Metadata Title Discharged on Antithrombotic Therapy FHIR Example Version 0.5.3 Short Name CMS104FHIR GUID (Version Independent) urn:uuid:4f57e4a2-097b-45f8-9c85-91b35ea92dc1 GUID (Version Specific) urn:uuid:e0b5379f-4b9c-4177-a530-d744fa95d080 CMS Identifier 104FHIR Effective Period 2024-01-01 through 2024-12-31 Approval Date 2023-08-01 Last Review Date 2023-08-01 Status Draft Use Context venue from http://terminology.hl7.org/CodeSystem/usage-context-type = EH Jurisdiction 001 from http://unstats.un.org/unsd/methods/m49/m49.htm Steward (Publisher) HL7 International - [Some] Work Group Developer The Joint Commission Description Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge Copyright Measure specifications are in the Public Domain LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved. 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. Rationale The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity and recurrence rates has been studied in several large clinical trials. While the use of these agents for patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist. or patients with a stroke due to a cardioembolic source (e.g. atrial fibrillation, mechanical heart valve), warfarin is recommended unless contraindicated. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. Anticoagulation therapy is not generally recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke. Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or transient ischemic attack (TIA). Clinical Recommendation Statement Clinical trial results suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist Guidance (Usage) The "Nonelective Inpatient Encounter" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective admissions include emergency, urgent and unplanned admissions. The "MedicationRequest" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS104v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html). Measure Group (Rate) (ID: 64403d17d4d7050edabb0562) Basis Encounter Scoring Proportion Type Process Initial Population ID: 937BAF2A-D36A-4EE5-B2B2-762A0FE04502 Description: Inpatient hospitalizations for patients age 18 and older, discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during the measurement period Criteria: Initial Population Denominator ID: 302C1DCC-7FE6-41EF-A94E-FDAE24B7BB1B Description: Inpatient hospitalizations for patients with a principal diagnosis of Ischemic stroke Criteria: Denominator Denominator Exclusion ID: 4B649804-9C55-4949-8CE0-01B462CAA74C Description: - Inpatient hospitalizations for patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations. - Inpatient hospitalizations for patients discharged to another hospital - Inpatient hospitalizations for patients who left against medical advice - Inpatient hospitalizations for patients who expired - Inpatient hospitalizations for patients discharged to home for hospice care - Inpatient hospitalizations for patients discharged to a health care facility for hospice care - Inpatient hospitalizations for patients with comfort measures documented Criteria: Denominator Exclusions Denominator Exception ID: 516A3DD0-69B0-49EF-BBD3-12809CDC843E Description: - Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge. - Inpatient hospitalizations for patients who receive Prasugrel as an antithrombotic therapy at discharge. Criteria: Denominator Exceptions Numerator ID: 99961E3A-EFC4-4858-A3EE-F7F1D5B222FB Description: Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge Criteria: Numerator Numerator Exclusion ID: 5f33f3ea-6ffb-4897-85dd-872dd7ac55b8 Description: No description provided Supplemental Data Guidance Guidance Patient's Ethnicity: Hispanic or Latino Not Hispanic or Latino Patient's Payer: Categories of types of health care payer entities as defined by the US Public Health Data Consortium SOP code system Patient's Race: Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Other Race White Black or African American Patient's Sex: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories. Supplemental Data Elements Supplemental Data Element ID: sde-ethnicity Usage Code: Supplemental Data Description: SDE Ethnicity Logic Definition: SDE Ethnicity Supplemental Data Element ID: sde-payer Usage Code: Supplemental Data Description: SDE Payer Logic Definition: SDE Payer Supplemental Data Element ID: sde-race Usage Code: Supplemental Data Description: SDE Race Logic Definition: SDE Race Supplemental Data Element ID: sde-sex Usage Code: Supplemental Data Description: SDE Sex Logic Definition: SDE Sex Measure Logic Primary Library DischargedonAntithromboticTherapyFHIRExample Contents Population Criteria Logic Definitions Terminology Dependencies Data Requirements Parameters Population Criteria Measure Group (Rate) (ID: 64403d17d4d7050edabb0562) Initial Population define "Initial Population": TJC."Encounter with Principal Diagnosis and Age" Definition Denominator define "Denominator": TJC."Ischemic Stroke Encounter" Definition Denominator Exclusion define "Denominator Exclusions": TJC."Ischemic Stroke Encounters with Discharge Disposition" union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke" Definition Denominator Exception define "Denominator Exceptions": "Encounter with Documented Reason for No Antithrombotic At Discharge" union "Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge" Definition Numerator define "Numerator": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["MedicationRequest": "Antithrombotic Therapy for Ischemic Stroke"] DischargeAntithrombotic such that DischargeAntithrombotic.authoredOn during IschemicStrokeEncounter.period Definition Logic Definitions Logic Definition Library Name: TJCOverallExample define "Non Elective Inpatient Encounter": ["Encounter": "Nonelective Inpatient Encounter"] NonElectiveEncounter where NonElectiveEncounter.period ends during day of "Measurement Period" Logic Definition Library Name: TJCOverallExample define "All Stroke Encounter": "Non Elective Inpatient Encounter" NonElectiveEncounter let ConditionCode: NonElectiveEncounter.principalDiagnosis().code where ( ConditionCode in "Hemorrhagic Stroke" or ConditionCode in "Ischemic Stroke" ) Logic Definition Library Name: TJCOverallExample define "Encounter with Principal Diagnosis and Age": "All Stroke Encounter" AllStrokeEncounter where AgeInYearsAt(date from start of AllStrokeEncounter.period ) >= 18 Logic Definition Library Name: TJCOverallExample define "Ischemic Stroke Encounter": "Encounter with Principal Diagnosis and Age" EncounterWithAge where EncounterWithAge.principalDiagnosis().code in "Ischemic Stroke" Logic Definition Library Name: TJCOverallExample define "Ischemic Stroke Encounters with Discharge Disposition": "Ischemic Stroke Encounter" IschemicStrokeEncounter let DischDisp: IschemicStrokeEncounter.hospitalization.dischargeDisposition where DischDisp in "Discharge To Acute Care Facility" or DischDisp in "Left Against Medical Advice" or DischDisp in "Patient Expired" or DischDisp in "Discharged to Home for Hospice Care" or DischDisp in "Discharged to Health Care Facility for Hospice Care" Logic Definition Library Name: TJCOverallExample define "Intervention Comfort Measures": ( ["ServiceRequest": code in "Comfort Measures"] SR where SR.status in { 'active', 'completed', 'on-hold' } and SR.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } and SR.doNotPerform is not true ) union ( ["Procedure": "Comfort Measures"] InterventionPerformed where InterventionPerformed.status in { 'completed', 'in-progress' } ) Logic Definition Library Name: SupplementalDataElementsExample define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end Logic Definition Library Name: SupplementalDataElementsExample define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period } Logic Definition Library Name: SupplementalDataElementsExample define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text } Logic Definition Library Name: SupplementalDataElementsExample define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text } Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "SDE Sex": SDE."SDE Sex" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Numerator": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["MedicationRequest": "Antithrombotic Therapy for Ischemic Stroke"] DischargeAntithrombotic such that DischargeAntithrombotic.authoredOn during IschemicStrokeEncounter.period Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Denominator": TJC."Ischemic Stroke Encounter" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "SDE Payer": SDE."SDE Payer" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Initial Population": TJC."Encounter with Principal Diagnosis and Age" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "SDE Ethnicity": SDE."SDE Ethnicity" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke": "Denominator" Encounter with TJC."Intervention Comfort Measures" ComfortMeasure such that Coalesce(start of ComfortMeasure.performed.toInterval(), ComfortMeasure.authoredOn) during Encounter.hospitalizationWithObservation ( ) Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Denominator Exclusions": TJC."Ischemic Stroke Encounters with Discharge Disposition" union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "SDE Race": SDE."SDE Race" Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Reason for Not Giving Antithrombotic at Discharge": ["MedicationNotRequested": "Antithrombotic Therapy for Ischemic Stroke"] NoAntithromboticDischarge where ( NoAntithromboticDischarge.reasonCode in "Medical Reason For Not Providing Treatment" or NoAntithromboticDischarge.reasonCode in "Patient Refusal" ) and ( NoAntithromboticDischarge.isCommunity ( ) or NoAntithromboticDischarge.isDischarge ( ) ) and NoAntithromboticDischarge.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Encounter with Documented Reason for No Antithrombotic At Discharge": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "Reason for Not Giving Antithrombotic at Discharge" NoDischargeAntithrombotic such that NoDischargeAntithrombotic.authoredOn during IschemicStrokeEncounter.period Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Pharmacological Contraindications for Antithrombotic Therapy at Discharge": ["MedicationRequest": "Pharmacological Contraindications For Antithrombotic Therapy"] Pharmacological where ( Pharmacological.isCommunity ( ) or Pharmacological.isDischarge ( ) ) and Pharmacological.status in { 'active', 'completed' } and Pharmacological.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } and Pharmacological.doNotPerform is not true Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "Pharmacological Contraindications for Antithrombotic Therapy at Discharge" DischargePharmacological such that DischargePharmacological.authoredOn during IschemicStrokeEncounter.period Logic Definition Library Name: DischargedonAntithromboticTherapyFHIRExample define "Denominator Exceptions": "Encounter with Documented Reason for No Antithrombotic At Discharge" union "Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge" Logic Definition Library Name: CQMCommonExample /* @description: Returns the condition that is specified as the principal diagnosis for the encounter */ define fluent function principalDiagnosis(Encounter Encounter ): singleton from ((Encounter.diagnosis D where D.rank = 1) PD return singleton from ([Condition] C where C.id = PD.condition.reference.getId()) ) Logic Definition Library Name: CQMCommonExample /* @description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter */ define fluent function hospitalizationWithObservation(TheEncounter Encounter ): TheEncounter Visit let ObsVisit: Last([Encounter: "Observation Services"] LastObs where LastObs.status = 'finished' and LastObs.period ends 1 hour or less on or before start of Visit.period sort by end of period ), VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period), EDVisit: Last([Encounter: "Emergency Department Visit"] LastED where LastED.status = 'finished' and LastED.period ends 1 hour or less on or before VisitStart sort by end of period ) return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period] Logic Definition Library Name: FHIRHelpers define function ToInterval(period FHIR.Period): if period is null then null else if period."start" is null then Interval(period."start".value, period."end".value] else Interval[period."start".value, period."end".value] Logic Definition Library Name: FHIRHelpers define function ToString(value uri): value.value Logic Definition Library Name: FHIRHelpers define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.value } Logic Definition Library Name: FHIRHelpers define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value } Logic Definition Library Name: QICoreCommonExample /* @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI). @comment: This function can be used to determine the logical id of a given resource. It can be used in a single-server environment to trace references. However, this function does not attempt to resolve or distinguish the base of the given url, and so cannot be used safely in multi-server environments. */ define fluent function getId(uri String): Last(Split(uri, '/')) Logic Definition Library Name: QICoreCommonExample /* @description: Returns true if the given MedicationRequest has a category of Community */ define fluent function isCommunity(medicationRequest MedicationNotRequested): exists (medicationRequest.category C where C ~ Community ) Logic Definition Library Name: QICoreCommonExample /* @description: Returns true if the given MedicationRequest has a category of Discharge */ define fluent function isDischarge(medicationRequest MedicationNotRequested): exists (medicationRequest.category C where C ~ Discharge ) Logic Definition Library Name: QICoreCommonExample /* @description: Returns true if the given MedicationRequest has a category of Community */ define fluent function isCommunity(medicationRequest MedicationRequest): exists (medicationRequest.category C where C ~ Community ) Logic Definition Library Name: QICoreCommonExample /* @description: Returns true if the given MedicationRequest has a category of Discharge */ define fluent function isDischarge(medicationRequest MedicationRequest): exists (medicationRequest.category C where C ~ Discharge ) Terminology Code System Description: Code system MedicationRequestCategory Resource: MedicationRequest Category Codes Canonical URL: http://terminology.hl7.org/CodeSystem/medicationrequest-category Value Set Description: Value set Nonelective Inpatient Encounter Resource: Non-Elective Inpatient Encounter Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.424 Value Set Description: Value set Hemorrhagic Stroke Resource: Hemorrhagic Stroke Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.212 Value Set Description: Value set Ischemic Stroke Resource: Ischemic Stroke Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.247 Value Set Description: Value set Antithrombotic Therapy for Ischemic Stroke Resource: Antithrombotic Therapy Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.62 Value Set Description: Value set Payer Type Resource: Payer Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 Value Set Description: Value set Discharge To Acute Care Facility Resource: Discharge To Acute Care Facility Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.87 Value Set Description: Value set Left Against Medical Advice Resource: Left Against Medical Advice Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.308 Value Set Description: Value set Patient Expired Resource: Patient Expired Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.309 Value Set Description: Value set Discharged to Home for Hospice Care Resource: Discharged to Home for Hospice Care Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.209 Value Set Description: Value set Discharged to Health Care Facility for Hospice Care Resource: Discharged to Health Care Facility for Hospice Care Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.207 Value Set Description: Value set Comfort Measures Resource: Comfort Measures Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/1.3.6.1.4.1.33895.1.3.0.45 Value Set Description: Value set Observation Services Resource: Observation Services Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1111.143 Value Set Description: Value set Emergency Department Visit Resource: Emergency Department Visit Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.292 Value Set Description: Value set Medical Reason For Not Providing Treatment Resource: Medical Reason Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.473 Value Set Description: Value set Patient Refusal Resource: Patient Refusal Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.117.1.7.1.93 Value Set Description: Value set Pharmacological Contraindications For Antithrombotic Therapy Resource: Pharmacological Contraindications For Antithrombotic Therapy Canonical URL: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1110.52 Direct Reference Code Display: Community Code: community System: http://terminology.hl7.org/CodeSystem/medicationrequest-category Direct Reference Code Display: Discharge Code: discharge System: http://terminology.hl7.org/CodeSystem/medicationrequest-category Dependencies Dependency Description: Library SDE Resource: SupplementalDataElementsExample Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/SupplementalDataElementsExample Dependency Description: Library TJC Resource: TJCOverallExample Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/TJCOverallExample Dependency Description: Library FHIRHelpers Resource: http://somewhere.org/fhir/uv/mycontentig/Library/FHIRHelpers|4.0.1 Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/FHIRHelpers|4.0.1 Dependency Description: Library CQMCommon Resource: CQMCommonExample Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/CQMCommonExample Dependency Description: Library QICoreCommon Resource: QICoreCommonExample Canonical URL: http://somewhere.org/fhir/uv/mycontentig/Library/QICoreCommonExample Data Requirements Data Requirement Type: Patient Profile(s): QICore Patient Must Support Elements: url, extension Data Requirement Type: Encounter Profile(s): QICore Encounter Must Support Elements: type, period, rank, rank.value, condition, condition.reference, condition.reference.value, hospitalization, hospitalization.dischargeDisposition Code Filter(s): Path: type ValueSet: Non-Elective Inpatient Encounter Data Requirement Type: Encounter Profile(s): QICore Encounter Must Support Elements: type, status, status.value, period, rank, rank.value, condition, condition.reference, condition.reference.value, hospitalization, hospitalization.dischargeDisposition Code Filter(s): Path: type ValueSet: Observation Services Data Requirement Type: Encounter Profile(s): QICore Encounter Must Support Elements: type, status, status.value, period, rank, rank.value, condition, condition.reference, condition.reference.value, hospitalization, hospitalization.dischargeDisposition Code Filter(s): Path: type ValueSet: Emergency Department Visit Data Requirement Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition Must Support Elements: id, id.value Data Requirement Type: MedicationRequest Profile(s): QICore MedicationRequest Must Support Elements: medication, authoredOn, authoredOn.value, status, status.value, intent, intent.value, doNotPerform, doNotPerform.value Code Filter(s): Path: medication ValueSet: Antithrombotic Therapy Data Requirement Type: MedicationRequest Profile(s): QICore MedicationRequest Must Support Elements: medication, authoredOn, authoredOn.value, status, status.value, intent, intent.value, doNotPerform, doNotPerform.value Code Filter(s): Path: medication ValueSet: Pharmacological Contraindications For Antithrombotic Therapy Data Requirement Type: MedicationRequest Profile(s): QICore MedicationRequest Must Support Elements: medication.reference.value, authoredOn, authoredOn.value, status, status.value, intent, intent.value, doNotPerform, doNotPerform.value Data Requirement Type: Medication Profile(s): QICore Medication Must Support Elements: id.value, code Data Requirement Type: Coverage Profile(s): QICore Coverage Must Support Elements: type, period Code Filter(s): Path: type ValueSet: Payer Data Requirement Type: ServiceRequest Profile(s): QICore ServiceRequest Must Support Elements: code, status, status.value, intent, intent.value, doNotPerform, doNotPerform.value Code Filter(s): Path: code ValueSet: Comfort Measures Data Requirement Type: Procedure Profile(s): QICore Procedure Must Support Elements: code, status, status.value Code Filter(s): Path: code ValueSet: Comfort Measures Data Requirement Type: MedicationRequest Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-mednotrequested Must Support Elements: medication, reasonCode, intent, intent.value, authoredOn, authoredOn.value Code Filter(s): Path: medication ValueSet: Antithrombotic Therapy Parameters Name Use Card. Type Documentation Measurement Period In 0..1 Period SDE Sex Out 0..1 Coding Numerator Out 0..* Resource Denominator Out 0..* Resource SDE Payer Out 0..* Resource Initial Population Out 0..* Resource SDE Ethnicity Out 0..1 Resource Denominator Exclusions Out 0..* Resource SDE Race Out 0..1 Resource Denominator Exceptions Out 0..* Resource Generated using version 0.5.3 of the sample-content-ig Liquid templates
define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end
define "Non Elective Inpatient Encounter": ["Encounter": "Nonelective Inpatient Encounter"] NonElectiveEncounter where NonElectiveEncounter.period ends during day of "Measurement Period"
define "All Stroke Encounter": "Non Elective Inpatient Encounter" NonElectiveEncounter let ConditionCode: NonElectiveEncounter.principalDiagnosis().code where ( ConditionCode in "Hemorrhagic Stroke" or ConditionCode in "Ischemic Stroke" )
Encounter with Principal Diagnosis and Age
define "Encounter with Principal Diagnosis and Age": "All Stroke Encounter" AllStrokeEncounter where AgeInYearsAt(date from start of AllStrokeEncounter.period ) >= 18
define "Ischemic Stroke Encounter": "Encounter with Principal Diagnosis and Age" EncounterWithAge where EncounterWithAge.principalDiagnosis().code in "Ischemic Stroke"
define "Numerator": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with ["MedicationRequest": "Antithrombotic Therapy for Ischemic Stroke"] DischargeAntithrombotic such that DischargeAntithrombotic.authoredOn during IschemicStrokeEncounter.period
define "Denominator": TJC."Ischemic Stroke Encounter"
define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period }
define "Initial Population": TJC."Encounter with Principal Diagnosis and Age"
define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text }
define "SDE Ethnicity": SDE."SDE Ethnicity"
Ischemic Stroke Encounters with Discharge Disposition
define "Ischemic Stroke Encounters with Discharge Disposition": "Ischemic Stroke Encounter" IschemicStrokeEncounter let DischDisp: IschemicStrokeEncounter.hospitalization.dischargeDisposition where DischDisp in "Discharge To Acute Care Facility" or DischDisp in "Left Against Medical Advice" or DischDisp in "Patient Expired" or DischDisp in "Discharged to Home for Hospice Care" or DischDisp in "Discharged to Health Care Facility for Hospice Care"
define "Intervention Comfort Measures": ( ["ServiceRequest": code in "Comfort Measures"] SR where SR.status in { 'active', 'completed', 'on-hold' } and SR.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } and SR.doNotPerform is not true ) union ( ["Procedure": "Comfort Measures"] InterventionPerformed where InterventionPerformed.status in { 'completed', 'in-progress' } )
Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke
define "Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke": "Denominator" Encounter with TJC."Intervention Comfort Measures" ComfortMeasure such that Coalesce(start of ComfortMeasure.performed.toInterval(), ComfortMeasure.authoredOn) during Encounter.hospitalizationWithObservation ( )
define "Denominator Exclusions": TJC."Ischemic Stroke Encounters with Discharge Disposition" union "Encounter with Comfort Measures during Hospitalization for Patients with Documented Ischemic Stroke"
define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text }
Reason for Not Giving Antithrombotic at Discharge
define "Reason for Not Giving Antithrombotic at Discharge": ["MedicationNotRequested": "Antithrombotic Therapy for Ischemic Stroke"] NoAntithromboticDischarge where ( NoAntithromboticDischarge.reasonCode in "Medical Reason For Not Providing Treatment" or NoAntithromboticDischarge.reasonCode in "Patient Refusal" ) and ( NoAntithromboticDischarge.isCommunity ( ) or NoAntithromboticDischarge.isDischarge ( ) ) and NoAntithromboticDischarge.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' }
Encounter with Documented Reason for No Antithrombotic At Discharge
define "Encounter with Documented Reason for No Antithrombotic At Discharge": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "Reason for Not Giving Antithrombotic at Discharge" NoDischargeAntithrombotic such that NoDischargeAntithrombotic.authoredOn during IschemicStrokeEncounter.period
Pharmacological Contraindications for Antithrombotic Therapy at Discharge
define "Pharmacological Contraindications for Antithrombotic Therapy at Discharge": ["MedicationRequest": "Pharmacological Contraindications For Antithrombotic Therapy"] Pharmacological where ( Pharmacological.isCommunity ( ) or Pharmacological.isDischarge ( ) ) and Pharmacological.status in { 'active', 'completed' } and Pharmacological.intent in { 'order', 'original-order', 'reflex-order', 'filler-order', 'instance-order' } and Pharmacological.doNotPerform is not true
Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge
define "Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge": TJC."Ischemic Stroke Encounter" IschemicStrokeEncounter with "Pharmacological Contraindications for Antithrombotic Therapy at Discharge" DischargePharmacological such that DischargePharmacological.authoredOn during IschemicStrokeEncounter.period
define "Denominator Exceptions": "Encounter with Documented Reason for No Antithrombotic At Discharge" union "Encounter with Pharmacological Contraindications for Antithrombotic Therapy at Discharge"
define function ToInterval(period FHIR.Period): if period is null then null else if period."start" is null then Interval(period."start".value, period."end".value] else Interval[period."start".value, period."end".value]
/* @description: Returns the condition that is specified as the principal diagnosis for the encounter */ define fluent function principalDiagnosis(Encounter Encounter ): singleton from ((Encounter.diagnosis D where D.rank = 1) PD return singleton from ([Condition] C where C.id = PD.condition.reference.getId()) )
/* @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI). @comment: This function can be used to determine the logical id of a given resource. It can be used in a single-server environment to trace references. However, this function does not attempt to resolve or distinguish the base of the given url, and so cannot be used safely in multi-server environments. */ define fluent function getId(uri String): Last(Split(uri, '/'))
define function ToString(value uri): value.value
define function ToCode(coding FHIR.Coding): if coding is null then null else System.Code { code: coding.code.value, system: coding.system.value, version: coding.version.value, display: coding.display.value }
/* @description: Hospitalization with Observation returns the total interval from the start of any immediately prior emergency department visit through the observation visit to the discharge of the given encounter */ define fluent function hospitalizationWithObservation(TheEncounter Encounter ): TheEncounter Visit let ObsVisit: Last([Encounter: "Observation Services"] LastObs where LastObs.status = 'finished' and LastObs.period ends 1 hour or less on or before start of Visit.period sort by end of period ), VisitStart: Coalesce(start of ObsVisit.period, start of Visit.period), EDVisit: Last([Encounter: "Emergency Department Visit"] LastED where LastED.status = 'finished' and LastED.period ends 1 hour or less on or before VisitStart sort by end of period ) return Interval[Coalesce(start of EDVisit.period, VisitStart), end of Visit.period]
define function ToConcept(concept FHIR.CodeableConcept): if concept is null then null else System.Concept { codes: concept.coding C return ToCode(C), display: concept.text.value }
/* @description: Returns true if the given MedicationRequest has a category of Community */ define fluent function isCommunity(medicationRequest MedicationNotRequested): exists (medicationRequest.category C where C ~ Community )
/* @description: Returns true if the given MedicationRequest has a category of Discharge */ define fluent function isDischarge(medicationRequest MedicationNotRequested): exists (medicationRequest.category C where C ~ Discharge )
/* @description: Returns true if the given MedicationRequest has a category of Community */ define fluent function isCommunity(medicationRequest MedicationRequest): exists (medicationRequest.category C where C ~ Community )
/* @description: Returns true if the given MedicationRequest has a category of Discharge */ define fluent function isDischarge(medicationRequest MedicationRequest): exists (medicationRequest.category C where C ~ Discharge )
Value set Nonelective Inpatient Encounter
Value set Antithrombotic Therapy for Ischemic Stroke
Value set Discharge To Acute Care Facility
Value set Discharged to Home for Hospice Care
Value set Discharged to Health Care Facility for Hospice Care
Value set Medical Reason For Not Providing Treatment
Value set Pharmacological Contraindications For Antithrombotic Therapy
Patient's Ethnicity: Hispanic or Latino Not Hispanic or Latino Patient's Payer: Categories of types of health care payer entities as defined by the US Public Health Data Consortium SOP code system Patient's Race: Native Hawaiian or Other Pacific Islander Asian American Indian or Alaska Native Other Race White Black or African American Patient's Sex: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Discharged on Antithrombotic Therapy FHIR Example
Ischemic stroke patients prescribed or continuing to take antithrombotic therapy at hospital discharge
The "Nonelective Inpatient Encounter" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective admissions include emergency, urgent and unplanned admissions. The "MedicationRequest" datatype refers to the discharge medication list and is intended to express medications ordered for post-discharge use. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS104v12. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Measure specifications are in the Public Domain LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved.
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.
The effectiveness of antithrombotic agents in reducing stroke mortality, stroke-related morbidity and recurrence rates has been studied in several large clinical trials. While the use of these agents for patients with acute ischemic stroke and transient ischemic attacks continues to be the subject of study, substantial evidence is available from completed studies. Data at this time suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist. or patients with a stroke due to a cardioembolic source (e.g. atrial fibrillation, mechanical heart valve), warfarin is recommended unless contraindicated. In recent years, novel oral anticoagulant agents (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. Anticoagulation therapy is not generally recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke. Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or transient ischemic attack (TIA).
Clinical trial results suggest that antithrombotic therapy should be prescribed at discharge following acute ischemic stroke to reduce stroke mortality and morbidity as long as no contraindications exist
Inpatient hospitalizations for patients age 18 and older, discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during the measurement period
Inpatient hospitalizations for patients with a principal diagnosis of Ischemic stroke
- Inpatient hospitalizations for patients admitted for elective carotid intervention. This exclusion is implicitly modeled by only including non-elective hospitalizations. - Inpatient hospitalizations for patients discharged to another hospital - Inpatient hospitalizations for patients who left against medical advice - Inpatient hospitalizations for patients who expired - Inpatient hospitalizations for patients discharged to home for hospice care - Inpatient hospitalizations for patients discharged to a health care facility for hospice care - Inpatient hospitalizations for patients with comfort measures documented
- Inpatient hospitalizations for patients with a documented reason for not prescribing antithrombotic therapy at discharge. - Inpatient hospitalizations for patients who receive Prasugrel as an antithrombotic therapy at discharge.
Inpatient hospitalizations for patients prescribed or continuing to take antithrombotic therapy at hospital discharge