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HL7®, FHIR® and the flame Design mark are the registered
trademarks of Health Level Seven International and are used with
per mission.
Boston, 19-21 June | @HL7 @FirelyTeam | #fhirdevdays18 |
www.fhirdevdays.com
Quality Improvement with FHIR
Bryn Rhodes, CTO, HarmonIQ Health Systems
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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
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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
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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
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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.
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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
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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
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CQL Declarations
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Initial Population
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Denominator/Numerator
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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”
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Dynamic Data Requirements
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Using Profiles to Communicate Requirements
Procedure resource: HEDIS Procedure Profile:
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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
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Can we do better?
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Refined BCS Measure
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BCS Decision Support
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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"
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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
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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
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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
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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
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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
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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?
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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
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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
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Walkthroughs
Activity Definition $apply
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https://github.com/DBCG/cqf-ruler/wiki/ActivityDefinition-$apply-Operation
Plan Definition $apply
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https://github.com/DBCG/cqf-ruler/wiki/PlanDefinition-$apply-Operation
CDS Hooks Request:
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https://github.com/DBCG/cqf-ruler/wiki/CDS-Hooks-Request-Processing
Quality Measure Evaluation:
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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
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Questions?