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CMS Measure ID: CMS996v5    Performance/Reporting Period: 2025    NQF Number: 3613e
Description:

Percentage of emergency department (ED) encounters for patients 18 years and older with a diagnosis of ST-segment elevation myocardial infarction (STEMI) that received appropriate treatment, defined as fibrinolytic therapy within 30 minutes of ED arrival, percutaneous coronary intervention (PCI) within 90 minutes of ED arrival, or transfer within 45 minutes of ED arrival

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for thrombolytic medications used for treatment of ST-segment elevation myocardial infaction (STEMI).
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes RXNORM codes that represent ingredients in thrombolytic medications for STEMI treatment.
Exclusion Criteria: No exclusions

Constrained to codes in the Thrombolytic medications value set (2.16.840.1.113762.1.4.1170.4)

QDM Datatype and Definition

"Adverse Event"

Data elements that meet criteria using this datatype should document the adverse event and its corresponding value set.

The relevant dateTime references the adverse event occurred.

The author dateTime references the time the adverse event was recorded.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for thrombolytic medications used for treatment of ST-segment elevation myocardial infaction (STEMI).
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes RXNORM codes that represent ingredients in thrombolytic medications for STEMI treatment.
Exclusion Criteria: No exclusions

Constrained to codes in the Thrombolytic medications value set (2.16.840.1.113762.1.4.1170.4)

QDM Datatype and Definition

"Allergy Intolerance"

Data elements that meet criteria using this datatype should document the allergy or intolerance and its corresponding value set.

Timing:

  • The prevalencePeriod references the time from the onset date to the abatement date. Often an abatement date is not present as allergy or intolerance is ongoing.
  • The author dateTime references the recorded time.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for active bleeding or bleeding diathesis (excluding menses).
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10CM and SNOMEDCT codes associated with active bleeding.
Exclusion Criteria: No exclusions.

Constrained to codes in the Active Bleeding Excluding Menses or Bleeding Diathesis value set (2.16.840.1.113883.3.3157.4036)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for peptic ulcer.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10 and SNOMED codes associated with active peptic ulcer.
Exclusion Criteria: No exclusions.

Constrained to codes in the Acute Peptic Ulcer value set (2.16.840.1.113883.3.3157.4031)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for allergies to thrombolytic medications used for treatment of ST-segment elevation myocardial infaction (STEMI).
Data Element Scope: This value set may use a model element related to Finding.
Inclusion Criteria: Includes SNOMED-CT codes that represent allergies to thrombolytic medications for STEMI treatment.
Exclusion Criteria: No Exclusions.

Constrained to codes in the Allergy to thrombolytics value set (2.16.840.1.113762.1.4.1170.5)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for aortic dissection or rupture.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10CM and SNOMEDCT codes that represent aortic dissection or rupture.
Exclusion Criteria: No exclusions.

Constrained to codes in the Aortic Dissection or Ruptured Aortic Aneurysm value set (2.16.840.1.113883.3.3157.4028)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for cardiopulmonary arrest.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10CM and SNOMEDCT codes associated with cardiopulmonary arrest.
Exclusion Criteria: No exclusions.

Constrained to codes in the Cardiopulmonary Arrest value set (2.16.840.1.113883.3.3157.4048)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for cerebral vascular lesion.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10 and SNOMEDCT codes associated with cerebral vascular lesions.
Exclusion Criteria: No exclusions.

Constrained to codes in the Cerebral Vascular Lesion value set (2.16.840.1.113883.3.3157.4025)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for closed head trauma or facial trauma.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10 and SNOMED codes associated with closed head trauma or facial trauma.
Exclusion Criteria: No exclusions.

Constrained to codes in the Closed Head and Facial Trauma value set (2.16.840.1.113883.3.3157.4026)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for dementia.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10CM and SNOMEDCT codes associated with dementia.
Exclusion Criteria: No exclusions.

Constrained to codes in the Dementia and Related Intracranial Pathologies value set (2.16.840.1.113883.3.3157.4043)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for diagnoses of ischemic strokes.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of ischemic stroke.
Exclusion Criteria: No exclusions.

Constrained to codes in the Ischemic Stroke value set (2.16.840.1.113883.3.117.1.7.1.247)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for malignant intracranial neoplasm.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10 and SNOMEDCT codes that represent malignant intracranial neoplasm diagnoses.
Exclusion Criteria: No exclusions.

Constrained to codes in the Malignant Intracranial Neoplasm Group value set (2.16.840.1.113762.1.4.1170.3)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for neurologic impairment.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent diagnoses related to neurologic impairment.
Exclusion Criteria: No exclusions.

Constrained to codes in the Neurologic impairment value set (2.16.840.1.113883.3.464.1003.114.12.1012)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for pregnant state.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10CM and SNOMEDCT codes associated with the state of pregnancy.
Exclusion Criteria: No exclusions.

Constrained to codes in the Pregnant State value set (2.16.840.1.113883.3.3157.4055)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Direct Reference Code

Constrained to Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility ICD10CM code

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for ST-segment elevation myocardial infarction (STEMI).
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes ICD-10 and SNOMEDCT codes associated with the diagnosis of STEMI.
Exclusion Criteria: No exclusions.

Constrained to codes in the STEMI value set (2.16.840.1.113883.3.3157.4017)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for an encounter with the discharge of a patient to an acute care facility.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter with a discharge to a short-term acute care hospital, including a specialty hospital.
Exclusion Criteria: No exclusions.

Constrained to codes in the Discharge To Acute Care Facility value set (2.16.840.1.113883.3.117.1.7.1.87)

QDM Datatype and Definition

dischargeDisposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for an encounter with a discharge disposition of patient who has died in the hospital.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that identify an encounter with a discharge disposition of a patient who has died in the hospital.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Expired value set (2.16.840.1.113883.3.117.1.7.1.309)

QDM Datatype and Definition

dischargeDisposition

The disposition, or location to which the patient is transferred at the time of hospital discharge.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters in the emergency department.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for care provided to new and established patients in the emergency department.
Exclusion Criteria: Excludes concepts that represent an encounter not representative of ED visits, including critical care and observation services.

Constrained to codes in the Emergency Department Evaluation and Management Visit value set (2.16.840.1.113883.3.464.1003.101.12.1010)

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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters in the emergency department (ED).
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter ocurring in the emergency department (ED).
Exclusion Criteria: Excludes concepts that represent services not performed in the emergency department, including critical care and observation services.

Constrained to codes in the Emergency Department Visit value set (2.16.840.1.113883.3.117.1.7.1.292)

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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for oral anticoagulant medications.
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes RXNORM codes that represent medications used to treat blood clots.
Exclusion Criteria: No exclusions.

Constrained to codes in the Oral Anticoagulant Medications value set (2.16.840.1.113883.3.3157.4045)

QDM Datatype and Definition

"Medication, Active"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set is being taken by the patient. Keep in mind that when this datatype is used with timing relationships, the criterion is looking for a medication being taken for the time frame indicated by the timing relationships.

Timing:

  • relevant dateTime references the time the medication is active on the medication record if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for an active medication on the medication record that is given or taken over a time interval:
  • The relevantPeriod addresses:
    • startTime = when the medication is first known to be used (generally the time of entry on the medication list).
    • stopTime = when the medication is no longer active.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for fibrinolytic therapy used in the treatment of ST-segment elevation myocardial infarction (STEMI).
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes RXNORM codes that represent medications used in STEMI treatment.
Exclusion Criteria: No exclusions.

Constrained to codes in the Fibrinolytic Therapy value set (2.16.840.1.113883.3.3157.4019)

QDM Datatype and Definition

"Medication, Administered"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing:

  • relevant dateTime references the time the medication is administered if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for medication administration if the administration event occurred over a time interval (e.g., an intravenous infusion). The relevantPeriod addresses:
    • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion).
    • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes:

  • Measure developers should address multiple administrations over a period of time using CQL logic.
  • 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.

Refer to Special Cases in Section 5.7 for scenarios to consider in calculating cumulative medication duration.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition

"Patient Characteristic, Ethnicity"

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payer entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Payer Type value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition

"Patient Characteristic, Payer"

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing:

The relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition

"Patient Characteristic, Race"

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition

"Patient Characteristic, Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent procedures used to define endotracheal intubation.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure. The intent of this data element is to identify patients who received endotracheal intubation as a medical procedure.
Inclusion Criteria: Includes only relevant concepts associated with identifying patients who had endotracheal intubation. This is a grouping of ICD-10-PCS and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Endotracheal Intubation value set (2.16.840.1.113762.1.4.1045.69)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for mechanical circulatory assist devices.
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes CPT and SNOMEDCT codes that represent procedures associated with mechanical circulatory devices used to support heart function.
Exclusion Criteria: No exclusions.

Constrained to codes in the Insertion or Replacement of Mechanical Circulatory Assist Device value set (2.16.840.1.113883.3.3157.4052)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for either intracranial or intraspinal surgeries.
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes ICD-10 and SNOMED codes that represent procedures for intracranial or intraspinal surgeries.
Exclusion Criteria: No exclusions.

Constrained to codes in the Intracranial or Intraspinal surgery value set (2.16.840.1.113762.1.4.1170.2)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for major surgical procedures.
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes ICD-10 and SNOMED codes that represent major surgical procedures.
Exclusion Criteria: No exclusions.

Constrained to codes in the Major Surgical Procedure value set (2.16.840.1.113883.3.3157.4056)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: This comprehensive set of codes is intended to capture a patient who undergoes a PCI procedure.
Data Element Scope: The intent of this data element is to identify patients with a PCI procedure.
Inclusion Criteria: Includes HCPCS/CPT/SNOMED-CT/ICD-10-PCS codes that indicate PCI procedures.
Exclusion Criteria: Excludes HCPCS/CPT/SNOMED-CT/ICD-10-PCS codes that do not indicate PCI procedures.

Constrained to codes in the Percutaneous Coronary Intervention value set (2.16.840.1.113883.3.3157.2000.5)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • 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.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for adverse reactions to thrombolytic medications used for treatment of ST-segment elevation myocardial infaction (STEMI).
Data Element Scope: This value set may use a model element related to Disorder.
Inclusion Criteria: Includes SNOMED-CT codes that represent adverse reactions to thrombolytic medications for STEMI treatment.
Exclusion Criteria: No exclusions.

Constrained to codes in the Thrombolytics Adverse Event value set (2.16.840.1.113762.1.4.1170.6)

QDM Datatype and Definition

type

The characterization of the reaction (e.g., hypersensitivity, rash, gastroenteric symptoms, etc.).