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TN906: HITSP Quality Measures

TN906: This document provides several examples of quality measures specified based on information available within electronic data sources as specified using the HITSP IS06 Quality Interoperability Specification. The examples include measures in the Stroke, Venous Thromboembolism and Emergency Department sets of quality measures provided to HITSP by CMS. These examples includes a description of the measures, the sets of data elements needed to address each measure (including any derived data elements), the associated value sets, the eMeasure representation, and the QRDA representation required to report performance based on these measures. Note that QRDA is the HL7 Quality Reporting Document Architecture that enables providers to use the same data constructs developed for information exchange to report on quality measures directly out of the EHR. This document also provides an example of the XML emeasure populated with sample data from the examples. This document is intended to exemplify the use of the HITSP specifications in specifying and reporting on a quality measure. This document is also intended to serve as guidance for the implementation of the example measures using the HITSP standards.

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Quality Measures

Admit Decision Time to ED Departure Time for Admitted ED Patients: Median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status [details] [logic] [expand]

Anticoagulation Therapy for Atrial Fibrillation/Flutter: Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. [details] [logic] [expand]

Antithrombolytic Therapy By End of Hospital Day 2: Ischemic stroke patients administered antithrombolytic therapy by the end of hospital day 2 [details] [logic] [expand]

Assessed for Rehabilitation: Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services. [details] [logic] [expand]

Discharged on Antithrombolytic Therapy: Ischemic stroke patients prescribed antithrombolytic therapy at hospital discharge [details] [logic] [expand]

Discharged on Statin Medication: [Ischemic stroke patients] with LDL >= 100 mg/dL, or LDL not measured, or, who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. [details] [logic] [expand]

Incidence of Potentially-Preventable Venous Thromboembolism: This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date [details] [logic] [expand]

Intensive Care Unit (ICU) VTE Prophylaxis: 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 the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) [details] [logic] [expand]

Median Time from ED Arrival to ED Departure for Admitted ED Patients: Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department [details] [logic] [expand]

Stroke Education: Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke [details] [logic] [expand]

Thrombolytic Therapy: Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well [details] [logic] [expand]

Venous Thromboembolism (VTE) Patients Receiving Unfractionated Heparin (UFH) with Dosages/Platelet Count Monitoring by Protocol (or Nomogram): This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol [details] [logic] [expand]

Venous Thromboembolism (VTE) Patients with Anticoagulation Overlap Therapy: This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they must be discharged on both medications. Overlap therapy must be administered for at least five days with an international normalized ratio (INR) 2 prior to discontinuation of the parenteral anticoagulation therapy or the patient must be discharged on both medications [details] [logic] [expand]

Venous Thromboembolism (VTE) Prophylaxis: Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission [details] [logic] [expand]

Venous Thromboembolism Discharge Instructions: This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, to home with home health or home hospice on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring and information about the potential for adverse drug reactions/interactions [details] [logic] [expand]

VTE Prophylaxis (VTE-1): 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 [details] [logic] [expand]

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