["Encounter, Performed": "Encounter Inpatient"]

Performance/Reporting Period

2021

Value Set Description from VSAC

Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.5 Guidance Update)

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.5 addresses that concept using the diagnosis rank=1.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing:

The relevantPeriod addresses:
- startTime - The time the encounter began (admission time).
- stopTime - The time the encounter ended (discharge time).
author dateTime references the time the action was recorded.
Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
The locationPeriod is an attribute of the attribute facility location that addresses:
- startTime - the time the patient arrived at the location. The time the encounter began (admission time).
- stopTime - the time the patient departed from the location.

eCQMs using this data element:

CMS506v3 - Safe Use of Opioids - Concurrent Prescribing

CMS190v9 - Intensive Care Unit Venous Thromboembolism Prophylaxis

CMS108v9 - Venous Thromboembolism Prophylaxis

CMS9v9 - Exclusive Breast Milk Feeding

CMS111v9 - Median Admit Decision Time to ED Departure Time for Admitted Patients

CMS136v10 - Follow-Up Care for Children Prescribed ADHD Medication (ADD)

CMS125v9 - Breast Cancer Screening

CMS127v9 - Pneumococcal Vaccination Status for Older Adults

CMS90v10 - Functional Status Assessments for Congestive Heart Failure

CMS146v9 - Appropriate Testing for Pharyngitis

CMS165v9 - Controlling High Blood Pressure

CMS139v9 - Falls: Screening for Future Fall Risk

CMS122v9 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)

CMS66v9 - Functional Status Assessment for Total Knee Replacement

CMS124v9 - Cervical Cancer Screening

CMS128v9 - Anti-depressant Medication Management

CMS75v9 - Children Who Have Dental Decay or Cavities

CMS131v9 - Diabetes: Eye Exam

CMS117v9 - Childhood Immunization Status

CMS156v9 - Use of High-Risk Medications in Older Adults

CMS137v9 - Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

CMS154v9 - Appropriate Treatment for Upper Respiratory Infection (URI)

CMS153v9 - Chlamydia Screening for Women

CMS74v10 - Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists

CMS130v9 - Colorectal Cancer Screening

CMS134v9 - Diabetes: Medical Attention for Nephropathy

CMS155v9 - Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

CMS56v9 - Functional Status Assessment for Total Hip Replacement

CMS529v1 - Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data

QDM Attributes

diagnoses

Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:

diagnosis (code)
presentOnAdmissionIndicator (code)
rank (positive integer)

To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.

The "Encounter, Performed" diagnosis attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnosis was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition for information about using the "Encounter, Performed" diagnosis attribute.

The "Encounter, Performed" diagnosis (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnosis with a diagnosis (code) and a rank of 1. See definition of rank attribute.

With an "Encounter, Performed" diagnosis, there is no dependency on the timing of the diagnosis in relation to the encounter.

Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
- The measure must assure that the diagnoses
  - have been present for at least some defined time period before the encounter, and
  - were addressed during the "Encounter, Performed"

dischargeDisposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.

facilityLocations

The particular locations in a facility in which the diagnostic study or encounter occurs or occurred. Examples include intensive care units (ICUs), nonICUs, burn critical care unit, neonatal ICU, and respiratory care unit. Each "Encounter, Performed" may have one or more locations. For example, a patient treated in multiple locations during an individual encounter might be expressed as:

"Encounter, Performed": Inpatient Admission, facility locations
- ICU (locationPeriod)
- Non-ICU Admission (locationPeriod)
- Rehab (locationPeriod)

relevantPeriod

Relevant Period addresses the time between the start of an action to the end of an action. Each datatype using relevant period defines specific definitions for the start and stop time for the action listed.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatyperelated actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod