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Quality Improvement with FHIR

Bryn Rhodes, CTO, HarmonIQ Health Systems

Quality Measurement with FHIR

• What is a Quality Measure • A quantitative tool to assess the performance of an individual or organization

related to a specific process or outcome

• An eMeasure is the digital, computable representation of a quality measure

• Typically evaluated at a population level, but can be evaluated at the individual patient level as well

Measure Types

• Process - A measure that focuses on ensuring a particular process is followed • e.g. A measure that evaluates cancer screening rates

• Outcome - A measure that focuses on a particular outcome • e.g. A measure that evaluates improvement in asthma control

• Structure - A measure that focuses on a health care provider’s capacity or systems

• e.g. A measure that evaluates the ratio of staff to providers

• Patient-reported Outcome - A measure that focuses on patient-report outcomes • e.g. A patient experience measure

• Composite - A measure that is made up of multiple measures and evaluated as a combined score

Measure Scoring Types

• Proportion – A measure that is calculated by determining the proportion of members of a population that meet the criteria

• Proportion of patients that have been appropriately screened for breast cancer

• Ratio – Evaluates the ratio of one population to another • Same as a proportion, except that the “numerator” and “denominator” may

come from different populations

• Continuous Variable – Evaluates a particular variable for every member of a population

• Median Time from Admission To Discharge for an ER Visit

Population Criteria Types

• Initial Population • Denominator

• Denominator Exclusions • Denominator Exceptions

• Numerator • Numerator Exclusions

NOTE: This diagram depicts proportion measure population relationships. Population relationships are different for each scoring.

Patient-Based vs Episode-of-Care Measures

• Patient-based • The individual members of the population are patients • Criteria are express as true/false conditions, whether a patient is in/our of

each population (initial, denominator, numerator, etc)

• Episode-of-care based • The individual cases in the population are encounters, or procedures • Criteria are expressed as lists of cases

• Key take-away is that the expressions in a particular measure all return the same type, and that type is determined by the measure scoring and whether it is a patient- or non-patient-based

Components of a measure

• Metadata • Identifiers, narrative description, supporting evidence, topics, governance,

relationship to other artifacts, etc.

• Structure • The population criteria of the measure (i.e. initial population, numerator,

denominator, etc)

• Logic • The conditions involved in building the criteria

CQL Declarations

Initial Population

Denominator/Numerator

The “Retrieve” and DataRequirements

Type Value Set

Retrieve “Procedures” for this patient that have a code that is a member of the

“Mammography Value Set”

Dynamic Data Requirements

Using Profiles to Communicate Requirements

Procedure resource: HEDIS Procedure Profile:

MeasureReport

• Individual – Evaluates the measure for a given patient

• Summary – Evaluates the measure for a population

• Patient-list – Evaluates for a population, but returns as a bundle of individual measure reports

Can we do better?

Refined BCS Measure

BCS Decision Support

Gaps in Care

• Quality measure population results are often used to identify potential "gaps-in-care"

• If a patient is in the "denominator", but not the "numerator" • Can we run a set of measures for a patient and provide details about

each measure?

• $care-gaps?topic=Preventive Care and Screening • Runs all measures for a patient that have the topic "Preventive Care and

Screening"

Care Gap Report

Bundle

Composition

Subject: Patient-1234

MeasureReport: BCS – Breast Cancer Screening Improvement Notation: Increase Initial Population: 1 Denominator: 1 Numerator: 0

MeasureReport: CCS – Cervical Cancer Screening Improvement Notation: Increase Initial Population: 1 Denominator: 1 Numerator: 0

A document bundle with a MeasureReport for every Preventive

Care and Screening measure where the patient is in the initial

population for the measure

Measures as a Query

• Often the "score" in a quality measure is the ultimate goal, but we'd like to be able to communicate the data involved as well

• $collect-data • Pulls the "retrieves" for the measure • lastUpdated parameter is used for incremental pull

Measure Subscription

• A subscription where the criteria for the notification is the "data of interest" for a specific measure

• Allows implementers to determine the method of implementation • Could be manual • Could be based on the DataRequirements for the measure • Could be immediate, or could be queued on a daily or weekly basis

• Prototyped with a mock Medication Reconciliation Post Discharge measure

Measure Subscription

EHR Payer

1. Payer subscribes to the MRP measure

2. EHR notifies Payer of a change in the data-of-interest (i.e. a Med Rec is performed)

3. Payer requests the data since "lastUpdated" via a $collect-data operation

4. EHR responds with a MeasureReport containing Med Rec data for the patient

QDM Mapping

• Quality Data Model (QDM) is the conceptual data model used to specify CMS program measures and NCQA HEDIS measures

• QI-Core Implementation Guide • Set of profiles that derives from US-Core, but introduces extensions and

profiles to support the data defined in QDM

• Profiles contain mappings back to QDM • IG contains a QDM-to-QI-Core Mapping

QRDA-to-FHIR

• Quality Reporting Document Architecture (QRDA) • A set of HL7 V3 templates for QDM • EHRs currently report quality measures using QRDA

• Category I – Patient data (MeasureReport, type individual in FHIR) • Category III – Summary data (MeasureReport, type population in FHIR)

• Using the mappings provided by QI-Core, can we produce FHIR resources using QRDA as input?

QDM-on-FHIR

• Alternatively, can we use the QDM-to-QI-Core mappings to run a QDM-specified measure against a FHIR Server?

Encounter, Performed: Inpatient Encounter: Inpatient, status = complete

• We are working on this as a major focus of the next connectathon • Actively seeking participants, if you're interested, come help us try it

out

Resources

CDC Opioid Prescribing Support Implementation Guide:

• http://build.fhir.org/ig/cqframework/opioid-cds/ HEDIS FHIR Implementation Guide:

• http://build.fhir.org/ig/cqframework/hedis-ig/ Publicly Available Clinical Reasoning Test Server (CQF Ruler) URL:

• http://measure.eval.kanvix.com/cqf-ruler/baseDstu3 Publicly Available CDS Hooks Server URL:

• http://measure.eval.kanvix.com/cqf-ruler/cds-services

http://build.fhir.org/ig/cqframework/opioid-cds/http://build.fhir.org/ig/cqframework/opioid-cds/http://build.fhir.org/ig/cqframework/opioid-cds/http://build.fhir.org/ig/cqframework/hedis-ig/http://build.fhir.org/ig/cqframework/hedis-ig/http://build.fhir.org/ig/cqframework/hedis-ig/http://measure.eval.kanvix.com/cqf-ruler/baseDstu3http://measure.eval.kanvix.com/cqf-ruler/baseDstu3http://measure.eval.kanvix.com/cqf-ruler/baseDstu3http://measure.eval.kanvix.com/cqf-ruler/cds-serviceshttp://measure.eval.kanvix.com/cqf-ruler/cds-serviceshttp://measure.eval.kanvix.com/cqf-ruler/cds-serviceshttp://measure.eval.kanvix.com/cqf-ruler/cds-serviceshttp://measure.eval.kanvix.com/cqf-ruler/cds-services

Walkthroughs

Activity Definition $apply

• https://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operation Plan Definition $apply

• https://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operation CDS Hooks Request:

• https://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processing Quality Measure Evaluation:

• https://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processing

https://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operationhttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processinghttps://github.com/DBCG/cqf-ruler/wiki/Quality-Measure-Processing

Questions?