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

Performance/Reporting Period
2023
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of inpatient hospitalization encounters.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for inpatient hospitalizations.
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

"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 5.6 addresses that concept using the diagnosis rank=1.

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:
CMS108v11 - Venous Thromboembolism Prophylaxis
CMS190v11 - Intensive Care Unit Venous Thromboembolism Prophylaxis
CMS9v11 - Exclusive Breast Milk Feeding
CMS111v11 - Median Admit Decision Time to ED Departure Time for Admitted Patients
CMS136v12 - Follow-Up Care for Children Prescribed ADHD Medication (ADD)
CMS117v11 - Childhood Immunization Status
CMS122v11 - Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)
CMS124v11 - Cervical Cancer Screening
CMS125v11 - Breast Cancer Screening
CMS127v11 - Pneumococcal Vaccination Status for Older Adults
CMS128v11 - Anti-depressant Medication Management
CMS130v11 - Colorectal Cancer Screening
CMS131v11 - Diabetes: Eye Exam
CMS137v11 - Initiation and Engagement of Substance Use Disorder Treatment
CMS138v11 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
CMS139v11 - Falls: Screening for Future Fall Risk
CMS146v11 - Appropriate Testing for Pharyngitis
CMS147v12 - Preventive Care and Screening: Influenza Immunization
CMS153v11 - Chlamydia Screening in Women
CMS154v11 - Appropriate Treatment for Upper Respiratory Infection (URI)
CMS155v11 - Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
CMS156v11 - Use of High-Risk Medications in Older Adults
CMS159v11 - Depression Remission at Twelve Months
CMS165v11 - Controlling High Blood Pressure
CMS347v6 - Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
CMS56v11 - Functional Status Assessment for Total Hip Replacement
CMS69v11 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
CMS74v12 - Primary Caries Prevention Intervention as Offered by Dentists
CMS75v11 - Children Who Have Dental Decay or Cavities
CMS90v12 - Functional Status Assessments for Heart Failure
CMS951v1 - Kidney Health Evaluation
CMS529v3 - Core Clinical Data Elements for the Hybrid Hospital-Wide Readmission (HWR) Measure with Claims and Electronic Health Record Data
CMS844v3 - Core Clinical Data Elements for the Hybrid Hospital-Wide (All-Condition, All-Procedure) Risk-Standardized Mortality Measure (HWM)
CMS506v5 - Safe Use of Opioids - Concurrent Prescribing
CMS816v2 - Hospital Harm - Severe Hypoglycemia
CMS871v2 - Hospital Harm - Severe Hyperglycemia
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" diagnoses 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" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.

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

With an "Encounter, Performed" diagnoses, 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), non-ICUs, 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)

iD

The identifier of a specific instance of any QDM data element. CQL logic uses the id reference to specify that a query expects a specific instance of an element to be retrieved.

See Section 5.8 for examples for using id to indicate specific instances of QDM data elements in CQL statements with the relatedTo attribute.

relevantPeriod

relevantPeriod addresses the time between the start of an action to the end of an action. Each QDM datatype using relevantPeriod 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 datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod

Last Updated: Jul 15, 2022