CQM Value Set Challenges in MU Stage 2

I cannot take credit for finding this issue.  One of the teams I work with discovered this particular challenge in working with the value sets for clinical quality measures.

It seems that several value sets in the Clinical Quality Measures have been used to identify appropriate medications for treatment, but have also been reused to identify patient allergies.

What is worrisome about this is how it impacts reporting.  Think this through:

I cannot take credit for finding this issue.  One of the teams I work with discovered this particular challenge in working with the value sets for clinical quality measures.

It seems that several value sets in the Clinical Quality Measures have been used to identify appropriate medications for treatment, but have also been reused to identify patient allergies.

What is worrisome about this is how it impacts reporting.  Think this through:

  • A  patient has been seen by a provider in the last year.  That makes them part of an initial population for a measure.
  • They've been diagnosed with a particular disease.  That would make them appear in the denominator.  
  • If they've been given a particular medication formulation, they also fall into the numerator.
  • The measure makes allowances for patients who are allergic to the treatment regimen.  But in the implementation, the measure exclusion or exception criteria REUSES the medication value set as a value set describing a medication allergy.

This is where the problem shows up, and it has two consequences.

  1. In the EHR, the substance that the patient is allergic to is recorded, not a specific medication formulation.  
  2. In reporting exceptions / exclusions, the EHR would report the substance, but this wouldn't match what the conformance tools check for, so the EHR would need to implement a work-around.

Formulation vs. Allergen

You cannot go from medication formulations to allergens and still preserve the meaning of the value set.  Unfortunately, the value set for treatment only lists drug formulations.  It doesn't explain which ingredients are relevant for treatment in the quality measure.  

While it is quite possible to go from formulations to active ingredients in RxNORM, and also possible to match medication allergens encoded in RxNORM to drugs that contain that active ingredient, it doesn't help.  All that does is identify one or medications in the treatment value set as being one the patient shouldn't be given.  It doesn't necessarily tell you whether there are other acceptable alternatives, nor whether there is an intention to provide an exception or exclusion if those alternatives are available.

Some formulations have two (or more) active ingredients, one of which could be the reason it is included in a value set for treatment of a particular condition, yet the patient could be allergic to another of the ingredients.  So, you'd avoid that formulation for treatment, but it wouldn't excuse the provider from finding another formulation that did contain the necessary ingredient for treatment, but didn't contain the allergen.

In other cases, related drugs are similar enough that if a patient is intolerant of one, it is sufficient to rule out others (e.g., an allergy to penicillin might also rule out amoxicillin).

Work-Arounds

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