eCQM Title | ASCP Grant Measure 6 - Rate of Notification to the Responsible Provider of a New Diagnosis of Malignancy within 5 Days of Pathology Report |
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eCQM Identifier (Measure Authoring Tool) | 981 | eCQM Version Number | 0.0.016 |
NQF Number | Not Applicable | GUID | 93ea4277-818f-4f97-8281-dca9783725b3 |
Measurement Period | January 1, 20XX through December 31, 20XX | ||
Measure Steward | IMPAQ International | ||
Measure Developer | IMPAQ International | ||
Endorsed By | None | ||
Description |
Percentage of pathology reports for patients with a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin), and communication of the diagnosis from the pathologist to the responsible provider was made within 5 days of finalization of the report. |
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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, and 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, 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 |
The diagnosis of a new malignancy has a significant impact on patient care, and is considered to be a "critical value" by most pathology laboratories. Just because a report is finalized in the laboratory information system does not ensure the responsible clinical provider receives the diagnosis in a timely fashion (or at all). Pathologists often notify the responsible provider through other means in addition the standard electronic reporting. This measure helps to avoid preventable harm by closing the loop on communicating a significant diagnosis that likely has a significant impact on patient treatment and outcomes. |
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Clinical Recommendation Statement |
None |
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Improvement Notation |
A higher rate indicates better quality. |
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Reference |
Al-Maghrabi JA, Sayadi HH. The importance of second opinion in surgical pathology referral material of lymphoma. Saudi Med J. 2012;33(4):399–405. |
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Reference |
Eskander RN, Baruah J, Nayak R, et al. Outside slide review in gynecologic oncology: impact on patient care and treatment. Int J Gynecol Pathol. 2013;32(3):293–8. |
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Reference |
Fajardo DA, Miyamoto H, Miller JS, Lee TK, Epstein JI. Identification of Gleason pattern 5 on prostatic needle core biopsy: frequency of underdiagnosis and relation to morphology. Am J Surg Pathol. 2011;35(11):1706–11. |
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Reference |
Finkelstein A, Levy GH, Cohen P, Domfeh A, Parkash V. Addenda in pathology reports: trends and their implications. Am J Clin Pathol. 2012;137(4):606–11. |
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Reference |
Frable WJ. Surgical pathology-second reviews, institutional reviews, audits, and correlations: what’s out there? Error or diagnostic variation? Arch Pathol Lab Med. 2006;130:620–5. |
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Reference |
Gupta R, McKenna R Jr, Marchevsky AM. Lessons learned from mistakes and deferrals in the frozen section diagnosis of bronchioloalveolar carcinoma and well-differentiated pulmonary adenocarcinoma. Am J Clin Pathol. 2008;130(1):11–20. |
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Reference |
Jain, RK, Mehta R, Dimitrov R, et al. Atypical ductal hyperplasia: interobserver and intraobserver variability. Mod Pathol. 2011;24:917–23. |
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Reference |
Manion, E, Cohen MB, Weydert J. Mandatory second opinion in surgical pathology referral material: clinical consequences of major disagreements. Am J Surg Pathol. 2008;32(5):732–7. |
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Reference |
Stephen S. Raab, MD; Raouf E. Nakhleh, MD; Stephen G. Ruby, MD, Patient Safety in Anatomic Pathology: Measuring Discrepancy Frequencies and Causes, Arch Pathol Lab Med—Vol 129, April 2005. |
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Reference |
Nakhleh RE, Myers JL, Allen TC, DeYoung BR, Fitzgibbons PL, Funkhouser WK, Mody DR, Lynn A, Fatheree LA, Smith AT, Lal A, Silverman JF. Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2012 Apr;136(4):342. |
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Reference |
Raouf E. Nakhleh, Rhona Souers, and Richard W. Brown (2009) Significant and Unexpected, and Critical Diagnoses in Surgical Pathology: A College of American Pathologists' Survey of 1130 Laboratories. Archives of Pathology & Laboratory Medicine: September 2009, Vol. 133, No. 9, pp. 1375-1378. |
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Reference |
Lundberg GD. When to panic over an abnormal value. MLO Med Lab Obs. 1972;4:47-54. |
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Reference |
Emancipator K. Critical values: ASCP practice parameter. Am J Clin Pathol. 1997;108:247-253. |
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Reference |
Clinical Laboratory Improvement Amendments of 1988. Final rule (42 CFR Part 405, et al). 57 Federal Register 7001-7186 (1992). |
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Reference |
Code of Federal Regulations. Title 42 CFR Parts 493 to end. Washington, DC: US Government Printing Office; 1998. 5. National Patient Safety Goals. Oak Brook, IL: Joint Commission on Accreditation of Healthcare Organizations. 2006. Available at http://www.jointcommission.org/Patient Safety/NationalPatientSafetyGoals/. Accessed April 19, 2006. |
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Reference |
College of American Pathologists. Laboratory Accreditation Program Inspection Checklists. 2005:48. Available at http://www.cap.org/apps/docs/laboratory_accreditation/checklist s/laboratory_general_october2005.pdf. Accessed April 19, 2006. |
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Reference |
College of American Pathologists. Laboratory Accreditation Program Inspection Checklists. 2005:28. Available at http://www.cap.org/apps/docs/laboratory_accreditation/checklists/laboratory_general_october2005.pdf. Accessed April 19, 2006. |
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Reference |
Lum G. Critical limits (alert values) for physician notification: universal or medical center specific limits? Ann Clin Lab Sci. 1998;28:261-271. |
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Reference |
Kost GJ. Critical limits for urgent clinician notification at US medical centers. JAMA. 1990;263:704-707. |
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Reference |
Fine RH. Laboratory critical limits [letter]. JAMA. 1990;264:335 |
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Reference |
Kaufman HW, Collins C. Notifying clients of life-threatening results. MLO Med Lab Obs. 1994;26:44-45. |
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Reference |
Lundberg GD. Panic values: five years later. MLO Med Lab Obs. 1977;9:27-34. |
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Reference |
Kost GJ. Using critical limits to improve patient outcome. MLO Med Lab Obs. 1993;25:22-27. |
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Reference |
http://www.adasp.org/News/Guideline-on-Effective-Communication-of-Urgent-Diagnoses-Posted-to-AHRQ-National-Guidelines-Clearin.html |
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Definition |
Communication is defined as a documented notification from the pathologist or laboratory personnel 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 period. The level of analysis for this measure is each pathology report with a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) from that specimen during the measurement period, including instances where more than one pathology specimen was evaluated during the measurement period. Every pathology report with a new diagnosis of malignancy during the measurement period should be counted as a measurable denominator event for the measure calculation. This measure specification defines how to determine if the diagnosis of malignancy is reported to the responsible provider is within 5 day of the completion of the pathology report, by calculating the time interval between the "Malignancy Pathology Report" authored date and time and the "Communication to Provider" 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 pathology reports for patients with a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin) 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 pathology reports for patients with a new diagnosis of malignancy (other than squamous or basal cell carcinoma of the skin), and communication of the diagnosis from the pathologist to the responsible provider was made within 5 days of finalization of the report. |
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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 |
"Malignancy Pathology Reports"
"Initial Population"
None
"Communication of Malignancy Pathology Reports Within 5 Days"
None
None
None
"Malignancy Pathology Reports" PathReport with "Communication to Provider" Communication such that Communication.sentDatetime 5 days or less after PathReport.authorDatetime and Communication.sentDatetime during "Measurement Period" and PathReport.id in Communication.relatedTo
["Communication, Performed": "Lab Communications"] Communication with "Malignancy Pathology Reports" MalignancyReports such that MalignancyReports.id in Communication.relatedTo
"Initial Population"
"Malignancy Pathology Reports"
["Procedure, Performed": "Pathology Reports"] PathReport where PathReport.authorDatetime during "Measurement Period" and PathReport.result in "New Malignancy"
"Communication of Malignancy Pathology Reports Within 5 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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