ecqm.measure

CMS31v7 - Hearing Screening Prior To Hospital Discharge (EHDI-1a)

Rationale:

Hearing Screening Prior To Hospital Discharge (EHDI-1a). 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.

Data Elements

LiveBirthNewbornBornInHospitalDiagnosis

Clinical Focus: This set of values contains diagnoses that are commonly used in the inpatient setting for newborn live born, and born in hospital. This value set is a grouping value set composed of ICD-10-CM and SNOMED CT value sets.

Data Element Scope: The intent of this data element is to identify patients who have active diagnosis, mapped to QDM 'Diagnosis' or to the 'Principal Diagnosis' or 'Diagnosis' attributes of the QDM 'Encounter' datatype.

Inclusion Criteria: This value set includes ICD-10-CM and SNOMED CT value sets.

Exclusion Criteria: None.

ResultValue constrained to codes in the Live Birth Newborn Born in Hospital valueset (2.16.840.1.113762.1.4.1046.6)

Diagnosis: Condition/Diagnosis/Problem represents a practitioner’s identification of a patient’s disease, illness, injury, or condition. This category contains a single datatype to represent all of these concepts: Diagnosis. A practitioner determines the diagnosis by means of examination, diagnostic test results, patient history, and/or family history. Diagnoses are usually considered unfavorable, but may also represent neutral or favorable conditions that affect a patient’s plan of care (e.g., pregnancy). The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. The preferred terminology for diagnoses is SNOMED-CT, but diagnoses may also be encoded using ICD-9/10. The Diagnosis datatype should not be used for differential diagnoses or rule-out diagnoses (neither of which are currently supported by the QDM).

DataType

Cardinality

LiveBirthNewbornBornInHospitalDiagnosis

0..*

LiveBirthNewbornBornInHospitalDiagnoses

Clinical Focus: This set of values contains diagnoses that are commonly used in the inpatient setting for newborn live born, and born in hospital. This value set is a grouping value set composed of ICD-10-CM and SNOMED CT value sets.

Data Element Scope: The intent of this data element is to identify patients who have active diagnosis, mapped to QDM 'Diagnosis' or to the 'Principal Diagnosis' or 'Diagnosis' attributes of the QDM 'Encounter' datatype.

Inclusion Criteria: This value set includes ICD-10-CM and SNOMED CT value sets.

Exclusion Criteria: None.

Diagnoses: Coded diagnoses/problems addressed during the encounter. The diagnoses attribute is intended to capture ALL diagnoses, including principal diagnosis. Use of the Encounter, Performed: diagnoses attribute and the Diagnosis datatype is redundant for relating the diagnosis to the Encounter, Performed. The Encounter, Performed: diagnoses 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 prevalence period, e.g., The measure must assure that the diagnoseis have been present for at least some defined time period before the encounter, and were addressed during the Encounter

DataType

Cardinality

LiveBirthNewbornBornInHospitalDiagnoses

0..*

NewbornHearingScreenLeftPerformed

Clinical Focus: This set of values contains procedures or evaluations for newborn hearing screening conducted on left ear. This value set contains LOINC codes.

Data Element Scope: The intent of this data element is to identify patients who have received newborn hearing screening on his/her left ear, mapped to QDM 'Diagnostic Study, Performed.'

Inclusion Criteria: Includes LOINC codes.

Exclusion Criteria: None.

Subject constrained to the Newborn Hearing Screen Left

DiagnosticStudyPerformed: Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – when the diagnostic study is initiated stopTime – when the diagnostic study is completed Examples: 1) Initiation of a treadmill stress test to the time the treadmill stress test has completed. 2) Initiation of the ultrasound study until completion of the ultrasound study

DataType

Cardinality

NewbornHearingScreenLeftPerformed

0..*

NewbornHearingScreenRightPerformed

Clinical Focus: This set of values contains procedures or evaluations for newborn hearing screening conducted on right ear. This value set contains LOINC codes.

Data Element Scope: The intent of this data element is to identify patients who have received newborn hearing screening on his/her right ear, mapped to QDM 'Diagnostic Study, Performed.'

Inclusion Criteria: Includes LOINC codes.

Exclusion Criteria: None.

Subject constrained to the Newborn Hearing Screen Right

DiagnosticStudyPerformed: Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set. Timing: The Relevant Period addresses: startTime – when the diagnostic study is initiated stopTime – when the diagnostic study is completed Examples: 1) Initiation of a treadmill stress test to the time the treadmill stress test has completed. 2) Initiation of the ultrasound study until completion of the ultrasound study

DataType

Cardinality

NewbornHearingScreenRightPerformed

0..*

PassOrReferResult

Clinical Focus: This set of values contains findings that indicate the normal findings on hearing examination or referral is needed. This value set contains SNOMED-CT codes.

Data Element Scope: The intent of this data element is to identify patients who have received newborn hearing screening with result of pass or refer, mapped to QDM attribute of result.

Inclusion Criteria: Includes SNOMED-CT codes. Includes normal finding on hearing examination and referral.

Exclusion Criteria: None.

Result: The final consequences or data collected from the datatype. Results can be used in five ways, to express: That a result is present in the electronic record but any entry is acceptable. A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units – examples: 100 mg/dL for a lab test, 140 mmHg for blood pressure, as a percentage (actually a quantity with % as units), as a ratio (e.g., 1:4, 1:80). Beginning with QDM 5.3 measures use CQL logic to express the mathematical operators to constrain desired results to those above or below a certain threshold. A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct referenced code. A result as a dateTime (Assessment, Performed and components).

DataType

Cardinality

PassOrReferResult

0..*

EncounterInpatientPerformed

Clinical Focus: This set of values identify the most common inpatient encounter types.

Data Element Scope: The intent of this data element is to identify patients who have had an inpatient encounter. Using the Quality Data Model, this particular element will map to the 'encounter' category.

Inclusion Criteria: Only SNOMED CT codes representing inpatient encounter should be included.

Exclusion Criteria: None.

Subject constrained to the Encounter Inpatient

EncounterPerformed: 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. Timing: The Relevant Period addresses: startTime – The time the encounter began (admission time) stopTime – The time the encounter ended (discharge time). The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained. The Location Period is an attribute of the attribute facility location addresses: startTime = the time the patient arrived at the location; stopTime = the time the patient departed from the location

DataType

Cardinality

EncounterInpatientPerformed

0..*

EthnicityPatientCharacteristicEthnicity

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Ethnicity valueset (2.16.840.1.114222.4.11.837)

PatientCharacteristicEthnicity: 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.

DataType

Cardinality

EthnicityPatientCharacteristicEthnicity

0..*

OncAdministrativeSexPatientCharacteristicGender

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.

ResultValue constrained to codes in the ONC Administrative Sex valueset (2.16.840.1.113762.1.4.1)

PatientCharacteristicGender: 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.

DataType

Cardinality

OncAdministrativeSexPatientCharacteristicGender

0..*

PayerPatientCharacteristicPayer

Clinical Focus: Categories of types of health care payor 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

ResultValue constrained to codes in the Payer valueset (2.16.840.1.114222.4.11.3591)

PatientCharacteristicPayer: 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 Relevant Period addresses: startTime – The first day of insurance coverage with the referenced payer stopTime – The last day of insurance coverage with the referenced payer

DataType

Cardinality

PayerPatientCharacteristicPayer

0..*

RacePatientCharacteristicRace

Clinical Focus:

Data Element Scope:

Inclusion Criteria:

Exclusion Criteria:

ResultValue constrained to codes in the Race valueset (2.16.840.1.114222.4.11.836)

PatientCharacteristicRace: 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.

DataType

Cardinality

RacePatientCharacteristicRace

0..*