1. Interoperability Standards for Quality Reporting
Holly Arends, CMQP
Program Manager
Interoperability Standards for Quality Reporting

2. Great Plains Quality Innovation Network
Antibiotic Stewardship
Cancer Prevention
Cardiac Health
Care Coordination
Diabetes Care
Healthcare Infections
Health Information Technology
Immunizations
Medication Safety
Nursing Home Care
Quality Payment Program
Transforming Clinical Practice

3. Time Well Spent Overview of Quality Measurement Standards Overview
QRDA Overview
Data Validation
MIPS Impact

4. Statements Quality Measurement in health care is complex.
For it to be evaluated, it must be standardized and communicated.
Accurate, interpretable data efficiently gathered and communicated is key in correctly assessing that quality care is delivered.
For care quality to be evaluated, it must be standardized and communicated to the appropriate organizations.
Standardization is vital to interoperability. Standardized coding terminologies (e.g., SNOMED CT) serve as universal languages for software systems. Each proprietary system vendor can map source code to standard data codes or build them directly into their product. Clinical document architecture standards (e.g., C-CDA, FHIR) are used to prepare the data for exchange. Information technology experts build protocols that collect and assemble the standard-based codes into standardized electronic documents. Standardized electronic documents can be received by software systems that follow these standards, often accomplished using a health information exchange (HIE) as a portal.
QRDA is a document format that provides a standard structure with which to report quality measure data to organizations that will analyze and interpret the data. Quality measurement in health care is complex. Accurate, interpretable data efficiently gathered and communicated is key in correctly assessing that quality care is

5. Standards Common Language Set of expectations
Enable interoperability between systems/devices
Standards provide a common language and set of expectations that enable interoperability between systems and/or devices. Normalizing data

6. Building Blocks to Support Interoperability
Vocabulary & Code Sets
Content Structure
Transport
Security
Services
See HIMSS FAQ document provided during session
Review the HIMSS FAQ

7. Benefit for Quality
Vehicle for improving quality and safety of patient care
Improves speed of information sharing
Reduces costs
Ability to aggregate data for
Research
Population Health Management
Condition Trending
Report data to Quality Programs
One of the many benefits to implementing interoperability within a health care system

8. Overview of Quality Reporting
eCQM
Informs
Individual Quality Report(s) Pa
Patient Data
Informs
Enterprise Health Data
Analytics Engine
Claims Data
Aggregate Quality Report
Other Data
Record Calculate Export/Report

9. 2015 EHR Certification Final Rule
§ (c)(1) CQMs- Record and Export
§ (c)(2) CQMs- Import and Calculate
§ (c)(3) CQMs- Report
§ (c)(4) CQMs- Filter

10. Quality Reporting Standards
Clinical Document Architecture (CDA)
Consolidated CDA (C-CDA)
Quality Reporting Document Architecture (QRDA)
QRDA Category I (QRDA-I)
QRDA Category III (QRDA-III)
Health Quality Measure Format (HQMF- eMeasure)
US-Realm: Quality Data Model (QDM)

11. HQMF HQMF: An HL7 International standard HQMF is NOT CDA
Represent health quality measure as an electronic document (eCQM)
HQMF is NOT CDA
<Quality Measure Document> HQMF Header HQMF Body <section> <title>Population criteria</title> <text> <entry>Initial Patient Popl</entry> <entry>Denominator</entry> <entry>Numerator</entry> … </section> <title>Data criteria</title> </QualityMeasureDocument>

12. What is a Quality Measure?
A Quantitative tool that provides an indication of the performance of an individual or organization in relation to a specified process or outcome via the measurement of an action, process, or outcome of clinical care
Usually derived from clinical guidelines
Designed to determine whether appropriate care was provided given a set of clinical criteria and an evidence base

13. Overview of Quality Reporting
HQMF
eCQM
Informs
Individual Quality Report(s) Pa
Patient Data
Informs
Enterprise Health Data
Analytics Engine
Claims Data
Aggregate Quality Report
Other Data
Record Calculate Export/Report

14. What is Clinical Document Architecture (CDA)?
A specification for exchange of clinical documents, defining their structure and semantics
ANSI standard developed by HL7’s Structured Documents Work Group (SWG)
ISO standard
CDA relies on
XML
HL7 RIM
HL7 development methodology
Controlled Vocabularies (SNOMED, LOINC, CIE-9, HL7, etc.)
An XML standard for building any Clinical Document

15. What is CDA?
The base standard for building electronic clinical documents
Defines building blocks used to contain healthcare data elements
These building blocks can be arranged as they are needed- Constraining
Arranged using Implementation Guides and Templates produces clinical documents

16. What is XML? Extensible Markup Language (www.w3c.org)
In XML, structure & format are conveyed by markup which is embedded into the information
- <section>
<code code=“ ” codeSystem=“ ”
codeSystemName-”LOINC” displayName=“HISTORY OF PAST ILLNESS” />
<title>Antecedents medicaux</title>
- <text>
- <table border=“1”>
- <tbody>
- <tr>
<th>Pathology</th>

17. CDA = Header + Body CDA Header CDA Body
Patient, provider, author, and encounter information
CDA Body
Clinical Report
Discharge Summary
Care Record Summary
Progress Note
H&P
Public Health Report
…any content that carries a signature

18. CDA Templates
Templates are rules that mold the CDA xml for a specific use case
a template for a physical exam or medication or allergy

19. CDA Constraints
Constraints in terms of HL7 structured documents (in simple terms):
Rules imposed on data that is being collected and/or exchanged
For example:
Data element SHALL (or must) be present
If data element cannot be provided nullFlavor must be provided
Data element values SHALL be drawn from one or more code systems
Sometimes the word Constraint is used synonymously with Optionality
inversely related  more constraints = less optionality

20. CDA Analogy Without CDA With CDA
Without- raw ingredients, not sure what ingredients I need for what recipe, I figure I will just figure it out when I get home, but usually I go back to the chips and salsa for dinner. Pretty much like not exploring the data available and only using reports that you had used for eons.
BUT with a CDA you have a defined recipe (template) and the constraints then group the ingredients, prep them and ultimately provide you with a meal.

21. What is Quality Reporting Document Architecture (QRDA)?
CDA-based standard for reporting patient quality data for one or more quality measures
QRDA Category I (Single Patient Report)
Individual patient-level report that contains data defined in the measure
QRDA Category III (Calculated Report)
Aggregate quality report with a result for a given population and period of time

22. Overview of Quality Reporting
HQMF
eCQM
Informs
Individual Quality Report(s)
QRDA I Pa
Patient Data
Informs
Enterprise Health Data
Analytics Engine
Claims Data
Aggregate Quality Report
QRDA III
Other Data
Record Calculate Export/Report

23. QRDA I Single Patient Report
Reports an individual patient-level quality report
One or more quality measures
Raw applicable patient data
QRDA-I Framework
Generic framework
Quality Data Model (QDM)-based QRDA-I
Specific use of the framework, to align with QDM-based eCQMs
QRDA I is designed as a framework for reporting patient-level data about any quality measure.

24. QRDA I Single Patient Report

25. QRDA I – Measure Section
Identifies the quality measure(s) being reported
Must contain a reference to at least one externalDocument ID from each measure

26. QRDA I Single Patient Report

27. QRDA I – Reporting Parameters
Reporting time interval
May contain other information that provides context for the patient data being reported

28. QRDA I Single Patient Report

29. QRDA I- Patient Data
Contains patient data elements as defined by the reference measure(s)

30. QRDA I Single Patient Report

31. QRDA Validation Schema Schematron
Validate the document XML is following the rules of CDA
Schematron
Validate constraints and rules specific to QRDA
Validate constraints that can’t be specified in W3C schema language
Example: a code element must contain either code and codeSystem attributes or a nullFlavor attribute

32. Validation Implementation Guide Schema Schematron CMS Schematron
Is it CDA?
Schematron
Is it QRDA?
CMS Schematron
Is it CMS QRDA?
Is it a car?
4 tires, seats, motor
Is it a muscle car?
Racing tires, turbo motor, muscular body design
Is it a Ford Mustang?
Ford brand, Ford engine, Mustang VIN#
There is a layering of requirements

33. Quality Data Model (QDM)
Building-Block to eMeasures
Model of information
Express patient, clinical, and community characteristics
Basic logic required to express CQM criteria
Describes data elements and contexts in which they are expected to exist in clinical information systems
Common language for all eCQM

34. QDM and Template Association
Each QDM Datatype
Maps to a unique HQMF XML ‘pattern’
Mapped to a corresponding QRDA I XML pattern, which is present in the patient level report
XML schemas contain numerous design patterns. Russian Doll, Salami Slice, Venetian Blind, Garden of Eden. Patterns vary according to the number of their glodal elements or types. Global element, which is a child of schema, contains a target namespace.

35. QDM Example in eCQM- ASA at Discharge NQF 444
Data Criteria (QDM Data Elements)
"Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set ( )"
"Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set ( )"
"Intervention, Order: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set ( )"
"Intervention, Performed: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set ( )"
"Medication, Administered: Aspirin" using "Aspirin RXNORM Value Set ( )"
"Medication, Administered not done: Medication Hold" using "Medication Hold SNOMEDCT Value Set ( )"
"Medication, Allergy: Aspirin Allergen" using "Aspirin Allergen RXNORM Value Set ( )"
"Medication, Discharge: Aspirin" using "Aspirin RXNORM Value Set ( )"
"Medication, Discharge: Aspirin ingredient specific" using "Aspirin ingredient specific RXNORM Value Set ( )"
"Medication, Discharge: Other Anticoagulants for Acute Myocardial Infarction (AMI)" using "Other Anticoagulants for Acute Myocardial Infarction (AMI) RXNORM Value Set ( )"
"Medication, Discharge: Warfarin" using "Warfarin RXNORM Value Set ( )"
"Medication, Discharge not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set ( )"
"Medication, Discharge not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set ( )"
"Medication, Order: Aspirin ingredient specific" using "Aspirin ingredient specific RXNORM Value Set ( )"
"Medication, Order not done: Medical Reason" using "Medical Reason SNOMEDCT Value Set ( )"
"Medication, Order not done: Patient Refusal" using "Patient Refusal SNOMEDCT Value Set ( )"
Attribute: "Discharge status: Patient Expired" using "Patient Expired SNOMEDCT Value Set ( )"
Attribute: "Discharge status: Left Against Medical Advice" using "Left Against Medical Advice SNOMEDCT Value Set ( )"
Attribute: "Discharge status: Discharged to Health Care Facility for Hospice Care" using "Discharged to Health Care Facility for Hospice Care SNOMEDCT Value Set( )"
Attribute: "Principal diagnosis: Acute Myocardial Infarction (AMI)" using "Acute Myocardial Infarction (AMI) Grouping Value Set ( )"
Attribute: "Discharge status: Discharge To Acute Care Facility" using "Discharge To Acute Care Facility SNOMEDCT Value Set ( )"
Attribute: "Discharge status: Discharged to Home for Hospice Care" using "Discharged to Home for Hospice Care SNOMEDCT Value Set ( )"

36. What is QRDA Category III?
A way of expressing aggregated calculation data for a CQM calculation
No patient identifiers included
Contains data for one or more measures
XML document (CDA-based)

37. QRDA III- Aggregate Report
Document Header
Reporting Parameters Section
Measures Section

38. CMS QRDA IG Implementation guide based on QRDA I and III
Defines program-specific submission requirements
Designed for a specific submission year
CMS IG QRDA I- Hospital
CMS IG QRDA I - Eligible Clinician

39. 2015 EHR Certification Final Rule
§ (c)(1) CQMs- Record and Export
§ (c)(2) CQMs- Import and Calculate
§ (c)(3) CQMs- Report
§ (c)(4) CQMs- Filter

40. 2015 CEHRT Base EHR
Health Level 7 (HL7) Quality Reporting Document Architecture (QRDA) I and III
Standard document format
Exchange of electronic clinical quality measure (eCQM) data
Makes use of CDA templates
Program agnostic
A baseline for interoperability of CQM data
Consensus-based and industry developed
Can support a number of data exchange use cases

41. §170.315(c)(1) Record and Export
QRDA Category I Release 3 IG (vol 1&2)
Too early for QUICK CQM standards, continue to support development in the future
Ability to export CQM data formatted to QRDA I without need of developer support, AKA ‘on-demand’
Record, previously capture in CEHRT 2014, recording data in a standardized formats – ICD 10, SNOMED, LOINC, RxNORM, reduces data entry burden and supports data reuse.
Export, must be able to submit CQM data directly to quality measurement organizations

42. §170.315(c)(2) Import and Calculate
Adopted QRDA Category I Release 3 IG (vol 1&2)
Import
Import data file for each CQM to which HIT is certified.
Functionality can streamline the testing and cert. process
Functionality can promote QI and data sharing between systems, standardized import
Ability for user to import without developer assistance
Did not prescribe what systems are to do with the imported data
Import,
Calculate, validation of data and consistency are key, as standards are refined the consistency and validation becomes stronger.

43. § (c)(3) Report
HIT enable a user to electronically create a data file for transmission of CQM data in accordance with:
HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture—Category I (QRDA I);Release 1, DSTU Release 3 (US Realm) (both Volumes 1 and 2); and
HL7 Implementation Guide for CDA® Release 2: Quality Reporting Document Architecture—Category III,DSTU Release 1 (US Realm) with September 2014 Errata
Report, standard format to be automatically consumer and operated upon by recipient databases. Aggregate I report to III report.

44. If Using CEHRT to Report
No need to recertify annually, as CQMS change,
Must be certified to the CMS QRDA IG
Updated to the latest annual measure specifications

45. § (c)(4) Filter
Filter CQM results as patient and aggregated levels
Ability to create a data file of the filtered data
In accordance with QRDA Cat I and III standards
Display in human readable format

46. Impact on MIPS Participation
Measure Selection
Measure Performance Monitoring
Measure Submission
CEHRT 2014 and/or 2015
Within the MIPS category of Quality we have learned that the measures selected and submitted and vehicle of submission has an effect on the benchmarks and the ‘topped out 'measures.

47. Question You Need Answered
What certification(s) does our product have for the 2017 reporting period?
For which CQMs is our product certified?
Which measures do I have selected to report on in my system?
How will I be submitting CQM data to the CMS QPP?
Has my vendor shown me QRDA report/export capability?

49. Great Plains QIN QPP Service Center
Contact Information
Holly Arends, CMQP
Program Manager
Great Plains QIN QPP Service Center
This material was prepared the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11S0W-GPQIN-GEN-01/0914