There are 15 required hospital quality measures but the 2 Emergency Department measures are stratified for reporting and must be presented in 3 different ways, so a total of 19 PQRI XML files need to be generated for Complete EHR Certification of hospital systems.
Each of the files uses identical XML. The only parameters that change are
pqri-measure-number which is set to the NQF measure being submitted such as NQF 0435 (see the graphic above for the list of NQF hospital measure names)
eligible-instances which is the number of patients who meet eligibility requirements to be measured for the time period being submitted
meets-performance-instances which is the numerator of the measure i.e. those patients who had the appropriate treatment or outcome
performance-exclusion-instances which is the number of patients removed from eligible-instances for specific clinical reasons. The denominator of the measures is always (eligible-instances minus performance-exclusion-instances)
performance-not-met-instances which is the number of eligible patients who did not have the appropriate treatment or outcome. It can be calculated as (eligible-instances minus meets-performance-instances minus performance-exclusion-instances)
reporting-rate which is a multiplier i.e. for a percentage the reporting rate is 100
performance-rate which is the calculated performance level and is equal to meets-performance-instances/(eligible-instances minus performance-exclusion-instances)*reporting-rate
Let's do a real example so this becomes clear. If we want to create PQRI XML for NQF Measure 0435, which is "Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge", we need to go the HITSP TN906 document and gather the definition from pages 48-52
In this case,
eligible-instances is defined as "Patients admitted to and discharged from the hospital for inpatient acute care with a diagnosis of ischemic stroke (ICD9 433.00-438.99)"
meets-performance-instances is defined as "eligible-instances patients prescribed anti-thrombotic therapy(page 355-358 of HITSP specification) at hospital discharge"
performance-exclusion-instances is defined as
"Patients with age < 18
Patients with length of stay >120 days
Patients with comfort measures only documented
Patients enrolled in clinical trial
Patients admitted for elective carotid intervention
Patients discharged/transferred to another hospital for inpatient care
Patients who left against medical advice or discontinued care
Patients who expired
Patients discharged/transferred to a federal healthcare facility
Patients discharged/transferred to hospice
Patients with a documented reason for not prescribing anti-thrombotic therapy at discharge"
Suppose that 110 patients are eligible, 80 received anti-thrombotic therapy, and 10 were excluded.
performance-not-met-instances would be (eligible-instances minus meets-performance-instances minus performance-exclusion-instances) or 110-80-10=20
performance-rate would be meets-performance-instances/(eligible-instances minus performance-exclusion-instances)*reporting-rate or 80/(110-10)*100 = 80%
The PQRI XML generated would be
<submission xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:noNamespaceSchemaLocation="Registry_Payment.xsd" type="PQRI-REGISTRY" option="TEST" version="1.0"> <file-audit-data> <create-date>31-01-2011</create-date> <create-time>04:22</create-time> <create-by>Your Organization Name Goes Here</create-by> <version>1.0</version> <file-number>1</file-number> <number-of-files>1</number-of-files> </file-audit-data> <registry> <registry-name>Your Application Name Goes Here</registry-name> <registry-id>123456</registry-id> <submission-method>C</submission-method> </registry> <measure-group ID="X"> <provider> <npi>1111111112</npi> <tin>123456</tin> <waiver-signed>Y</waiver-signed> <encounter-from-date>2010-01-01T00:00:00</encounter-from-date> <encounter-to-date>2010-12-31T00:00:00</encounter-to-date> <pqri-measure> <pqri-measure-number>NQF 0435</pqri-measure-number> <eligible-instances>110</eligible-instances> <meets-performance-instances>80</meets-performance-instances> <performance-exclusion-instances>10</performance-exclusion-instances> <performance-not-met-instances>20</performance-not-met-instances> <reporting-rate>100.00</reporting-rate> <performance-rate>80</performance-rate> </pqri-measure> </provider> </measure-group> </submission>
For the ED measures, which capture time measurement rather than patient counts, you need to create 3 files for each measure, stratified by
1. All patients that were admitted via the ED, excluding the ICD-9 range for PSYCH (ICD9 290-319) and Observation Patients.
2. All observation patients that were admitted via the ED, excluding the ICD-9 range for PSYCH (ICD9 290-319)
3. All psychiatric patients that were admitted via the ED, including only the ICD-9 range for PSYCH (ICD9 290-319)
eligible-instances is recorded in the same way as other measures.
meets-performance-instances is used to record the median time data.
performance-exclusion-instances, performance-not-met-instances, reporting-rate, and performance-rate are set to zero.
Hopefully this explanation makes it easier for hospitals and vendors to create the necessary PQRI XML for certification.