June 30, 2009

Version 1.0

HITSP Quality Measure Reference Document for Public Comment on Quality Interoperability Specification

Submitted to:

Healthcare Information Technology Standards Panel

Submitted by:

Quality Measures Tiger Team

Table of Contents

1.0 Introduction. 6

1.1 Purpose and Scope. 6

1.2 Copyright Permissions. 6

1.3 Version 3.0 Acknowledgement 6

2.0 How to Use HITSP IS06 for Implementing Measures: STK-3. 7

2.1 Measure Descriptions. 7

2.1.1 Stroke STK-3 Measure Description. 7

2.2 Quality Measure Data Dictionary: [STK-3] 7

2.3 Quality Measure Value Sets: [STK-3] 12

2.4 Quality Measure Derived Data: [STK-3] 12

2.4.1 Data Elements Cross Reference. 12

2.5 Quality Measure eMeasure Specification: [STK-3] 18

2.5.1 eMeasure Metadata. 18

2.5.2 Joint Commission Stroke 3 Quality eMeasure Example. 20

2.6 Quality Measure QRDA Specification: [STK-3] 33

2.6.1 Overview. 33

2.6.2 Measure Information. 33

2.6.3 Additional Header Constraints. 35

2.6.4 Additional Body Constraints. 36

2.6.5 Additional Section Constraints. 36

2.7 USHIK Support: [STK-3] 43

3.0 Appendix. 44

3.1 Exemplar Example Value Sets. 44

3.1.1 HITSP Admission Source Value Set 44

3.1.2 HITSP Discharge Disposition Value Set 45

3.1.3 HITSP Ethnicity Value Set 45

3.1.4 HITSP Health Insurance Type Value Set 46

3.1.5 HITSP Hispanic Ethnicity Value SEt 48

3.1.6 Patient Class. 49

3.1.7 HITSP Postal Code Value Set 50

3.1.8 HITSP Race Value Set 50

3.1.9 HITSP Sex Value Set 51

3.1.10 CDA and HL7 V3 Administrative Gender (Joint commission sex) 51

3.1.11 Joint Commission Anticoagulant Medications - Stroke. 52

3.1.12 Joint Commission Atrial Fib/Flutter Clinical Finding Value Set 54

3.1.13 Joint Commission Atrial Fib/Flutter History Value Set 55

3.1.14 Joint Commission Atrial Fib/Flutter Procedure Value Set 56

3.1.15 Joint Commission Clinical Trial Value Set 57

3.1.16 Joint Commission Comfort Measures Only Value Set 58

3.1.17 Joint Commission Carotid Intervention Value Set 59

3.1.18 Joint Commission Elective Surgery Value Set 62

3.1.19 Joint Commission Acute Stroke Value Set 63

3.1.20 Joint Commission Ischemic Stroke Value Set 64

3.1.21 Joint Commission Hemorrhagic Acute Stroke Value Set 66

3.1.22 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Procedure Value Set 68

3.1.23 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Anticoagulant Allergy Value Set 69

3.1.24 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Finding/Situation Value Set 70

Figures and Tables

Figure 2-1 STK-3 recordTarget and birthTime example. 36

Figure 2-2 Anticoagulation therapy prescribed at discharge measure section example. 38

Figure 2-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter reporting parameters section example. 39

Table 2-1 Stroke STK-3 Measure Description. 7

Table 2-2 Patient Data Mapping for STK-3. 8

Table 2-3 Visit Data Mapping. 8

Table 2-4 Problem Data Mapping. 10

Table 2-5 Discharge Diagnosis Data Mapping. 10

Table 2-6 Vital Signs Data Mapping. 11

Table 2-7 Procedures and Diagnostic Data Mapping. 11

Table 2-8 Other Clinical Data Elements Data Mapping. 11

Table 2-9 Other Clinical Data Elements Data Mapping. 12

Table 2-10 Data Elements Cross Reference. 13

Table 2-11 Derived Data. 14

Table 2-12 eMeasure Metadata. 18

Table 3-1 Example Value Set Definition. 44

Table 3-2 Admission Source Vocabulary. 44

Table 3-3 Admission Source Vocabulary. 44

Table 3-4 Discharge Disposition Vocabulary. 45

Table 3-5 Discharge Disposition Vocabulary. 45

Table 3-6 Ethnicity Value Set 45

Table 3-7 Ethnicity Code System.. 46

Table 3-8 Health Insurance Type Value Set 46

Table 3-9 Health Insurance Type Code System.. 46

Table 3-10 Health Insurance Type Value Set Definition. 46

Table 3-11 Hispanic Ethnicity Value Set 48

Table 3-12 Hispanic Ethnicity Code System.. 48

Table 3-13 Hispanic Ethnicity Value Set Definition. 48

Table 3-14 Patient Class Value Set 49

Table 3-15 Patient Class Value Set Definition. 49

Table 3-16 Postal Code Value Set 50

Table 3-17 Postal Code Code System.. 50

Table 3-18 Race Value Set 50

Table 3-19 Race Code System.. 51

Table 3-20 Administrative Gender Value Set 51

Table 3-21 Administrative Gender Code System.. 51

Table 3-22 Administrative Gender Value Set Definition. 51

Table 3-23 Joint Commission Anticoagulant Medications-Stroke Value Set 52

Table 3-24 Joint Commission Anticoagulant Medications-Stroke Code System.. 52

Table 3-25 Joint Commission Anticoagulant Medications-Stroke Value Set Definition. 52

Table 3-26 Joint Commission Atrial Fib/Flutter Clinical Finding Value Set 54

Table 3-27 Joint Commission Atrial Fib/Flutter - Findings Code System.. 54

Table 3-28 Joint Commission Atrial Fib/Flutter - Findings Value Set Definition. 54

Table 3-29 Joint Commission Atrial Fib/Flutter History Value Set 55

Table 3-30 Joint Commission Atrial Fib/Flutter History Code System.. 55

Table 3-31 Joint Commission Atrial Fib/Flutter History Value Set Definition. 56

Table 3-32 Joint Commission Atrial Fib/Flutter Procedure Value Set 56

Table 3-33 Joint Commission Atrial Fib/Flutter - Procedure Code System.. 56

Table 3-34 Joint Commission Atrial Fib/Flutter - Procedure Value Set Definition. 56

Table 3-35 Joint Commission Clinical Trial Value Set 57

Table 3-36 Joint Commission Clinical Trial Code System.. 57

Table 3-37 Joint Commission Clinical Trial Value Set Definition. 57

Table 3-38 Joint Commission Comfort Measures Only Value Set 58

Table 3-39 Joint Commission Comfort Measures Only Code System.. 58

Table 3-40 Joint Commission Comfort Measures Only Value Set Definition. 58

Table 3-41 Joint Commission Carotid Intervention Value Set 59

Table 3-42 Joint Commission Carotid Intervention Code System.. 59

Table 3-43 Joint Commission Carotid Intervention Value Set Definition. 59

Table 3-44 Joint Commission Elective Surgery Value Set 62

Table 3-45 Joint Commission Elective Surgery Code System.. 62

Table 3-46 Joint Commission Carotid Intervention Value Set Definition. 62

Table 3-47 Joint Commission Acute Stroke Value Set 63

Table 3-48 Joint Commission Acute Stroke Code System.. 63

Table 3-49 Joint Commission Acute Stroke Value Set Definition. 63

Table 3-50 Joint Commission Ischemic Stroke Value Set 64

Table 3-51 Joint Commission Ischemic Stroke Code System.. 64

Table 3-52 Joint Commission Ischemic Stroke Value Set Definition. 64

Table 3-53 Joint Commission Hemorrhagic Stroke Value Set 66

Table 3-54 Joint Commission Hemorrhagic Stroke Code System.. 67

Table 3-55 Joint Commission Hemorrhagic Stroke Value Set Definition. 67

Table 3-56 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Procedure Value Set 68

Table 3-57 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Procedure Code System.. 68

Table 3-58 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Procedure Value Set Definition. 68

Table 3-59 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Anticoagulant Allergy Value Set 69

Table 3-60 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge - Anticoagulant Allergy Code System.. 69

Table 3-61 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Situation - Anticoagulant Allergy Value Set Definition. 69

Table 3-62 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Finding/Situation Value Set 70

Table 3-63 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Finding/Situation Code System.. 70

Table 3-64 Joint Commission Reason For Not Prescribing Anticoagulation Therapy at Discharge Finding/Situation Value Set Definition. 70