Hearing Screening Prior To Hospital Discharge

eCQM Title	Hearing Screening Prior To Hospital Discharge
eCQM Identifier (Measure Authoring Tool)	31	eCQM Version number	7.5.000
NQF Number	1354	GUID	0924fbae-3fdb-4d0a-aab7-9f354e699fde
Measurement Period	January 1, 20XX through December 31, 20XX
Measure Steward	CDC National Center on Birth Defects and Developmental Disabilities
Measure Developer	CDC Early Hearing Detection and Intervention Program
Endorsed By	National Quality Forum
Description	This measure assesses the proportion of births that have been screened for hearing loss before hospital discharge
Copyright	Measure specifications are in the Public Domain. This material contains SNOMED Clinical Terms (R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved. LOINC (R) is a registered trademark of the Regenstrief Institute.
Disclaimer	These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The measures and specifications are provided without warranty. CMS has contracted with Mathematica Policy Research and its subcontractors, Lantana and Telligen, for the continued maintenance of this electronic measure.
Measure Scoring	Proportion
Measure Type	Process
Stratification	None
Risk Adjustment	None
Rate Aggregation	None
Rationale	Birthing facility staff should review the effectiveness and timeliness of screening relative to nursery discharge. Benchmarks set within the EHCP may trigger hospital or jurisdictional compliance activities, such as re-writing of procedural guidelines or re-training of screening staff.
Clinical Recommendation Statement	None
Improvement Notation	Improvement noted as an increase in rate
Reference	HRSA Title V Block Grant MCHB Performance Measure: Percentage of newborns who have been screened for hearing before hospital discharge.
Reference	U.S. Preventive Services Task Force (http://www.ahrq.gov/professionals/prevention-chronic-care/decision/uspstf/index.html) Year 2007 Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs. Joint Committee on Infant Hearing. Pediatrics 2007;120;898-921 (http://pediatrics.aappublications.org/cgi/content/full/120/4/898?ijkey=oj9BAleq21OlA&keytype=ref&siteid=aapjournals)
Definition	None
Guidance	Complete hearing screening is defined as having both ears screened during the inpatient encounter. The Medical Reasons value set (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.
Transmission Format	TBD
Initial 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	Denominator is equal to the Initial Population
Denominator Exclusions	A live birth encounter where the newborn expires prior to discharge and has not received a complete hearing screening
Numerator	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
Supplemental Data Elements	For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria
Definitions
Functions
Terminology
Data Criteria (QDM Data Elements)
Supplemental Data Elements
Risk Adjustment Variables

Population Criteria

Initial Population

"Encounter with Live Birth Diagnosis"
	union "Diagnosis Live Birth Newborn Born in Hospital"

- Denominator
  - "Initial Population"

Denominator Exclusions

"Initial Population" LiveBirthEncounter
	where LiveBirthEncounter.dischargeDisposition ~ "Patient deceased during stay (discharge status = dead) (finding)"
		and not exists "Has Complete Hearing Screening"

Numerator

"Has Complete Hearing Screening"
	union "Hearing Screen Not Done Due to Medical Reasons"

- Numerator Exclusions
  - None
- Denominator Exceptions
  - None
- Stratification
  - None

Definitions

Denominator
- - "Initial Population"

Denominator Exclusions

"Initial Population" LiveBirthEncounter
	where LiveBirthEncounter.dischargeDisposition ~ "Patient deceased during stay (discharge status = dead) (finding)"
		and not exists "Has Complete Hearing Screening"

Diagnosis Live Birth Newborn Born in Hospital

"Inpatient Encounters" InpatientEncounter
	with ["Diagnosis": "Live Birth Newborn Born in Hospital"] QualifyingDiagnosis
		such that QualifyingDiagnosis.prevalencePeriod starts during InpatientEncounter.relevantPeriod

Encounter with Live Birth Diagnosis

"Inpatient Encounters" InpatientEncounter
	where exists InpatientEncounter.diagnoses EncounterDiagnosis
		where EncounterDiagnosis in "Live Birth Newborn Born in Hospital"

Has Complete Hearing Screening

"Inpatient Encounters" InpatientEncounter
	where exists "Left Hearing Screen Performed" LeftHearingScreen
		where LeftHearingScreen.authorDatetime during InpatientEncounter.relevantPeriod
			and exists "Right Hearing Screen Performed" RightHearingScreen
				where RightHearingScreen.authorDatetime during InpatientEncounter.relevantPeriod

Hearing Screen Not Done Due to Medical Reasons

"Initial Population" LiveBirthEncounter
	with ( ["Diagnostic Study, Not Performed": "Newborn Hearing Screen Left"]
		union ["Diagnostic Study, Not Performed": "Newborn Hearing Screen Right"] ) ScreenNotDone
		such that ScreenNotDone.negationRationale in "Medical Reasons"
			and ScreenNotDone.authorDatetime during LiveBirthEncounter.relevantPeriod

Initial Population

"Encounter with Live Birth Diagnosis"
	union "Diagnosis Live Birth Newborn Born in Hospital"

Inpatient Encounters

["Encounter, Performed": "Encounter Inpatient"] Encounter
	where Global."LengthInDays"(Encounter.relevantPeriod)<= 120
		and Encounter.relevantPeriod ends during "Measurement Period"

Left Hearing Screen Performed

["Diagnostic Study, Performed": "Newborn Hearing Screen Left"] LeftScreen
	where LeftScreen.result in "Pass Or Refer"

Numerator

"Has Complete Hearing Screening"
	union "Hearing Screen Not Done Due to Medical Reasons"

Right Hearing Screen Performed

["Diagnostic Study, Performed": "Newborn Hearing Screen Right"] RightScreen
	where RightScreen.result in "Pass Or Refer"

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Functions

Global.LengthInDays(Value Interval<DateTime>)

difference in days between start of Value and end of Value

Terminology

codesystem "SNOMEDCT" using "2.16.840.1.113883.6.96 version 2017-09"
code "Patient deceased during stay (discharge status = dead) (finding)" using "SNOMEDCT version 2017-09 Code (371828006)"
valueset "Encounter Inpatient" using "2.16.840.1.113883.3.666.5.307"
valueset "Ethnicity" using "2.16.840.1.114222.4.11.837"
valueset "Live Birth Newborn Born in Hospital" using "2.16.840.1.113762.1.4.1046.6"
valueset "Medical Reasons" using "2.16.840.1.114222.4.1.214079.1.1.7"
valueset "Newborn Hearing Screen Left" using "2.16.840.1.114222.4.1.214079.1.1.3"
valueset "Newborn Hearing Screen Right" using "2.16.840.1.114222.4.1.214079.1.1.4"
valueset "ONC Administrative Sex" using "2.16.840.1.113762.1.4.1"
valueset "Pass Or Refer" using "2.16.840.1.114222.4.1.214079.1.1.6"
valueset "Payer" using "2.16.840.1.114222.4.11.3591"
valueset "Race" using "2.16.840.1.114222.4.11.836"

Data Criteria (QDM Data Elements)

"Diagnosis: Live Birth Newborn Born in Hospital" using "Live Birth Newborn Born in Hospital (2.16.840.1.113762.1.4.1046.6)"
"Diagnostic Study, Not Performed: Newborn Hearing Screen Left" using "Newborn Hearing Screen Left (2.16.840.1.114222.4.1.214079.1.1.3)"
"Diagnostic Study, Not Performed: Newborn Hearing Screen Right" using "Newborn Hearing Screen Right (2.16.840.1.114222.4.1.214079.1.1.4)"
"Diagnostic Study, Performed: Newborn Hearing Screen Left" using "Newborn Hearing Screen Left (2.16.840.1.114222.4.1.214079.1.1.3)"
"Diagnostic Study, Performed: Newborn Hearing Screen Right" using "Newborn Hearing Screen Right (2.16.840.1.114222.4.1.214079.1.1.4)"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
"Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
"Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
"Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
"Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"

Supplemental Data Elements

SDE Ethnicity

["Patient Characteristic Ethnicity": "Ethnicity"]

SDE Payer

["Patient Characteristic Payer": "Payer"]

SDE Race
- - ["Patient Characteristic Race": "Race"]

SDE Sex

["Patient Characteristic Sex": "ONC Administrative Sex"]

Risk Adjustment Variables

None

Measure Set

Early Hearing Detection and Intervention (EHDI)