eCQM Title | ASCP Grant Measure 7 - Rate of Communicating Results of an Amended Report with a Major Discrepancy to the Responsible Provider |
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eCQM Identifier (Measure Authoring Tool) | 984 | eCQM Version Number | 0.0.026 |
NQF Number | Not Applicable | GUID | 39cf05a9-a4c4-475c-ae9d-4e6365662768 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | IMPAQ International | ||
Measure Developer | IMPAQ International | ||
Endorsed By | None | ||
Description |
Number of amended reports due to a major diagnostic discrepancy and communication of the discrepancy from the pathologist to the responsible provider was made within 3 days from when the amended reports' diagnostic results were documented. |
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Copyright |
This appropriate utilization measure was developed through consensus of an ASCP technical expert panel and vetted through a formal review process by all medical specialties participating in the ABIM's Choosing Wisely Campaign. Additionally, it is based on published Choosing Wisely recommendations. Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. IMPAQ disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2018 American Medical Association. LOINC(R) is copyright 2004-2018 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2018 International Health Terminology Standards Development Organization. ICD-10 is copyright 2018 World Health Organization. All Rights Reserved. |
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Disclaimer |
This measure and specifications are subject to further revisions. The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. |
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Measure Scoring | Proportion | ||
Measure Type | Process | ||
Stratification |
None |
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Risk Adjustment |
None |
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Rate Aggregation |
None |
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Rationale |
If a major diagnostic discrepancy is found after sign-out, pathology reports should be amended to reflect the correct diagnosis. If the ordering provider is not made aware of a change in diagnosis, there could be serious negative consequences for the patient. Just because a report is amended in the laboratory information system, does not ensure the responsible provider is made aware of this change. This measure helps to prevent the potential harm of an ordering provider not knowing about a change in diagnosis, with potential downstream negative outcomes for the patient. |
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Clinical Recommendation Statement |
Amendments to reports that would significantly affect patient care should be reported promptly to the responsible clinician. Records of notification should include date and person notified, and preferably appear in the amended report along with a record of what was changed in the initial report. Periodic evaluation of amended reports is commonly included as part of a laboratory’s quality management program. Records of date of communication of significant/unexpected findings are required for compliance with certification of the laboratory. Laboratory medicine is a highly-structured field, for which the accuracy and safety of diagnostic reports have continuously been evaluated and regulated for the last several decades. To provide diagnostic information to clinicians, pathologists utilize an abundance of diagnostic tools to form a diagnosis, such as electronic medical records, diagnostic imaging, submission of additional histologic levels, specialized immunohistochemical and molecular studies, access to prior related specimen slides, and submission of additional tissue. After a diagnosis is rendered using these tools, re-evaluation of case material by various QA measurements often occurs. These QA strategies are employed by practicing laboratories, not only as a means of decreasing diagnostic error, but also to meet regulatory guidelines for accreditation. Secondary case review has been built into some pathology quality assurance practices (e.g., review of a set percentage of cases, intradepartmental ‘‘difficult case’’ conferences, cytologic-histologic correlation, or review of all malignancies). Secondary case review also occurs in hospital patient-centered conferences (e.g., tumor board); external consultation practices; or at the behest of clinicians, who may initiate communication when the pathology report does not correlate with the clinical findings. An error detected by one of these processes may be referred to as a discrepancy or a difference in interpretation or reporting between two pathologists. Error detection rates based on the different methods of secondary review have been variably studied. 1. Rosai J, Bonfiglio TA, Corson JM, et al. Standardization of the surgical pathology report. Mod Pathol.1992 Mar;5(2):197-9 2. Zarbo RJ, Nakhleh RE, Walsh M; Quality Practices Committee, College of American Pathologists. Customer satisfaction in anatomic pathology. A College of American Pathologists Q-Probes study of 3065 physician surveys from 94 laboratories. Arch Pathol Lab Med. 2003 Jan;127(1):23-9 3. Silverman JF, Pereira TC. Critical values in anatomic pathology. Arch Pathol Lab Med. 2006;130:638-640 4. LiVolsi VA. Critical values in anatomic pathology; how do we communicate? Am J Clin Pathol 204;122:171-172 5. Allen TC. Critical Values in anatomic pathology? Arch Pathol Lab Med 2007;131:684-68 6. Pereira TC, Liu Y, Silverman JF. Critical Values in surgical pathology. Am J Clin Pathol 2004;122:201-205 7. Association of Directors of Anatomic and Surgical Pathology. Critical diagnosis (critical values) in anatomic pathology. Am J Surg Pathol 2006;30:897-899 8. Nakhleh RE, Souers R, Brown RW. Significant and Unexpected Diagnoses in Surgical Pathology: A College of American Pathologists Survey of 1130 Laboratories. Arch Pathol Lab Med. 2009; 133;1375-1378. 9. Sarewitz SJ, Williams RB. Significant and Unexpected versus Critical Results in Surgical Pathology. Editorial. Arch Pathol Lab Med. 2009; 133:1366. |
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Improvement Notation |
A higher rate indicates better quality. |
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Reference |
Rosai J, Bonfiglio TA, Corson JM, et al. Standardization of the surgical pathology report. Mod Pathol.1992 Mar;5(2):197-9 |
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Reference |
Zarbo RJ, Nakhleh RE, Walsh M; Quality Practices Committee, College of American Pathologists. Customer satisfaction in anatomic pathology. A College of American Pathologists Q-Probes study of 3065 physician surveys from 94 laboratories. Arch Pathol Lab Med. 2003 Jan;127(1):23-9 |
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Reference |
Silverman JF, Pereira TC. Critical values in anatomic pathology. Arch Pathol Lab Med. 2006;130:638-640 |
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Reference |
LiVolsi VA. Critical values in anatomic pathology; how do we communicate? Am J Clin Pathol 204;122:171-172 |
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Reference |
Allen TC. Critical Values in anatomic pathology? Arch Pathol Lab Med 2007;131:684-68 |
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Reference |
Pereira TC, Liu Y, Silverman JF. Critical Values in surgical pathology. Am J Clin Pathol 2004;122:201-205 |
||
Reference |
Association of Directors of Anatomic and Surgical Pathology. Critical diagnosis (critical values) in anatomic pathology. Am J Surg Pathol 2006;30:897-899 |
||
Reference |
Nakhleh RE, Souers R, Brown RW. Significant and Unexpected Diagnoses in Surgical Pathology: A College of American Pathologists Survey of 1130 Laboratories. Arch Pathol Lab Med. 2009; 133;1375-1378 |
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Reference |
Sarewitz SJ, Williams RB. Significant and Unexpected versus Critical Results in Surgical Pathology. Editorial. Arch Pathol Lab Med. 2009; 133:1366. |
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Definition |
A major diagnostic discrepancy is defined as one causing potential major harm to/impact on patient care. Examples of major discrepancies are; missed malignancy, over-diagnosis of malignancy and/or high-grade dysplasia, and misclassification of malignancy or margin status. A minor diagnostic discrepancy is defined as a potential minor harm to/impact on patient care. Examples of minor discrepancies are; misclassification of a colon polyp resulting in change in follow-up, basal cell versus squamous cell carcinoma, Gleason grade/extent of prostate cancer not resulting in change in treatment. Communication is defined as a documented notification from the pathologist to the responsible provider. The notification can take many forms, e.g., telephone, or secure electronic transmission such as text messaging, Electronic Health Records systems, or email with read receipt functionality. Best practice is to document the communication modality, the date and time the communication was sent, to whom the communication was sent, and if the communication was received. The responsible provider is identified by each pathology team based on their own clinical care and communication protocols. |
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Guidance |
This is an episode-based measure, meaning there may be more than one reportable event for a given patient during the measurement year. The level of analysis for this measure is each amended report due to a major diagnostic discrepancy during the measurement year, including instances where there are more than one amended reports during the measurement year. Only amended reports that are completed 3 days or more before the end of the measurement year will be considered for the measure, in order to determine if the communication of the amended report occurs within 3 days and before the end of the measurement year. This measure specification defines how to determine if the communication of the discrepancy from the pathologist to the responsible provider was made within 3 days from when the amended reports' diagnostic results were documented, by calculating the time interval between the amended report authored date and time and the communication sent date and time. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM. |
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Transmission Format |
TBD |
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Initial Population |
Number of amended reports due to a major diagnostic discrepancy during the measurement year. |
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Denominator |
Equals Initial Population |
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Denominator Exclusions |
None |
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Numerator |
Number of amended reports due to a major diagnostic discrepancy and communication of the discrepancy from the pathologist to the responsible provider was made within 3 days from when the amended reports' diagnostic results were documented. |
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Numerator Exclusions |
None |
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Denominator Exceptions |
None |
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Supplemental Data Elements |
For every patient evaluated by this measure also identify payer, race, ethnicity and sex |
"Amended Pathology Reports"
"Initial Population"
None
"Communication of Amended Pathology Reports Within 3 Days"
None
None
None
["Procedure, Performed": "Amended Reports"] Amendment where Amendment.authorDatetime during "Measurement Period" and Amendment.authorDatetime 3 days or more before end of "Measurement Period" and Amendment.result in "New Malignancy"
"Amended Pathology Reports" AmendedReport with "Communication to Provider" Communication such that Communication.sentDatetime 3 days or less after AmendedReport.authorDatetime and Communication.sentDatetime during "Measurement Period" and AmendedReport.id in Communication.relatedTo
["Communication, Performed": "Lab Communications"] Communication with "Amended Pathology Reports" AmendedReport such that AmendedReport.id in Communication.relatedTo
"Initial Population"
"Amended Pathology Reports"
"Communication of Amended Pathology Reports Within 3 Days"
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
["Patient Characteristic Ethnicity": "Ethnicity"]
["Patient Characteristic Payer": "Payer"]
["Patient Characteristic Race": "Race"]
["Patient Characteristic Sex": "ONC Administrative Sex"]
Measure Set |
Pathology |
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