Final HIT Incentive Rule Quality Measures: VTE Measure Set

Final HIT Incentive Rule Quality Measures: VTE Measure Set

(Link to full report)

Developed by Beth Dibbert and Louis Wenzlow

This is the third in a series of 3 reports describing the final HIT incentive rule’s quality measure requirements. The first two reports summarize the QI measure language in the final rule and describe the ER Throughput and Stroke measure sets. This report focuses on the VTE measure set. Readers are encouraged to submit questions or offer additional information through the comment function.

Venous Thromboembolism (VTE) Measure Set

The 6 VTE process measures describe clinical decision-making and care for three adult inpatient populations: patients who have no VTE, patients who have a principal diagnosis of VTE, and patients who have an “other” diagnosis of VTE.

The measures which apply to the “No VTE” subpopulation focus on prophylaxis (or prevention) of a VTE developing during hospitalization, while the measures for the other 2 sub-populations reflect VTE best practice diagnostic, treatment, and education. As with the other measure sets we have described, population denominators exclusions by measure apply, and we will summarize these for you in the following sections.

Each of the measures applies to either one or two of the sub-populations, and identifying the sub-populations and calculating the correct measures will present unique challenges over and above the challenges associated with the ED Throughput and Stroke measure sets described previously.

All three VTE sub-populations will include the following data elements:

• Admission date
• Birthdate
• Discharge Date

ICD-9- CM Principal and Other Diagnosis Codes will further define a patient’s inclusion into one of the three sub-populations.

1. Measure VTE-1: VTE prophylaxis within 24 hours of arrival (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 admissions or surgery end date for surgeries that start the day of or the day after hospital admission: NQF #0371)

“No-VTE” patients make up the denominator population. The following data elements will be used to exclude patients to create the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay less than 2 days are excluded
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients with Comfort Measures Only documented on day of or day after hospital arrival (Data elements required: procedure performed, problem code, diagnosis code, problem status)
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• Patients who are direct admits to the Intensive Care Unit (ICU), or transferred to the ICU the day of or the day after hospital admission with ICU Length of Stay (LOS) greater than or equal to one day (Data elements required: Facility Location value, Admit date/time, ICU admit date, ICU discharge date).
• Patients with a principal diagnosis of Mental Disorders (Data element: Treatment Location value)
• Patients with a principal diagnosis code of Hemorrhagic or Ischemic Stroke (Data elements: diagnosis code, diagnosis priority)
• Patients with a principal diagnosis code of Obstetrics (Data element: Treatment Location value)
• Patients with a principal diagnosis of VTE (Data element: VTE Confirmed Value Set definitions, diagnosis priority, problem status)

There are two methods of VTE prophylaxis, pharmacological and mechanical, and several types of prophylaxis within each method that are on the list of allowable values. The numerator will not only need to capture which type of prophylaxis was received by the patient, but also if there was documentation of a reason for the patient not receiving one or both types of prophylaxis.

The numerator includes only those patients in the denominator who received VTE prophylaxis within the appropriate timeframe unless there was an acceptable reason documented for not performing VTE prophylaxis. Data elements for numerator capture will include:

• VTE Prophylaxis (Data elements: Medications administered [to be compared to the VTE Prophylaxis Medications Value Set], procedure performed)
• VTE Prophylaxis Hospital Admission (Data elements: Admit date/time, medications administered [to be compared to a medication value set], medication administered date/time, procedure date/time, procedure performed [to be compared to a VTE mechanical device value set])
• VTE Prophylaxis Hospital Admission Surgery (Data elements: Admit Date/Time, Procedure Date/time, medications administered [to be compared to a medication value set], medication administered date/time, procedure performed [to be compared to a VTE mechanical device value set])
• Reasons for No VTE Prophylaxis – Hospital Admission (Data elements: Problem code and diagnoses [to be compared to a value set of reasons for no pharmacological VTE prophylaxis as well as a value set of reasons for no mechanical VTE prophylaxis], problem date/time, admit date/time, procedure declined [which is derived from procedure performed and the VTE application of mechanical device value set and Tense Act Mood Intent and the predetermined value sets for allowable medical and patient reasons].
• Medication Declined (Data elements: Medication administered, value set for VTE prophylaxis medications, Tense Act Mood Intent, and Reason [to be compared to the predetermined value sets for allowable medical and patient reasons])
• Reasons for No VTE Prophylaxis – Hospital Admission Surgery (Data elements: Problem code and diagnoses [to be compared with a value set of reasons for no pharmacological VTE prophylaxis as well as a value set of reasons for no mechanical VTE prophylaxis], problem date/time, diagnosis date/time, admit date/time, procedure end date, procedure start date,
• Procedure declined (which is derived from procedure performed and the VTE application of mechanical device procedure value set and Tense Act Mood Intent and the predetermined value sets for allowable medical and patient reasons)
• VTE Prophylaxis Date (Data elements: medication administration date/time, procedure date/time, medications administered, procedure performed)

Challenges:

1. As with the ED and Stroke measures, some of the required data elements may or may not be discretely located within the electronic medical record (“Medication Declined” or “Reason for no VTE prophylaxis,” for instance). Presumably certified EHR vendors will be required to incorporate the appropriate discrete fields and make the required calculations. However, there may be significant workflow issues involved in entering the required data.
2. As with the ED and Stroke measures, if the medical record is “missing” data element dates or times, the record will be rejected and not able to be calculated successfully. If the record is “unable to determine” data element dates or times, the measure will not be calculable. Both of these scenarios will require a collaborative “drill-down” by the facility and the vendor to determine whether the missing or undeterminable data is a result of workflow, technical, or a combination of causes.
3. As with the ED and Stroke measures, the updates to data definitions have historically been a source of constant vigilance for vendors and hospitals alike. Care will need to be taken that the vendor applies the updates appropriately and in a timely manner. Updates to the value sets will also need to be considered.
4. As with the ED and Stroke measures, without appropriate vendor tools/reports that optimize the use of the data for internal purposes, hospital personnel will find it difficult to apply quality improvement strategies and interventions to improve outcomes.
5. QI Abstractors are used to finding these elements in the “suggested data sources” listed in the national specifications manual. How certified EHRs will capture the many judgments, inferences and nuances that abstractors have been trained to interpret remains an open question.
6. Specific to VTE: this measure re-visits certain data elements throughout the calculations for the numerator. One reason is that the denominator includes both surgical and medical patients. Additionally, it needs to be established whether the patient had no existing contraindications for either one or both types of VTE prophylaxis and then determined whether the patient who had no contraindications received VTE prophylaxis. This is a complexity that will characterize this measure set, and setting the logic checks correctly will be critical to attaining an accurate calculation.
7. Currently the chart-abstracted VTE Core Measure set excludes inpatients with certain surgical procedure codes. The prophylaxis quality measure is reported in the Surgical Care Improvement Project (SCIP) Core Measure Set. The SCIP VTE measures not only measure the proportion of eligible patients who received VTE prophylaxis, but also measures whether the patient received the appropriate prophylaxis. Presumably HITSP does not exclude these patients in order to capture all appropriate surgical patients in the denominator for this MU measure.

2. Measure VTE-2: Intensive Care Unit (ICU) VTE Prophylaxis (This measure assesses the number of patients who received VTE prophylaxis or have documentation that 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): NQF 0372).

“No-VTE” patients make up the denominator population. The following data elements will be used to exclude patients to create the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay less than 2 days are excluded
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients with Comfort Measures Only documented on day of or day after hospital arrival (Data elements required: procedure performed, problem code, diagnosis code, problem status)
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• Patients with ICU Length of Stay (LOS) less than one day without VTE prophylaxis administered and without documentation for no VTE prophylaxis.
• Patients with a principal diagnosis code of Obstetrics (Data element: Treatment Location value)
• Patients with a principal diagnosis of VTE (Data element: VTE Confirmed Value Set definitions, diagnosis priority, problem status)

There are two methods of VTE prophylaxis, pharmacological and mechanical, and several types of prophylaxis within each method that are on the list of allowable values. The numerator will not only need to capture which type of prophylaxis was received by the patient, but also if there was documentation of a reason for the patient not receiving one or both types of prophylaxis.

The numerator includes only those patients in the denominator who received VTE prophylaxis within the appropriate timeframe unless there was an acceptable reason documented for not performing VTE prophylaxis. Data elements for numerator capture will include:

• VTE Prophylaxis (Data elements: Medications administered [to be compared to the VTE Prophylaxis Medications Value Set], procedure performed)
• Reasons for No VTE Prophylaxis-ICU Admission (Data elements: Facility location linked to the value set for VTE Prophylaxis ICU Surgery, Problem code and diagnoses [to be compared to a value set of reasons for no pharmacological VTE prophylaxis as well as a value set of reasons for no mechanical VTE prophylaxis], problem date/time, admit date/time)
• Procedure Declined (VTE Prophylaxis-Mechanical Intervention Procedure Declined) (Data elements: procedure performed [to be compared to Joint Commission VTE Prophylaxis-Application of Mechanical Device Value Set], Tense Act Mood Intent, and Reason [to be compared to the predetermined value sets for allowable medical and patient reasons])
• Medication Declined (VTE Prophylaxis Medications Value Set) (Data elements: Tense Act Mood Intent, and Reason [to be compared to the predetermined value sets for allowable medical and patient reasons])
• Reasons for No VTE Prophylaxis-ICU Surgery (Data elements: Facility location linked to the value set for VTE Prophylaxis ICU Surgery, Problem code and diagnoses [to be compared to the value set of reasons for no pharmacological VTE prophylaxis as well as a value set of reasons for no mechanical VTE prophylaxis], problem date/time, diagnosis date/time, ICU admit date/time, procedure end and start date)
• VTE Prophylaxis Date (Data elements: medication administration date/time, procedure date/time, medications administered [to be compared to the VTE prophylaxis medications value set], procedure performed)
• VTE Prophylaxis – ICU Surgery (Data elements: Facility location linked to the value set for VTE Prophylaxis ICU Surgery, procedure end and start date, VTE Prophylaxis Date/Time [itself a derived data element], ICU Admit Date, ICU Transfer Date)
• VTE Prophylaxis – ICU Admission (Data elements: Facility location linked to the value set for VTE Prophylaxis ICU Surgery, VTE Prophylaxis Date/Time [itself a derived data element], ICU Admit Date, ICU Transfer Date)

Challenges:

1. The same challenges associated with VTE-1 apply.

3. Measure VTE-3: 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. NQF 0373)

For VTE 3, two distinct subpopulations will need to be determined.

• In addition to the general population criteria (Admission date, Birthdate, Discharge Date), sub-population 2 (Principal VTE) inclusions will now add principal code for confirmed VTE.
• Sub population 3 is defined as “Other VTE Only” and will include those patients that have a confirmed VTE as an “other” diagnosis code.
• Additionally, there will be exclusions that will require the identification of patients (1) without warfarin (an anticoagulant drug) therapy during hospitalization, (2) patients without warfarin prescribed at discharge, and (3) patients without VTE confirmed by diagnostic testing.

The following data elements will be used to exclude patients to create the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients with Comfort Measures Only (Data elements required: procedure performed, problem code, diagnosis code, problem status)
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• Warfarin Administration (Data element: medications administered [to be compared to the Warfarin medication value set])
• Warfarin Prescribed at Discharge (Data element: Discharge medication ordered [to be compared to the Warfarin medication value set])
• VTE Diagnostic Test (Data Element: procedure performed [to be compare to the VTE diagnostic test value set])

The numerator statement for this measure will include patients who received warfarin and parenteral anticoagulation:

• Five or more days, with an INR ≥ 2 prior to discontinuation of parenteral therapy OR
• Five or more days, with an INR < 2 and discharged on overlap therapy OR
• Less than five days and were discharged on overlap therapy

The data elements for numerator capture will include:

• INR Value greater than or equal to 2 prior to discontinuing anticoagulation therapy (Data elements: result type [to be compared to a lab result data value set], result value, report date/time, discontinue order date/time, medications [to be compared to an anticoagulant medication value set], discontinue medication)
• INR Value less than 2 prior to discontinuing anticoagulation therapy (Data elements: result type which will be a lab result data value set, result value, report date/time, discontinue order date/time, medications [to be compared to an anticoagulant medication value set], discontinue medication)
• Patients who received warfarin and parenteral anticoagulation greater than or equal to 5 days (data elements: medications administered [to be compared to the anticoagulation VTE medicine value set], medications administered date/time,)
• Patients who received warfarin and parenteral anticoagulation less than 5 days (data elements: medications administered, medications administered date/time,)
• Discharged on Overlap Therapy (data elements: discharge medication [to be compared to the Warfarin medication value set.])

Challenges:

1. Many of the same challenges associated with VTE-1 apply. Unlike VTE-1, there is no requirement to electronically document the reasons a therapy was not prescribed.
2. Additional challenges include the complexity of the derived data calculations and the timeliness of lab results reporting.

4. Measure VTE-4: Platelet monitoring on unfractionated heparin (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.  NQF 0374)

For VTE 4, two distinct subpopulations will need to be determined.

• In addition to the general population criteria (Admission date, Birthdate, Discharge Date), sub-population 2 (Principal VTE) inclusions will now add principal code for confirmed VTE.
• Sub population 3 is defined as “Other VTE Only” will include those patient that have a confirmed VTE as an “other” diagnosis code.
• Additionally, there will be exclusions that will require the identification of patients (1) without IV UFH (an anticoagulant drug) therapy during hospitalization, and (2) patients without VTE confirmed by diagnostic testing.

The following data elements will be used to exclude patients to create the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients with Comfort Measures Only (Data elements required: procedure performed, problem code, diagnosis code, problem status)
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• UFH Therapy Administration (data element: medications administered [to be compared to a value set defining unfractionated heparin])
• VTE Diagnostic Test (Data Element: procedure performed)

The numerator statement for this measure will include patients who have their IV UFH dosages and platelet counts monitored according to defined parameters such as nomogram or protocol:

The data elements for numerator capture will include:

• Monitoring documentation (Data elements: procedure ordered, medication administered [to be compared to a value set defining unfractionated heparin], medication indication [to be compared to a “treatment adjusted by protocol” value set], result type [to be compared to “platelet count laboratory result” value set])

Challenges:

1. Many of the same challenges associated with VTE-1 apply.
2. Hospitals that have not implemented clinical pathway protocols for this or other populations will find themselves at a disadvantage.

5. Measure VTE-5: VTE 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. NQF 0375)

For VTE 5, two distinct subpopulations will need to be determined.

• In addition to the general population criteria (Admission date, Birthdate, Discharge Date), sub-population 2 (Principal VTE) inclusions will now add principal code for confirmed VTE.
• Sub population 3 is defined as “Other VTE Only” will include those patient that have a confirmed VTE as an “other” diagnosis code.

The denominator statement will include the following:

• Patients with confirmed VTE discharged on warfarin therapy
• Patients with confirmed VTE who received warfarin
• Principal Diagnosis Code or Other Diagnosis Code for VTE,
• Discharged to home
• Discharged to home with home health
• Discharged to home hospice

The following data elements will be used to exclude patients to further define the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• Patients without Warfarin Prescribed at Discharge (Data elements: discharge medication ordered [to be compared to the Warfarin Medication value set])
• Patients without VTE confirmed by diagnostic testing (Data element: procedure performed [to be compare to the VTE diagnostic test value set])

There are no numerator exclusions. This is an “all or nothing measure” (i.e. if one element is missing from the discharge instruction set, the measure will not be included in the numerator count).

The data elements for numerator capture will include:

• Discharge Instructions Address Compliance Issues (Data element: discharge instructions)
• Discharge Instructions Address Dietary Advice (Data element: discharge instructions)
• Discharge Instructions Address Follow-up Monitoring (Data element: discharge instructions)
• Discharge Instructions Address Potential for Adverse Drug Reactions and Interactions (Data element: discharge instructions)

Each of these data elements will be compared to a specific discharge instructions value set, as well as a value set for providing material.

Challenges:

1. Many of the same challenges associated with VTE-1 apply.
2. Most hospitals are familiar with the discharge instructions concept, mostly through abstracting the Heart Failure Core Measure set. If the hospital has not participated in the VTE measure set, and has not adopted a standard set of discharge instructions for patients on warfarin, they will be at a disadvantage.
3. Another challenge is that the current Joint Commission VTE core measure set includes patients discharged to law enforcement (discharge status code 21) for this measure. As we stated in the comments on the Stroke measures, abstractors are now instructed to answer “Yes” to the question of whether the patient/caregiver received the instructions if they were refused by the patient.
4. In the current Core Measure specification manual there are 7 data sources listed from which the abstractor can gather information for answering this measure. This is especially helpful when it comes to reconciling medications at discharge. How will this issue of multiple data sources, many of which will not be machine readable, be handled in the meaningful use specification for this measure?

6. Measure VTE-6: Incidence of Potentially Preventable VTE (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. NQF 0376)

This measure will include patients in sub-population 3 (Other VTE Only)

The denominator statement includes patients who developed confirmed VTE during hospitalization.

The following data elements will be used to exclude patients to create the denominator for this measure:

• Patient Age (which is derived from a calculation of Admission Date minus Birthdate. Patients under the age of 18 on admission will be excluded)
• Length of Stay (which is a calculation derived from the Discharge Date minus Admission Date). Patients with a length of stay greater than 120 days are excluded
• Patients with Comfort Measures Only (Data elements required: procedure performed, problem code, diagnosis code, problem status)
• Patients enrolled in a Clinical Trial (Data elements required: problem code, diagnoses, problem status)
• Patients with VTE present on arrival (Data elements: arrival date/time, problem code, problem status)
• Patients with reasons for not administering mechanical and pharmacological VTE prophylaxis (Data elements: Problem code and diagnoses [to be compare with a value set of reasons for no pharmacological VTE prophylaxis as well as a value set of reasons for no mechanical VTE prophylaxis], problem date/time, admit date/time, procedure declined [which is derived from procedure performed and the VTE mechanical device value set and value sets for medical and patient reasons]. There is an additional value set that is included in the calculation of this derived data element: Tense Act Mood Intent, used to try to capture the “reason” that the prophylaxis was not, is not, or will not be indicated for the patient.)
• Patients without VTE confirmed by diagnostic testing (Data element: procedure performed)

The data elements for numerator capture will include:

• VTE Prophylaxis Status (Data element: admit date/time)
• VTE Diagnostic Test Order Date (Data element: procedure ordered, procedure date )
• VTE Prophylaxis Date and Time (Data element: medication administered date/time)
• VTE Prophylaxis (Data element: medications administered [to be compared to a value set for VTE prophylaxis medications], procedure performed)
• Any diagnosis of VTE Confirmed (Data elements: problem status active)

Challenges:

1. The same challenges associated with VTE-1 apply.
2. The HITSP manual appears to have an error, as it includes certain categories of patients in the denominator, which the current Core Measures specification manual excludes. We have assumed this is a typo, and have placed these categories of patients in our exclusion list.
3. This is one of the first measures that hospitals report as a “healthcare-acquired condition.” The pay-for-performance march has started. Everyone on the team: coders, QI leaders, CFOs, IT, and medical staff will rely on accurate information in and out of the medical record to eventually avoid reporting, auditing, and payment consequences for these occurrences. Locations, content, and intent of documentation will be critical. Patients who develop a VTE during hospitalization and did not receive prophylactic treatment may be calculated and reported electronically, but the systems failures that contributed to the condition cannot. Making the actual patient safety improvements—the intended goal of meaningful use—will require humans and teams of stakeholders to connect the dots.