Dimensional Warehouse Model Data Model

Entity

Entity Core Measures

Description	Measures for Inpatient Hospital Data and Outpatient Hospital Data required by CMS (Center for Medicare and Services) and TJC (The Joint Commission)
Abbreviation	Core_Measures

Attributes
AMI 1 Aspirin At Arrival
AMI 2 Aspirin Prescribed At Discharge
AMI 3 AMI LVSD Prescribed ACEI Or ARB At Discharge
AMI 5 Beta-Blocker Prescribed At Discharge
AMI 7 Median Time To Fibrinolysis For AMI
AMI 8 Median Time To PCI For AMI
CAC 1 Relievers For Inpatient Asthma
CAC 2 Systemic Corticosteroids For Inpatient Asthma
CAC 3 HMPC Document Given To Patient/Caregiver
Calendar Dk
CLABSI Central Line Associated Bloodstream Infection
Data Accuracy And Completeness Acknowledgement
ED 1 Median Time From ED Arrival To Departure
ED 2: Admit Decision Time To ED Departure Time
Encounter Dk
HBIPS 1 Admission Screening
HBIPS 2 Physical Restraint
HBIPS 3 Seclusion
HBIPS 4 Multiple Antipsychotic Medications At Discharge
HBIPS 5 Antipsychotic Medications At Discharge With Justification
HBIPS 6 Post Discharge Continuing Care Plan
HBIPS 7 Post Discharge Continuing Care Plan Transmitted
HCAHPS Hospital Consumer Assessment
HF 1 Discharge Instructions
HF 2 Evaluation Of LVS Function
HF 3 ACEI Or ARB For LVSD
IMM 1 Pneumococcal Immunization
IMM 2 Influenza Immunization
OP 10 Abdomen CT- Use Of Contrast Material
OP 11 Thorax CT - Use Of Contrast Material
OP 12 HIT To Receive Lab Data Directly Into EHR System
OP 13 Cardiac Imaging Risk Assessment Non Cardiac Surgery
OP 14 Simultaneous Use Of Brain CT And Sinus CT
OP 15 Use Of Brain CT In ED For Traumatic Headache
OP 16 Troponin Results For ED AMI Within 1 Hour Of Arrival
OP 17 Tracking Clinical Results Between Visits
OP 18 Median Time From ED Arrival To ED Departure
OP 19 Transition Record Received By Discharged Patients
OP 1 Median Time To Fibrinolysis
OP 20 Door To Diagnostic Evaluation By Qualified Professional
OP 21 Median Time To Pain Management For Long Bone Fracture
OP 22 Patients Left Without Being Seen
OP 23 ED Head CT Scan For Stroke
OP 2 Fibrinolytic Therapy Within 30 Min Of ED Arrival
OP 3 Median Time To Transfer Acute Coronary Intervention
OP 4 Aspirin At Arrival
OP 5 Median Time To ECG
OP 6 Timing Of Antibiotic Prophylaxis
OP 7 Prophylactic Antibiotic Selection For Surgical Patients
OP 8 MRI Lumbar Spine For Low Back Pain
OP 9 Mammography Follow-Up Rates
Participation In A Registry For General Surgery
Participation In Registry For Nursing Sensitive Care
Participation In Registry For Stroke Care
Participation In Systematic Database For Cardiac Surgery
Patient Dk
PC 01 Elective Delivery
PC 02 Cesarean Section
PC 03 Antenatal Steroids
PC 04 Associated Bloodstream Infections In Newborns
PC 05 Exclusive Breast Milk Feeding
PN 3a Blood Culture Within 24 Hrs Of Arrival
PN 3b Blood Culture In ED Prior To Initial Antibiotic
PN 6 Initial Antibiotic For Cap Immunocompetent Patients
Practitioner Dk
Provider Dk
SCIP Card 2 Beta Blocker During Perioperative Period
SCIP INF 10 Perioperative Temperature Management
SCIP INF 1 Prophylactic Antibiotic 1 Hour Prior To Incision
SCIP INF 2 Prophylactic Antibiotic Selection For Surgical Patients
SCIP INF 3 Prophylactic Antibiotics Discontinued In 24 Hours
SCIP INF 4 Cardiac With Controlled Postoperative Blood Glucose
SCIP INF 6 Surgery Patients With Appropriate Hair Removal
SCIP INF 9 Urinary Catheter Removed In 2 Days Of Surgery
SCIP VTE 1 Surgery Patients With VTE Prophylaxis Ordered
SCIP VTE 2 Appropriate VTE Prophylaxis Prior To Surgery
SSI Surgical Site Infection
STK 10 Assessed For Rehabilitation
STK 1 VTE Prophylaxis
STK 2 Discharged On Antithrombotic Therapy
STK 3 Anticoagulation Therapy
STK 4 Thrombolytic Therapy
STK 5 Antithrombotic Therapy By End Of Hospital
STK 6 Discharged On Statin Medication
STK 8 Stroke Education
SUB 1 Alcohol Use Screening
SUB 2 Alcohol Use Brief Intervention
SUB 3 Alcohol And Drug Use Treatment At Discharge
SUB 4 Alcohol And Drug Use Status After Discharge
TOB 1 Tobacco Use Screening
TOB 2 Tobacco Use Treatment Provided Or Offered
TOB 3 Tobacco Use Treatment At Discharge
TOB 4 Tobacco Use Assessing Status After Discharge
VTE 1 VTE Prophylaxis
VTE 2 ICU VTE Prophylaxis
VTE 3 VTE Patients With Anticoagulation Overlap Therapy
VTE 4 VTE Heparin With Dosages Platelet Count Monitoring
VTE 5 VTE Discharge Instructions
VTE 6 Incidence Of Potentially Preventable VTE

Relationship
Core Measures_Provider Dimension_FK
Core Measures_Calendar Dimension_FK
Core Measures_Patient Dimension_FK
Core Measures_Practitioner Dimension_FK
Core Measures_Encounter Dimension_FK

Primary Key
Core Measures PK

Dependencies
NONE

Reverse Dependencies

Attribute Details

AMI 1 Aspirin At Arrival

Label	AMI 1
Description	Acute myocardial Infarction (AMI) patients who received aspirin within 24 hours before or after hospital arrival.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

AMI 2 Aspirin Prescribed At Discharge

Label	AMI 2
Description	Acute myocardial Infarction (AMI) patients who are prescribed aspirin at hospital discharge
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

AMI 3 AMI LVSD Prescribed ACEI Or ARB At Discharge

Label	AMI 3
Description	Acute myocardial Infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

AMI 5 Beta-Blocker Prescribed At Discharge

Label	AMI 5
Description	Acute myocardial Infarction (AMI) patients who are prescribed a beta-blocker at hospital discharge
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

AMI 7 Median Time To Fibrinolysis For AMI

Label	AMI 7
Description	Median time from arrival to administration of fibrinolytic therapy in acute myocardial Infarction (AMI) patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

AMI 8 Median Time To PCI For AMI

Label	AMI 8
Description	Median time from hospital arrival to primary percutaneous coronary intervention (PCI) in acute myocardial Infarction (AMI) patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

CAC 1 Relievers For Inpatient Asthma

Label	CAC 1a
Description	Use of relievers in pediatric patients admitted for inpatient treatment of asthma. - (age 2 ‐ 17 years)
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

CAC 2 Systemic Corticosteroids For Inpatient Asthma

Label	CAC 2a
Description	Use of relievers in pediatric patients admitted for inpatient treatment of asthma. - (age 2 ‐ 17 years)
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

CAC 3 HMPC Document Given To Patient/Caregiver

Label	CAC 3
Description	An assessment that there is documentation in the medical record that a Home Management Plan of Care (HMPC) document was given to the pediatric asthma patient/caregiver.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Calendar Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

CLABSI Central Line Associated Bloodstream Infection

Label	CLABSI
Description	CLABSI are bloodstream Infections in patients that had a central line in place within 48 hours before the development of the Infection. Central line Infections are important because they are the most common bloodstream Infections and can harm patients. CLABSI are also reasonably preventable with proper care of patients' central lines. Rate =(number of line Infections)/(number of central line days)
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Data Accuracy And Completeness Acknowledgement

Label	ACCURACY
Description	Hospitals acknowledge that all Information Submitted for the Hospital IQR Program is complete and accurate to the best of their knowledge at the time of submission.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

ED 1 Median Time From ED Arrival To Departure

Label	ED 1a
Description	Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department- Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

ED 2: Admit Decision Time To ED Departure Time

Label	ED 2
Description	Median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status – Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Encounter Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

HBIPS 1 Admission Screening

Label	HBIPS 1a
Description	Patients admitted to a hospital-based inpatient psychiatric setting who are screened within the first three days of admission for all of the following: risk of violence to self or others, Substance use, psychological trauma history and patient strengths.-Admission Screening‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 2 Physical Restraint

Label	HBIPS 2a
Description	The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.-Physical Restraint‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 3 Seclusion

Label	HBIPS 3a
Description	The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.-Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 4 Multiple Antipsychotic Medications At Discharge

Label	HBIPS 4a
Description	Patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications. -Multiple Antipsychotic Medications at Discharge‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 5 Antipsychotic Medications At Discharge With Justification

Label	HBIPS 5a
Description	Patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification. - Multiple Antipsychotic Medications at Discharge with Appropriate Justification‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 6 Post Discharge Continuing Care Plan

Label	HBIPS 6a
Description	Patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan created. - Post Discharge Continuing Care Plan‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HBIPS 7 Post Discharge Continuing Care Plan Transmitted

Label	HBIPS 7a
Description	Patients discharged from a hospital-based inpatient psychiatric setting with a continuing care plan provided to the next level of care clinician or entity. Post Discharge Continuing Care Plan Transmitted‐ Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HCAHPS Hospital Consumer Assessment

Label	HCAHPS
Description	Hospital Consumer Assessment of Healthcare Providers and Systems Survey
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HF 1 Discharge Instructions

Label	HF 1
Description	Heart failure patients discharged home with written instructions or educational material given to patient or caregiver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HF 2 Evaluation Of LVS Function

Label	HF 2
Description	Heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

HF 3 ACEI Or ARB For LVSD

Label	HF 3
Description	Heart failure patients with left ventricular systolic dysfunction (LVSD) who are prescribed an ACEI or ARB at hospital discharge. For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

IMM 1 Pneumococcal Immunization

Label	IMM 1
Description	This prevention measure addresses acute care hospitalized inpatients 65 years of age and older (IMM-1b) AND inpatients aged between 6 and 64 years (IMM-1c) who are considered high risk and were screened for receipt of 23-valent Pneumococcal polysaccharide vaccine (PPV23) and were vaccinated prior to discharge if indicated. The numerator captures two activities; screening and the intervention of vaccine administration when indicated. As a result, patients who had documented contraindications to PPV23, patients who were offered and declined PPV23 and patients who received PPV23 anytime in the past are captured as numerator events.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

IMM 2 Influenza Immunization

Label	IMM 2
Description	This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal Influenza Immunization status and were vaccinated prior to discharge if indicated. The numerator captures two activities: screening and the intervention of vaccine administration when indicated. As a result, patients who had documented contraindications to the vaccine, patients who were offered and declined the vaccine and patients who received the vaccine during the current year's Influenza season but prior to the current hospitalization are captured as numerator events.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 10 Abdomen CT- Use Of Contrast Material

Label	OP 10
Description	This measure calculates the percentage of abdomen studies that are performed with and without contrast out of all abdomen studies performed (those with contrast, those without contrast, and those with both). The measure is calculated based on a one-year window of claims data.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 11 Thorax CT - Use Of Contrast Material

Label	OP 11
Description	This measure calculates the percentage of thorax studies that are performed with and without contrast out of all thorax studies performed (those with contrast, those without contrast, and those with both). The measure is calculated based on a one year window of claims data.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 12 HIT To Receive Lab Data Directly Into EHR System

Label	OP 12
Description	Documents the extent to which a provider uses an Office of the National Coordinator for Health Information Technology (ONC) certified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data in the EHR as discrete searchable data elements. This measure applies to all outpatient departments associated with the facility that bill under the Outpatient Prospective Payment System (OPPS). This may include the emergency department (ED), the outpatient imaging department, the outpatient surgery department, and the facility's clinics. Measure ascertains response to the following question(s): Does/did your facility have the ability to receive laboratory data electronically directly into your ONC certified EHR system as discrete searchable data? Yes/No. Did your facility use this feature during the performance period? Yes/No
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 13 Cardiac Imaging Risk Assessment Non Cardiac Surgery

Label	OP 13
Description	This measure calculates the percentage of Stress Echocardiography, SPECT MPI (Single Photon Emission Computed tomography Myocardial Perfusion Imaging) or Stress MRI (Magnetic Resonance Imaging) studies performed at a hospital outpatient facility in the 30 days prior to an ambulatory low-risk, non-cardiac surgery performed anywhere.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 14 Simultaneous Use Of Brain CT And Sinus CT

Label	OP 14
Description	This measure calculates the percentage of Brain CT studies with a simultaneous Sinus CT (i.e., Brain and Sinus CT studies performed on the same day at the same facility).
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 15 Use Of Brain CT In ED For Traumatic Headache

Label	OP 15
Description	This measure calculates the percentage of Emergency Department (ED) visits for a traumatic headache with a coincident brain computed tomography (CT) study for Medicare beneficiaries.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 16 Troponin Results For ED AMI Within 1 Hour Of Arrival

Label	OP 16
Description	Emergency Department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) with an order for troponin during the stay and having a time from ED Arrival to completion of Troponin results within 60 minutes of arrival.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 17 Tracking Clinical Results Between Visits

Label	OP 17
Description	The extent to which a provider uses an Office of the National Coordinator for Health Information Technology (ONC) certified electronic health record (EHR) system to track pending laboratory tests, diagnostic studies (including common preventive screenings), or patient referrals. This measure applies to all outpatient departments associated with the facility that bill under the Outpatient Prospective Payment System (OPPS). This may include the emergency department (ED), the outpatient imaging department, the outpatient surgery department, and the facility's clinics. Measure ascertains response to the following question(s): Does/did your facility have the ability to track pending laboratory tests, diagnostic studies (including common preventive screenings), or patient referrals through the ONC certified EHR system? Yes/No. Did your facility use the ONC certified EHR to track pending laboratory tests, diagnostic studies (including common preventive screenings), or patient referrals during the performance period? Yes/No. This question would be answered only if the previous question was answered "yes."
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 18 Median Time From ED Arrival To ED Departure

Label	OP 18
Description	Median Time from ED Arrival to ED Departure for Discharged ED Patients
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 19 Transition Record Received By Discharged Patients

Label	OP 19
Description	This measure is used to assess the percentage of patients, regardless of age, discharged from an emergency department (ED), or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elements. A transition record is a core, standardized set of data elements related to patient's diagnosis, treatment, and care plan that is discussed with and provided to patient or caregiver(s) in printed or electronic format at the time of emergency department (ED) discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 1 Median Time To Fibrinolysis

Label	OP 1
Description	Time (in minutes) from emergency department arrival to administration of fibrinolytic therapy in AMI patients with ST-segment elevation or LBBB on the ECG performed closest to ED Arrival and prior to transfer.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 20 Door To Diagnostic Evaluation By Qualified Professional

Label	OP 20
Description	Median Time from ED Arrival to Provider Contact for Emergency Department Patients
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 21 Median Time To Pain Management For Long Bone Fracture

Label	OP 21
Description	Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF).
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 22 Patients Left Without Being Seen

Label	OP 22
Description	Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advance practice nurse/physician's assistant (physician/APN/PA).
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 23 ED Head CT Scan For Stroke

Label	OP 23
Description	Emergency Department Acute Ischemic Stroke or Hemorrhagic Stroke patients who arrive at the ED within 2 hours of the onset of symptoms who have a head CT or MRI scan performed during the stay and having a time from ED Arrival to interpretation of the Head CT or MRI scan within 45 minutes of arrival.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 2 Fibrinolytic Therapy Within 30 Min Of ED Arrival

Label	OP 2
Description	Emergency Department acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the ED stay and having a time from ED Arrival to fibrinolysis of 30 minutes or less.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 3 Median Time To Transfer Acute Coronary Intervention

Label	OP 3
Description	Median time from emergency department arrival to time of transfer to another facility for acute coronary intervention
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 4 Aspirin At Arrival

Label	OP 4
Description	Emergency Department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) who received aspirin within 24 hours before ED Arrival or prior to transfer.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 5 Median Time To ECG

Label	OP 5
Description	Median time from emergency department arrival to ECG (performed in the ED prior to transfer) for acute myocardial infarction (AMI) or Chest Pain patients (with Probable Cardiac Chest Pain).
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 6 Timing Of Antibiotic Prophylaxis

Label	OP 6
Description	Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylaxis should have the antibiotic initiated within two hours prior to surgical incision. Due to the longer infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 7 Prophylactic Antibiotic Selection For Surgical Patients

Label	OP 7
Description	Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure).
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 8 MRI Lumbar Spine For Low Back Pain

Label	OP 8
Description	This measure calculates the percentage of MRI (Magnetic Resonance Imaging) of the Lumbar Spine studies with a diagnosis of low back pain on the imaging claim and for which the patient did not have prior claims-based evidence of antecedent conservative therapy.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

OP 9 Mammography Follow-Up Rates

Label	OP 9
Description	This measure calculates the percentage of patients with mammography screening studies that are followed by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting within 45 days.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Participation In A Registry For General Surgery

Label	PART 4
Description	Participation in a Systematic Clinical Database Registry for General Surgery. Documents if the hospital reports whether or not it participates in a systematic clinical database registry for General Surgery. These measures do not require the hospital to participate in a registry. Hospitals participating in the Hospital Inpatient Quality Reporting Program must answer the questions annually during the CMS specified time period.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Participation In Registry For Nursing Sensitive Care

Label	PART 3
Description	Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care. Documents if the hospital reports whether or not it participates in a systematic clinical database registry for nursing sensitive care. These measures do not require the hospital to participate in a registry. Hospitals participating in the Hospital Inpatient Quality Reporting Program must answer the questions annually during the CMS specified time period.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Participation In Registry For Stroke Care

Label	PART 2
Description	Participation in a Systematic Clinical Database Registry for Stroke Care. Documents if the hospital reports whether or not it participates in a database registry for stroke care. These measures do not require the hospital to participate in a registry. Hospitals participating in the Hospital Inpatient Quality Reporting Program must answer the questions annually during the CMS specified time period.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Participation In Systematic Database For Cardiac Surgery

Label	PART 1
Description	Participation in a Systematic Database for Cardiac Surgery. Documents if the hospital reports whether or not it participates in a cardiac surgery registry. These measures do not require the hospital to participate in a registry. Hospitals participating in the Hospital Inpatient Quality Reporting Program must answer the questions annually during the CMS specified time period.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Patient Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

PC 01 Elective Delivery

Label	PC 01
Description	Patients with elective vaginal deliveries or elective cesarean sections at = 37 and 39 weeks of gestation completed
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PC 02 Cesarean Section

Label	PC 02a
Description	Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section- - Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PC 03 Antenatal Steroids

Label	PC 03
Description	Patients at risk of preterm delivery at =24 and 32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PC 04 Associated Bloodstream Infections In Newborns

Label	PC 04
Description	Staphylococcal and gram negative septicemias or bacteremias in high-risk newborns
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PC 05 Exclusive Breast Milk Feeding

Label	PC 05
Description	Exclusive breast milk feeding during the newborn's entire hospitalization
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PN 3a Blood Culture Within 24 Hrs Of Arrival

Label	PN 3a
Description	Pneumonia patients transferred or admitted to the ICU within 24 hours of hospital arrival, who had blood cultures performed within 24 hours prior to or the day prior to arrival, the day of arrival, or within 24 hours after arrival to the hospital.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PN 3b Blood Culture In ED Prior To Initial Antibiotic

Label	PN 3b
Description	Pneumonia patients whose initial emergency room blood culture specimen was collected prior to first hospital dose of antibiotics. This measure focuses on the treatment provided to Emergency Department patients prior to admission orders.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

PN 6 Initial Antibiotic For Cap Immunocompetent Patients

Label	PN 6
Description	Immunocompetent patients with Community-Acquired Pneumonia who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Practitioner Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

Provider Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

SCIP Card 2 Beta Blocker During Perioperative Period

Label	SCIP Card 2
Description	Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 10 Perioperative Temperature Management

Label	SCIP INF 10
Description	Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8° Fahrenheit/36° Celsius recorded within the 30 minutes Immediately prior to or the 15 minutes Immediately after Anesthesia End Time.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 1 Prophylactic Antibiotic 1 Hour Prior To Incision

Label	SCIP INF 1a
Description	Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received vancomycin or a fluoroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer Infusion time required for vancomycin or a fluoroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time. - Prophylactic antibiotic received within 1 hour prior to surgical incision - Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 2 Prophylactic Antibiotic Selection For Surgical Patients

Label	SCIP INF 2a
Description	Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). - Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 3 Prophylactic Antibiotics Discontinued In 24 Hours

Label	SCIP INF 3a
Description	Surgical patients whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time. The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery.-Overall Rate
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 4 Cardiac With Controlled Postoperative Blood Glucose

Label	SCIP INF 4
Description	Cardiac surgery patients with controlled 6 A.M. blood glucose (less than or equal to 200 mg/dL) on postoperative day one (POD 1) and postoperative day two (POD 2) with Anesthesia End Date being postoperative day zero (POD 0).
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 6 Surgery Patients With Appropriate Hair Removal

Label	SCIP INF 6
Description	Surgery patients with appropriate surgical site hair removal. No hair removal, hair removal with clippers or depilatory is considered appropriate. Shaving is considered inappropriate.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP INF 9 Urinary Catheter Removed In 2 Days Of Surgery

Label	SCIP INF 9
Description	Surgical patients with urinary catheter removed on Postoperative Day 1 or Postoperative Day 2 with day of surgery being day zero.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP VTE 1 Surgery Patients With VTE Prophylaxis Ordered

Label	SCIP VTE 1
Description	Surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SCIP VTE 2 Appropriate VTE Prophylaxis Prior To Surgery

Label	SCIP VTE 2
Description	Surgery patients who received appropriate Venous Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SSI Surgical Site Infection

Label	SSI
Description	A surgical site Infection is an Infection that occurs after surgery in the part of the body where the surgery took place. Surgical site Infections can sometimes be superficial Infections involving the skin only. Other surgical site Infections are more serious and can involve tissues under the skin, organs, or implanted material. CDC provides guidelines and tools to the healthcare community to help end surgical site Infections and resources to help the public understand these Infections and take measures to safeguard their own health when possible. Rate = (number of SSIs/number of specific operative procedures) x 100
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 10 Assessed For Rehabilitation

Label	STK 10
Description	Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 1 VTE Prophylaxis

Label	STK 1
Description	Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 2 Discharged On Antithrombotic Therapy

Label	STK 2
Description	Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 3 Anticoagulation Therapy

Label	STK 3
Description	Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 4 Thrombolytic Therapy

Label	STK 4
Description	Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-PA was initiated at this hospital within 3 hours of time last known well.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 5 Antithrombotic Therapy By End Of Hospital

Label	STK 5
Description	Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 6 Discharged On Statin Medication

Label	STK 6
Description	Ischemic stroke patients with LDL greater than or equal to 100 mg/dL, or LDL not measured, or who were on a lipid-lowering medication prior to hospital arrival are prescribed statin medication at hospital discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

STK 8 Stroke Education

Label	STK 8
Description	Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SUB 1 Alcohol Use Screening

Label	SUB 1
Description	Hospitalized patients who are screened during the hospital stay using a validated screening questionnaire for unhealthy alcohol use.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SUB 2 Alcohol Use Brief Intervention

Label	SUB 2a
Description	Patients who received the brief intervention during the hospital stay.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SUB 3 Alcohol And Drug Use Treatment At Discharge

Label	SUB 3a
Description	Patients who are identified with alcohol or drug disorder who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

SUB 4 Alcohol And Drug Use Status After Discharge

Label	SUB 4
Description	Discharged patients who screened positive for unhealthy alcohol use or who received a diagnosis of alcohol or drug disorder during their inpatient stay, who are contacted within 30 days after hospital discharge and follow-up Information regarding their alcohol or drug use status post discharge is collected.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

TOB 1 Tobacco Use Screening

Label	TOB 1
Description	Hospitalized patients who are screened during the hospital stay for tobacco use (cigarettes, smokeless tobacco, pipe and cigars) within the past 30 days
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

TOB 2 Tobacco Use Treatment Provided Or Offered

Label	TOB 2
Description	Patients identified as tobacco product users within the past 30 days who receive or refuse practical counseling to quit AND receive or refuse FDA-approved cessation medications during the hospital stay
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

TOB 3 Tobacco Use Treatment At Discharge

Label	TOB 3a
Description	Patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication upon discharge as well as those who were referred to outpatient counseling and had reason for not receiving a prescription for medication.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

TOB 4 Tobacco Use Assessing Status After Discharge

Label	TOB 4
Description	Discharged patients who are identified through the screening process as having used tobacco products (cigarettes, smokeless tobacco, pipe, and cigars) within the past 30 days who are contacted within 30 days after hospital discharge and follow-up Information regarding tobacco use status is collected.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 1 VTE Prophylaxis

Label	VTE 1
Description	This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 2 ICU VTE Prophylaxis

Label	VTE 2
Description	This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer).
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 3 VTE Patients With Anticoagulation Overlap Therapy

Label	VTE 3
Description	This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of parenteral (intravenous [IV] or SUBcutaneous [SUBcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a Reason for Discontinuation of Overlap Therapy. Overlap therapy should be administered for at least five days with an international normalized ratio (INR) greater than or equal to 2 prior to discontinuation of the parenteral anticoagulation therapy, discharged on both medications or have a Reason for Discontinuation of Overlap Therapy
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 4 VTE Heparin With Dosages Platelet Count Monitoring

Label	VTE 4
Description	This measure assesses the number of patients diagnosed with confirmed VTE who received intravenous (IV) UFH therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 5 VTE Discharge Instructions

Label	VTE 5
Description	This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home care, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: compliance issues, dietary advice, follow-up monitoring, and Information about the potential for adverse drug reactions/interactions.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

VTE 6 Incidence Of Potentially Preventable VTE

Label	VTE 6
Description	This measure assesses the number of patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.
Data Type	Standards - Data Domains.ddm/Data Domains/Rate [FLOAT(5)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	true
Is Surrogate Key	false

Relationship Details

Core Measures_Provider Dimension_FK

Is Identifying Relationship	true
Child Table	Core Measures
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Provider Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Core Measures_Calendar Dimension_FK

Is Identifying Relationship	true
Child Table	Core Measures
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Calendar Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Core Measures_Patient Dimension_FK

Is Identifying Relationship	true
Child Table	Core Measures
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Patient Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Core Measures_Practitioner Dimension_FK

Is Identifying Relationship	true
Child Table	Core Measures
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Practitioner Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Core Measures_Encounter Dimension_FK

Is Identifying Relationship	true
Child Table	Core Measures
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Encounter Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Primary Key Details

Core Measures PK

Key Attribute	Provider Dk
Key Attribute	Patient Dk
Key Attribute	Practitioner Dk
Key Attribute	Calendar Dk
Key Attribute	Encounter Dk

Overview

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Package

Entity

Dimensional Warehouse Model Data Model