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Measure: CMS68

Documentation of Current Medications in the Medical Record

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS68v11 2022 11.0.000 Documentation of Current Medications in the Medical Record
CMS68v10 2021 10.3.000 Documentation of Current Medications in the Medical Record
CMS68v9 2020 9.1.000 Documentation of Current Medications in the Medical Record
CMS68v8 2019 8.1.000 Documentation of Current Medications in the Medical Record
CMS68v7 2018 7.1.000 Documentation of Current Medications in the Medical Record
CMS68v6 2017 6.1.000 Documentation of Current Medications in the Medical Record

Description

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Guidance

This measure is to be reported for every encounter during the measurement period. Eligible professionals reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. This list must include all prescriptions, over-the-counter (OTC) products, herbals, vitamins, minerals, dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. This measure should also be reported if the eligible professional documented the patient is not currently taking any medications. By reporting the action described in this measure, the provider attests to having documented a list of current medications utilizing all immediate resources available at the time of the encounter.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationAll visits occurring during the 12 month reporting period for patients aged 18 years and older before the start of the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsNone
NumeratorEligible professional attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administrationWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsMedical Reason: Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health statusWebchart Instructions

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS68v6 68 2017 6.1.000 0419 9a032d9c-3d9b-11e1-8634-00237d5bf174
Steward Developer Endorsed By
Quality Insights of Pennsylvania Centers for Medicare & Medicaid Services (CMS) National Quality Forum
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

Higher score indicates better quality

Rationale

Maintaining an accurate and complete medication list has proven to be a challenging documentation endeavor for various health care provider settings. While most of outpatient encounters (2/3) result in providers prescribing at least one medication, hospitals have been the focus of medication safety efforts (Stock et al., 2009). Nassaralla et al. (2007) caution that this is at odds with the current trend, where patients with chronic illnesses are increasingly being treated in the outpatient setting and require careful monitoring of multiple medications. Additionally Nassaralla etal. (2007) reveal that it is in fact in outpatient settings where more fatal adverse drug events (ADE) occur when these are compared to those occurring in hospitals (1 of 131 outpatient deaths compared to 1 in 854 inpatient deaths). In the outpatient setting, adverse drug events (ADEs) occur 25% of the time and over one-third of these are considered preventable (Tache et al., 2011). Particularly vulnerable are patients over 65 years, with evidence suggesting that the rate of ADEs per 10,000 person per year increases with age; 25-44 years old at 1.3; 45-64 at 2.2, and 65 + at 3.8 (Sarkar et al., 2011). Another vulnerable group are chronically ill individuals. These population groups are more likely to experience ADEs and subsequent hospitalization. A multiplicity of providers and inadequate care coordination among them has been identified as barriers to collecting complete and reliable medication records. Documentation of current medications in the medical record facilitates the process of medication review and reconciliation by the provider, which are necessary for reducing ADEs and promoting medication safety. The need for provider to provider coordination regarding medication records, and the existing gap in implementation, is highlighted in the American Medical Association's (AMA) Physician's Role in Medication Reconciliation (2007), which states that "critical patient information, including medical and medication histories, current medications the patient is receiving and taking, and sources of medications, is essential to the delivery of safe medical care. However, interruptions in the continuity of care and information gaps in patient health records are common and significantly affect patient outcomes" (p.7). This is because clinical decisions based on information that is incomplete and/or inaccurate are likely to lead to medication error and ADEs. Weeks et al. (2010) noted similar barriers and identified the utilization of health information technology as an opportunity for facilitating the creation of universal medication lists.

Clinical Recommendation Statement

The Joint Commission's 2015 Ambulatory Care National Patient Safety Goals guide providers to maintain and communicate accurate patient medication information. Specifically, the section "Use Medicines Safely NPSG.03.06.01" states the following: "Maintain and communicate accurate patient medication information. The types of information that clinicians use to reconcile medications include (among others) medication name, dose, frequency, route, and purpose. Organizations should identify the information that needs to be collected to reconcile current and newly ordered medications and to safely prescribe medications in the future." (Joint Commission, 2015, retrieved at: http://www.jointcommission.org/assets/1/6/2015_NPSG_AHC1.PDF).

The National Quality Forum's 2010 update of the Safe Practices for Better Healthcare, states healthcare organizations must develop, reconcile, and communicate an accurate patient medication list throughout the continuum of care (p. 40).

Definition

Current Medications: Medications the patient is presently taking including all prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication's name, dosage, frequency and administered route. Route: Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical).

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1
Procedure, Performed Current Medications Documented SNMD 2.16.840.1.113883.3.600.1.462
Procedure, Performed Medical or Other reason not done 2.16.840.1.113883.3.600.1.1502

References

American Medical Association (2007).  The physician's role in medication reconciliation:  Issues, strategies and safety principles.  Retrieved from https://bcpsqc.ca/documents/2012/09/AMA-The-physician%e2%80%99s-role-in-Medication-Reconciliation.pdf
Stock, R., Scott, J., & Gurtel, S. (2009).  Using an Electronic Prescribing System to Ensure Accurate Medication Lists in a Large Multidisciplinary Medical Group.  The Joint Commission Journal on Quality and Patient Safety; 35(5), 271-277.
Nassaralla, C.L., Naessens, J.M., Chaudhry, R., et al. (2007).  Implementation of a medication reconciliation process in an ambulatory internal medicine clinic.  Quality and Safety in Health Care 2007; (16), 90-94.
Sarkar, U., Lopez, A., Maselli, J.H., Gonzalez, R. (2011). Adverse Drug Events in U.S. Adult Ambulatory Medical Care. Health Services Reserach, 46(5), 1517-1533.
Weeks, D.L., Corbette, C.F., Stream, G. (2010).   Beliefs of Ambulatory Care Physicians about Accuracy of Patient Medication Records and Technology-Enhanced Solutions to Improve Accuracy.  Journal for Healthcare Quality; 32(5), 12-21.
The Joint Commission (2015).  Ambulatory Care National Patient Safety Goals.   Retrieved from  http://www.jointcommission.org/assets/1/6/2015_NPSG_AHC1.PDF
National Quality Forum (2010).  Safe Practices for Better Healthcare - 2010 Update.  Retrieved from http://www.qualityforum.org/Projects/Safe_Practices_2010.aspx
Tache, S.V., Sonnichsen, A., & Ashcroft, D.M. (2011).  Prevalence of Adverse Drug Events in Ambulatory Care: A Systematic Review. The Annals of Pharmacotherapy, 45(7-8), 977-989. doi: 10.1345/aph.1P627.

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 "AS IS" WITHOUT WARRANTY OF ANY KIND.

Copyright

Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

CPT (R) contained in the Measure specifications is copyright 2007- 2016 American Medical Association. 

LOINC (R) copyright 2004-2015 [2.54] Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2015 [2015-09] International Health Terminology Standards Development Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Source: https://ecqi.healthit.gov/ecqm/measures/cms68v6