department, also stated as: the Emergency Department departure time minus the
     
    Department, also stated as: the Emergency Department departure time minus the
     
    Emergency Department arrival time. The calculation requires the median of all
     
    Emergency Department arrival time. The calculation requires the median of all
    -
    ED encounter durations. This measure specification defines how to determine
    +
    ED encounter durations. This measure specification defines how to determine
     
    an individual Emergency Department stay. Reporting requires the median of all
     
    an individual Emergency Department stay. Reporting requires the median of all
     
    patient stays (.departuredatetime - [Encounter:
     
    patient stays (.departuredatetime - [Encounter:
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    3:22pm EDT
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    3:22pm EDT
    ...
    Changes to Guidance
     
    * Environmental control and control of other triggers: information on
     
    * Environmental control and control of other triggers: information on
     
    avoidance or mitigation of environmental and other triggers.
     
    avoidance or mitigation of environmental and other triggers.
      +
     
     
     
    In addition to the information outlined in the asthma action plan form (or
     
    In addition to the information outlined in the asthma action plan form (or
     
    telephone number and time frame for appointment for follow-up care (eg,
     
    telephone number and time frame for appointment for follow-up care (eg,
     
    7-10 days).
     
    7-10 days).
      +
     
     
     
    The home management plan of care can only be considered to comply with the
     
    The home management plan of care can only be considered to comply with the
     
    * Outpatient Services including outpatient procedures at another hospital,
     
    * Outpatient Services including outpatient procedures at another hospital,
     
    Outpatient Chemical Dependency Programs and Partial Hospitalization.
     
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    3:21pm EDT
    Too many differences to list. See Revisions for details.
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    3:20pm EDT
    Changes to Guidance
     
     
     
    The very first step for this measure, identifying all term singleton infants
     
    The very first step for this measure, identifying all term singleton infants
    -
    can be surprisingly challenging. Some hospitals do not do a good job of
    +
    can be surprisingly challenging. Some hospitals do not do a good job of using
    -
    using the proper v-codes or DRGs so that clinical information such as
    +
    the proper v-codes or DRGs so that clinical information such as birthweight
    -
    birthweight and gestational age need to be used in the first step.
    +
    and gestational age need to be used in the first step.
     
     
     
    The logic phrase AND: /Occurrence A of Encounter, Performed: Inpatient
     
    The logic phrase AND: /Occurrence A of Encounter, Performed: Inpatient
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    3:20pm EDT
    Changes to Denominator Statement
     
    placed between hospital arrival and the end of the recovery period, defined
     
    placed between hospital arrival and the end of the recovery period, defined
     
    as within 6 hours after the end of anesthesia for a SCIP selected surgery as
     
    as within 6 hours after the end of anesthesia for a SCIP selected surgery as
    -
    defined in the Initial Population. The catheter must still be in place after
    +
    defined in the Initial Population. The catheter must still be in place after
     
    the end of the recovery period.
     
    the end of the recovery period.
     
     
     
     
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    3:19pm EDT
    ...
    Changes to Denominator Exclusions
     
    that occurred within 3 days (4 days for CABG or Other Cardiac Surgery)
     
    that occurred within 3 days (4 days for CABG or Other Cardiac Surgery)
     
    prior to or after the procedure of interest (during separate surgical
     
    prior to or after the procedure of interest (during separate surgical
    -
    episodes) during this hospital stay. This could also include implantation
    +
    episodes) during this hospital stay. This could also include implantation
     
    of pocketed devices.
     
    of pocketed devices.
     
     
     
     
    Changes to Guidance
     
    The measurement period is one calendar year but the reporting period is 3
     
    The measurement period is one calendar year but the reporting period is 3
    -
    months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul -
    +
    months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul - Sep,
    -
    Sep, Q4 = Oct - Dec.
    +
    Q4 = Oct - Dec.
     
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  • Your profile picture
    3:18pm EDT
    Changes to Guidance
     
    The measurement period is one calendar year but the reporting period is 3
     
    The measurement period is one calendar year but the reporting period is 3
    -
    months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul -
    +
    months as a calendar quarter; Q1 = Jan - Mar, Q2 = Apr - Jun, Q3 = Jul - Sep,
    -
    Sep, Q4 = Oct - Dec.
    +
    Q4 = Oct - Dec.
     
     
     
     
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    3:17pm EDT
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