next generation quality measurement with fhir · 2019. 12. 12. · 1 quality measurement with fhir:...

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Next Generation Quality Measurement with FHIR

Ben Hamlin (NCQA) Samuel Sayer (MITRE)

1

Quality Measurement with FHIR: Learning Goals

• Comprehend FHIR’s role in quality measure development • Understand the differences between current and future-state quality

measures (the Next Generation of CQMs)

• Identify key resources and operations required for quality measurement & reporting

• Understanding of FHIR reporting workflows • Next Steps

2

Measuring What Matters: The Next Generation of Quality Measurement and Fast Healthcare Interoperability Resources (FHIR) Ben Hamlin

3

“Quality measurement is its own worst enemy. By design it advances principles that render it

ultimately irrelevant.”

4

Person-specific Outcomes

The Next Generation of Quality Measurement

Reducing Burden

Measuring What

Matters

Improving Accuracy

Quality Measurement Goes Digital

Reducing Burden

Measuring What

Matters

Improving Accuracy

6

FHIR® and Quality Measurement The next generation standards framework for the next generation of Quality Measures

An Interoperable Platform for Healthcare Measures

FHIR defines a common way to structure health data that becomes the building blocks for how data is to be exchanged

Enables automated data exchange through APIs (this is important!)

Levels III and IV are used to represent data in eCQMs

Level V provides structure for eCQMs and Reporting

Administration Patient,

Practitioner, Organization,

Healthcare Service

Record &

Exchange Encounters,

Diagnoses, Medications, Observations

Clinical

Reasoning Measure

Measure Report

Data Model Specifications & Reporting

Reducing Burden

Measuring What

Matters

Improving Accuracy

7

Machine Readable Specifications

NCQA produces standardized measure code

Use standard logic (CQL) to represent measure query

Uses standard data model to define data elements

Specifications perform all functions of measure query

Improve accuracy and reduce the burden of producing quality scores

Reducing Burden

Improving Accuracy

Digital Quality Measures What is an electronic clinical quality measure (eCQM)?

The Next Generation Quality Measures A Person-specific Quality Measurement Model

Person-specific definitions that relate to an individual’s unique healthcare circumstances

NextGen Measures are a “compass” pointing healthcare towards Quality Improvement that:

o is patient-centered

o is meaningful to many

o Prospectively supports care processes (not retrospectively

assessing care coordination failures)

NextGen measures require a lot of individual-specific data from multiple source systems

Measuring What

Matters

•

•

•

9

Current CQMs vs. The Next Generation

Current Measure Description:

The percentage of women, 52-74 years of

age who have been enrolled in a health plan

for at least two years who have had a

mammogram to screen for breast cancer

every other year.

• Does not account for patient risk profile • Does not include women who have recently

changed plans

• Does not account for patient preferences • Does not consider the difference between positive

and negative findings

Person-Specific

Measure Description:

Women…

…are they getting high quality healthcare?

Example: Breast Cancer Screening

•

•

•

10

BCS NextGen Example Finding a Patient’s personal Risk Profile

Person-Specific Information → Care Goals Authoring Quality Measures as Patient-Centered Decision Support (PCCDS)

Clinicians and patients both need coordinated information presented in a patient-specific context to inform:

decisions about improvement targets how important achievement of those particular goals are to the patient how difficult it may be for the patient to achieve

NextGen CQMs on FHIR provide all the necessary resources and contextual info to facilitate high quality, person-centered care

NextGen measures are still very aspirational-none deployed on a large scale to date

12

At

Ou

tco

me

(Goa

l 3)

At

Ou

tco

me

(Goa

l 2)

At

Ou

tco

me

(Goa

l 1)

Base

lin

e

Go

al S

ett

ing

With respect to each goal, does patient have?

Some Function

No Function

Yes

Yes

FSA

Using elements of the FSA tool, patient & provider set

at least 3 SMART goals

Was goal 2

achieved?

A lot more

A little more

AS EXPECTED

NO CHANGE

Worsening

YES

NO

YES

NO

A little more

Worsening

AS EXPECTED

NO CHANGE

A lot more

Was goal 1

achieved?

-1

-2

Yes

Yes

+2

+1

Yes 0

Yes

Yes

-1

-2

+2

+1

0

-1

-2

YES

NO

Yes

Yes

Yes

Yes

YesWorsening

Was goal 3

achieved?

NO CHANGE

A lot more

+1A little more

+2

-1

-2

AS EXPECTED 0

Yes

Yes

Yes

Yes

Yes

weight is assigned to each goal by provider

weight=importance x difficultyGoal score

x

Weight

Goal score

x

Weight

Goal score

x

Weight

Structured Data Entry

Measure Calculation

[FHIR-CQL]

Measure

Report

GAS score

calculated

for all

goals

FHIR Resources: CarePlan Goal Observation Condition QuestionnaireResponse

Goal: an expressed, desired

health state to be achieved by

an individual over a predefined

time period.

Elements: • Goals set • Time period for assessment • Attainment (partial/full) of

Goal

• Adjustment of Goal

Goal Attainment Scaling of Patient-selected SMART Goals for Management of Asthma

•

•

•

13 13

14

Quality Measure Reporting FHIR APIs - Background Samuel Sayer (MITRE)

This presentation was produced for the U. S. Government under

Contract Number HHSM-500-2012-00008, and is subject to Federal

Acquisition Regulation Clause 52.227-14, Rights in Data-General.

No other use other than that granted to the U. S. Government, or to

those acting on behalf of the U. S. Government under that Clause is

authorized without the express written permission of The MITRE

Corporation. For further information, please contact The MITRE

Corporation, Contracts Management Office, 7515 Colshire Drive,

McLean, VA 22102-7539, (703) 983-6000. (c) 2019 The MITRE

Corporation.

Approved for Public Release, Distribution Unlimited 19-1676. Please review the data rights legend on slide 4

15

Quality Measure Reporting - Current State

Vendors understand Quality Reporting Data Architecture (QRDA) format, but issues remain with generating valid QRDA submission documents

Implementers request more detailed data mapping guidance to ensure that interfaces and data input fields capture quality data

Clinicians find data collection obtrusive to their workflow and care of the patient

Submitters request real-time feedback on quality data submissions

Submitters suggest exploring alternative data transport standards like data exchange using FHIR


16

Quality Measure Reporting - Background

Centers for Medicare & Medicaid Services Center for Clinical Standards and Quality (CMS CCSQ) reporting programs have piloted Application Programming Interfaces (API) for quality reporting (e.g. Quality Payment Program API, Web Interface API)

MITRE delivered an electronic Clinical Quality Measure (eCQM) strategy report to CMS in 2018 with recommendations on increasing value and reducing burden of quality reporting

CMS CCSQ has begun exploring the use of FHIR for quality reporting


17

Quality Measure Reporting - Why FHIR APIs?

The Health IT industry is rapidly moving towards HL7 FHIR®

Many vendors have implemented the Argonauts/US Core

APIs remove manual step of submitting data through a website

Integration of clinical quality reporting with Health IT systems

Continuous/increment reporting and improvement

Alignment to FHIR simplifies data mapping

Shared data model with Clinical Decision Support (CDS)


18

Quality Measure FHIR Reporting - Work So Far

Clinical Reasoning track

• HL7 Connectathon 12+ • Jacksonville Da Vinci Connectathon

Measures

• Medication Reconciliation • Colorectal Cancer Screening • Venous Thromboembolism (VTE-1)


19

Quality Measure Reporting - Current & Future State

2018 Annual Update 2019

Reporting

Through 2018

Reporting Period

Starting 2019

Reporting

Period

Proposed Future

State

Reporting

Standards

QRDA Category I & III QI-Core / DEQM

Data Model Quality Data Model (QDM) QUICK

Measure Logic QDM Clinical Quality Language (CQL)

Measure Structure Health Quality Measure Format (HQMF)

FHIR Quality Measure IG


20

FHIR Key Resources - Measure

Contains metadata and populations about a single clinical quality measure

References a Library resource containing measure logic

Operations for quality reporting are executed through Measure Resource

Operations can be scoped to individual providers

Operation Description

$evaluate-measure

Calculation results for a single measure as a MeasureReport

$data-requirements

List of data of interest for the quality measure as a Library

$submit-data Submit a MeasureReport resource

$collect-data Data of interest for measure contained in FHIR server as a MeasureReport


21

FHIR Key Resources - MeasureReport

Represents a calculation result for a single measure for a measurement period

Replaces all QRDA Type defines the format of calculation results

Contains calculation result in group attribute

Type Description MeasureReport

Attribute

Current

Equivalent

individual Calculation results for a single patient

Population Count (Integer)

N/A

subject-list List of patients

subjectResults (List)

QPP Web Interface API

summary Total members of each population

Population Count (Integer)

QRDA Category III

data-collection

Data of interest for measure

evaluatedResource (Any)

QRDA Category I


22

FHIR Key Resources - Library

Generic resource representing knowledge artifacts

• content attribute contains CQL logic • dataRequirement attribute contains list of data elements


23

FHIR Reporting Workflow - Push

EHR Clinical

Database

Quality

Measuremen

t System

Authentication + Authorization

Authorization Token

$submit-data Operation Implements

DEQM IG +

OAuth 2

Inferno/Crucible

Validates MeasureReport

Exchange

initiated by

the provider

$data-requirements Operation

Library Resource

Vendor

FHIR

Client

FHIR

Server


24

FHIR Reporting Workflow - Pull

EHR Clinical

Database

Quality

Measuremen

t System

Authentication + Authorization

Authorization Token

MeasureReport Resource (+ Patient Resources)

Implements

DEQM IG +

OAuth 2


Exchange

initiated by

the quality

measureme

nt system

$collect-data, $evaluate-measure Operation, $data-requirements + FHIR

Queries

Vendor

FHIR

API

FHIR

Client


Inferno/Crucible

25

FHIR Reporting Workflow - Subscription

EHR Clinical

Database

Vendor

FHIR

API

Quality

Measuremen

t System

Implements

DEQM IG +

OAuth 2


Updates

initiated by

the provider

Authentication + Authorization Request

Authorization Token

Create Subscription Resource

Update Notification

$collect-data, $calculate-measure Operation

MeasureReport Resource (+ Resources)

$data-requirements FHIR

API

Quality

reporting

system

pulls in

response to

the

notification


Inferno/Crucible

26

FHIR Quality Measures Next Steps

Specification Testing Outreach

QI-Core R4 (September 2019)

Measure Implementation

Public Comment & Feedback

DEQM R4 (January 2020) Health IT Systems Pilots

Program specific IGs Receiving Systems

FHIR Bulk Data PI

OAuth


27

Questions


28

Thank You

[email protected]

www.ncqa.org

[email protected]

MITRE’s mission-driven teams are dedicated to solving problems for a safer world. Learn more at www.mitre.org

Please attend “Let's build! Next Generation Quality Reporting with FHIR” with Bryn Rhodes right after the break


mailto:[email protected]://www.ncqa.org/mailto:[email protected]:[email protected]://www.mitre.org/

29

Appendix:

FHIR Quality Measure IGs

CQL FHIR

FHIR® and Quality Measurement

30

FHIR

31

HL7 FHIR® Standards for Quality Measurement Data Model Standards Landscape

next generation quality measurement with fhir · 2019. 12. 12. · 1 quality measurement with fhir:...

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