Data Exchange For Quality Measures Implementation Guide
5.0.0-ballot - STU5 Ballot
Data Exchange For Quality Measures Implementation Guide
5.0.0-ballot - STU5 Ballot
This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v5.0.0-ballot: STU5 (v5.0.0) Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 4.0.0. For a full list of available versions, see the Directory of published versions
| Active as of 2022-02-22 |
<Measure xmlns="http://hl7.org/fhir">
<id value="measure-exm108-example"/>
<meta>
<profile
value="http://hl7.org/fhir/uv/crmi/StructureDefinition/crmi-shareablemeasure"/>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"/>
</meta>
<text>
<status value="generated"/>
<div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: Measure measure-exm108-example</b></p><a name="measure-exm108-example"> </a><a name="hcmeasure-exm108-example"> </a><a name="measure-exm108-example-en-US"> </a><p><b>url</b>: <a href="Measure-measure-exm108-example.html">Measure EXM108 - Venous Thromboembolism Prophylaxis</a></p><p><b>identifier</b>: <code>http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms</code>/108 (use: official, ), <a href="http://terminology.hl7.org/5.5.0/NamingSystem-uri.html" title="As defined by RFC 3986 (http://www.ietf.org/rfc/rfc3986.txt)(with many schemes defined in many RFCs). For OIDs and UUIDs, use the URN form (urn:oid:(note: lowercase) and urn:uuid:). See http://www.ietf.org/rfc/rfc3001.txt and http://www.ietf.org/rfc/rfc4122.txt
This oid is used as an identifier II.root to indicate the the extension is an absolute URI (technically, an IRI). Typically, this is used for OIDs and GUIDs. Note that when this OID is used with OIDs and GUIDs, the II.extension should start with urn:oid or urn:uuid:
Note that this OID is created to aid with interconversion between CDA and FHIR - FHIR uses urn:ietf:rfc:3986 as equivalent to this OID. URIs as identifiers appear more commonly in FHIR.
This OID may also be used in CD.codeSystem.">Uniform Resource Identifier (URI)</a>/urn:oid:2.16.840.1.113883.4.642.40.2.29.2</p><p><b>version</b>: 5.0.0-ballot</p><p><b>name</b>: DEQMVenousThromboembolismProphylaxis</p><p><b>title</b>: EXM108 - Venous Thromboembolism Prophylaxis</p><p><b>status</b>: Active</p><p><b>experimental</b>: true</p><p><b>date</b>: 2022-02-22</p><p><b>publisher</b>: HL7 International / Clinical Quality Information</p><p><b>contact</b>: <a href="http://www.hl7.org/Special/committees/cqi">http://www.hl7.org/Special/committees/cqi</a></p><p><b>description</b>: </p><div><p>This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission</p>
</div><h3>UseContexts</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Code</b></td><td><b>Value[x]</b></td></tr><tr><td style="display: none">*</td><td><a href="http://terminology.hl7.org/5.5.0/CodeSystem-usage-context-type.html#usage-context-type-program">UsageContextType</a> program: Program</td><td><span title="Codes:{http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs-example eh-cah}">EH/CAH</span></td></tr></table><p><b>jurisdiction</b>: <span title="Codes:{urn:iso:std:iso:3166 US}">United States of America</span></p><p><b>copyright</b>: </p><div><p>Measure specifications are in the Public Domain.</p>
<p>LOINC(R) is a registered trademark of the Regenstrief Institute.</p>
<p>This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved.</p>
</div><p><b>approvalDate</b>: 2019-03-08</p><p><b>lastReviewDate</b>: 2019-03-08</p><p><b>effectivePeriod</b>: 2018-01-01 --> 2018-12-31</p><p><b>topic</b>: <span title="Codes:{http://loinc.org 57024-2}">Health Quality Measure Document</span></p><p><b>library</b>: <a href="Library-library-exm108-example.html">EXM108 - Venous Thromboembolism Prophylaxis Library</a></p><p><b>disclaimer</b>: </p><div><p>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</p>
</div><p><b>scoring</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-scoring proportion}">Proportion</span></p><p><b>type</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-type process}">Process</span></p><p><b>rationale</b>: </p><div><p>Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008).</p>
<p>The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that "the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism" (Shojania, 2001).</p>
<p>Despite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008).</p>
<p>In a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients (Shojania, 2001). Updated "safe practices" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006).</p>
<p>As noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008).</p>
<p>Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure.</p>
</div><p><b>clinicalRecommendationStatement</b>: </p><div><p>Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated.</p>
</div><p><b>improvementNotation</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-improvement-notation increase}">Increased score indicates improvement</span></p><p><b>guidance</b>: </p><div><p>When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.</p>
<p>Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed."</p>
</div><blockquote><p><b>group</b></p><blockquote><p><b>population</b></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-population initial-population}">Initial Population</span></p><p><b>description</b>: Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period</p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>Initial Population</td></tr></table></blockquote><blockquote><p><b>population</b></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-population numerator}">Numerator</span></p><p><b>description</b>: Patients who received VTE prophylaxis:
- the day of or the day after hospital admission
- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission
Patients who have documentation of a reason why no VTE prophylaxis was given:
- between arrival and hospital admission
- the day of or the day after hospital admission
- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)</p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>Numerator</td></tr></table></blockquote><blockquote><p><b>population</b></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-population denominator}">Denominator</span></p><p><b>description</b>: All patients in the initial population</p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>Denominator</td></tr></table></blockquote><blockquote><p><b>population</b></p><p><b>code</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-population denominator-exclusion}">Denominator Exclusion</span></p><p><b>description</b>: * Patients who have a length of stay less than 2 days
* Patients with comfort measures documented anytime between arrival and the day after hospital admission
* Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
* Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day
* Patients with a principal diagnosis of mental disorders or stroke
* Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries</p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>Denominator Exclusion</td></tr></table></blockquote></blockquote><blockquote><p><b>supplementalData</b></p><p><b>usage</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-data-usage supplemental-data}">Supplemental Data</span></p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>SDE Ethnicity</td></tr></table></blockquote><blockquote><p><b>supplementalData</b></p><p><b>usage</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-data-usage supplemental-data}">Supplemental Data</span></p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>SDE Payer</td></tr></table></blockquote><blockquote><p><b>supplementalData</b></p><p><b>usage</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-data-usage supplemental-data}">Supplemental Data</span></p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>SDE Race</td></tr></table></blockquote><blockquote><p><b>supplementalData</b></p><p><b>usage</b>: <span title="Codes:{http://terminology.hl7.org/CodeSystem/measure-data-usage supplemental-data}">Supplemental Data</span></p><h3>Criteria</h3><table class="grid"><tr><td style="display: none">-</td><td><b>Language</b></td><td><b>Expression</b></td></tr><tr><td style="display: none">*</td><td>text/cql-identifier</td><td>SDE Sex</td></tr></table></blockquote></div>
</text>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis">
<valueCode value="Encounter"/>
</extension>
<url
value="http://hl7.org/fhir/us/davinci-deqm/Measure/measure-exm108-example"/>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms"/>
<value value="108"/>
</identifier>
<identifier>
<system value="urn:ietf:rfc:3986"/>
<value value="urn:oid:2.16.840.1.113883.4.642.40.2.29.2"/>
</identifier>
<version value="5.0.0-ballot"/>
<name value="DEQMVenousThromboembolismProphylaxis"/>
<title value="EXM108 - Venous Thromboembolism Prophylaxis"/>
<status value="active"/>
<experimental value="true"/>
<date value="2022-02-22"/>
<publisher value="HL7 International / Clinical Quality Information"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/cqi"/>
</telecom>
</contact>
<description
value="This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission"/>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="program"/>
</code>
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs-example"/>
<code value="eh-cah"/>
<display value="EH/CAH"/>
</coding>
</valueCodeableConcept>
</useContext>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
</coding>
</jurisdiction>
<copyright
value="Measure specifications are in the Public Domain.
LOINC(R) is a registered trademark of the Regenstrief Institute.
This material contains SNOMED Clinical Terms(R) (SNOMED CT(C)) copyright 2004-2017 International Health Terminology Standards Development Organization. All rights reserved."/>
<approvalDate value="2019-03-08"/>
<lastReviewDate value="2019-03-08"/>
<effectivePeriod>
<start value="2018-01-01"/>
<end value="2018-12-31"/>
</effectivePeriod>
<topic>
<coding>
<system value="http://loinc.org"/>
<code value="57024-2"/>
<display value="Health Quality Measure Document"/>
</coding>
</topic>
<library
value="http://hl7.org/fhir/us/davinci-deqm/Library/library-exm108-example"/>
<disclaimer
value="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"/>
<scoring>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-scoring"/>
<code value="proportion"/>
<display value="Proportion"/>
</coding>
</scoring>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-type"/>
<code value="process"/>
</coding>
</type>
<rationale
value="Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected. The majority of fatal events occur as sudden or abrupt death, underscoring the importance of prevention as the most critical action step for reducing death from PE (Geerts, et al, 2008).
The estimated annual incidence of deep-vein thrombosis (DVT) and pulmonary embolism (PE), known collectively as venous thromboembolism (VTE), is approximately 900,000 (Geerts, et al, 2008). Approximately two-thirds of cases of DVT or PE are associated with recent hospitalization. This is consistent with the 2001 report by The Agency for Healthcare Research and Quality (AHRQ). AHRQ indicates that "the appropriate application of effective preventive measures in hospitals has major potential for improving patient safety by reducing the incidence of venous thromboembolism" (Shojania, 2001).
Despite its proven effectiveness, rates of appropriate thromboprophylaxis remain low in both medical and surgical patients. A recent analysis from the ENDORSE survey, which evaluated prophylaxis rates in 17,084 major surgery patients, found that more than one third of patients at risk for VTE (38%) did not receive prophylaxis and that rates varied by surgery type (Cohen, et al., 2008).
In a review of evidence-based patient safety practices, the Agency for Healthcare Research and Quality defined thromboprophylaxis against VTE as the "number one patient safety practice" for hospitalized patients (Shojania, 2001). Updated "safe practices" published by the National Quality Forum (NQF) recommend routine evaluation of hospitalized patients for risk of VTE and use of appropriate prophylaxis (National Quality Forum. National Voluntary Consensus Standards for Prevention and Care of Venous Thromboembolism, 2006).
As noted by the ACCP, a vast number of randomized clinical trials provide irrefutable evidence that thromboprophylaxis reduces VTE events, and there are studies that have also shown that fatal PE is prevented by thromboprophylaxis (Geerts, et al. 2008).
Some select surgeries have previously been monitored in the Surgical Care Improvement Project; since performance on these surgeries has achieved very high levels, they are not included in this measure."/>
<clinicalRecommendationStatement
value="Failure to recognize and protect patients at risk for venous thromboembolism (VTE) increases the chances for acutely ill hospitalized patients at high risk for developing a deep vein thrombosis or dying from a pulmonary emboli. Screening all patients is the only evidence based practice in reducing incidence of disease. All hospitalized patients should be evaluated for primary VTE prophylaxis, and given appropriate prophylaxis when indicated."/>
<improvementNotation>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
<code value="increase"/>
<display value="Increased score indicates improvement"/>
</coding>
</improvementNotation>
<guidance
value="When low dose unfractionated heparin is administered for VTE Prophylaxis, the intended administration route for low dose unfractionated heparin is subcutaneous.
Reasons for no pharmacological and no mechanical VTE prophylaxis must be explicitly documented by the MD/APN/PA or pharmacist and linked with VTE prophylaxis. Ambulation alone is not a sufficient reason for not administering VTE prophylaxis. In order for ambulation/patient ambulating to be considered as an acceptable reason, there needs to be explicit documentation, e.g., "patient out of bed and ambulating in halls - no VTE prophylaxis needed.""/>
<group>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="initial-population"/>
<display value="Initial Population"/>
</coding>
</code>
<description
value="Patients age 18 and older discharged from hospital inpatient acute care without a diagnosis of venous thromboembolism (VTE) or obstetrics with a length of stay less than or equal to 120 days that ends during the measurement period"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Initial Population"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="numerator"/>
<display value="Numerator"/>
</coding>
</code>
<description
value="Patients who received VTE prophylaxis:
- the day of or the day after hospital admission
- the day of or the day after surgery end date for surgeries that end the day of or the day after hospital admission
Patients who have documentation of a reason why no VTE prophylaxis was given:
- between arrival and hospital admission
- the day of or the day after hospital admission
- the day of or the day after surgery end date (for surgeries that end the day of or the day after hospital admission)"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Numerator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator"/>
<display value="Denominator"/>
</coding>
</code>
<description value="All patients in the initial population"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exclusion"/>
<display value="Denominator Exclusion"/>
</coding>
</code>
<description
value="* Patients who have a length of stay less than 2 days
* Patients with comfort measures documented anytime between arrival and the day after hospital admission
* Patients with comfort measures documented by the day after surgery end date for surgeries that start the day of or the day after hospital admission
* Patients who are direct admits to intensive care unit (ICU), or transferred to ICU the day of or the day after hospital admission with ICU length of stay greater than or equal to one day
* Patients with a principal diagnosis of mental disorders or stroke
* Patients with a principal procedure of Surgical Care Improvement Project (SCIP) VTE selected surgeries"/>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exclusion"/>
</criteria>
</population>
</group>
<supplementalData>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-includeInReportType">
<valueCode value="summary"/>
</extension>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Ethnicity"/>
</criteria>
</supplementalData>
<supplementalData>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-includeInReportType">
<valueCode value="summary"/>
</extension>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Payer"/>
</criteria>
</supplementalData>
<supplementalData>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-includeInReportType">
<valueCode value="summary"/>
</extension>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Race"/>
</criteria>
</supplementalData>
<supplementalData>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-includeInReportType">
<valueCode value="summary"/>
</extension>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Sex"/>
</criteria>
</supplementalData>
</Measure>
IG © 2020+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.davinci-deqm#5.0.0-ballot based on FHIR 4.0.1. Generated 2024-08-27
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