Clinical Quality Framework

cqframework.info

All Hands MeetingApril 17, 2014

11am-12:30pm ET

Logistics• As a reminder, please mute your phone when you are not talking to the group. • When speaking, please say your name before making your comment.• You can ask questions by unmuting or by using the “Chat” feature on the web

meeting.

• Send your “chat” to All Panelists in order to ensure the comments are addressed publicly.

• Should you need to take another call, please leave the meeting and rejoin (i.e., please do not put the meeting line on hold).

To find the chat feature look for the chat bubble at the top of the meeting window

From S&I Framework to Participants:Could you please explain how the terminologies are used in this instance?

All Panelists

2

Goals

3

• Finalize charter based on consensus results• Discuss potential pilots with the community and solicit

additional ideas• Obtain community input on logical model considerations• Get volunteers for pilot(s) and model development

Agenda

4

Topic PresenterWelcome Ken Kawamoto, CQF Co-Coordinator

Charter Consensus Ken Kawamoto, CQF Co-Coordinator

Pilots Chris Snyder, Peninsula Regional Medical CenterBob Cooke, National Decision Support CompanyMarc Hadley, CQF Co-Coordinator

VTE ProphylaxisRadiologyChlamydia Screening

Logical Data Model Considerations

Marc Hadley, CQF Co-CoordinatorAziz Boxwala, Standards Sub-Team Co-Lead

Next Steps Ken Kawamoto, CQF Co-Coordinator

Questions and Discussion Ken Kawamoto, CQF Co-Coordinator

Welcome

5

• Announcements, Meeting Schedules, Agendas, Minutes, Reference Materials, Use Cases, Project Charter, and General Information are posted on cqframework.info

• All-Hands meetings are held weekly on Thursdays from 11am-12:30pm ET

• https://siframework1.webex.com/siframework1/onstage/g.php?t=a&d=666535029

• Dial In: +1-650-479-3208 • Access code: 666 535 029

• CQF Data Model meetings are held weekly on Tuesdays from 1-2pm ET

• http://www.anymeeting.com/Meliorix1

• Dial In: +1-770-657-9270• Participant Passcode: 217663

Welcome

6

• Voluntary 2015 Edition Electronic Health Record Certification Criteria: Interoperability Updates and Regulatory Improvements; Correction

Provide formal comments via regulations.gov until 4/28/14.  • Health Level Seven International (HL7)

– Listserv– Membership

Charter Consensus

7

Charter Consensus

• Charter Development Timeline– 3/14/14: The draft charter is available on the Clinical

Quality Framework initiative wiki (cqframework.info)– 4/3/14: Review the draft charter– 4/3/14-4/9/14: Collect comments via the wiki– 4/10/14: Review comment disposition during the CQF

Community Meeting– 4/10/14-4/11/14: Committed Members vote on the

charter– 4/18/14: Finalize the charter

8

Charter Consensus

9

• Voting closed at 8pm ET on 4/11/14• Of 27 committed members, 11 voted via the wiki• Consolidating votes from the same organization resulted

in 10 votes• Consensus resulted in 10 yes votes for the charter• The charter will be finalized today, after review of the

comments received during the voting process

10

Vote Charter Section

Comment Name • Org • Role

Yes(with comments)

Scope Statement

Our charter seems focused on EMR implementation of CDS and CQF, which is appropriate, but I would also suggest that clinical decision support occurs at levels in the organization not directly associated with the EMR. For example, Integrated Practice Teams evaluate aggregate data about costs, access, outcomes, and best practices. The IPTs' evaluation of that data is then used to inform the configuration of CDS alerts and algorithms in the EMR. As population health management evolves, the accountable healthcare delivery organization will look more like a public health system, where the CQF should encompass socio-economic factors. I believe our framework needs to be capable of expanding to these other levels of CDS, though we might want to start with a focused approach on the EMR.

Dale Sanders • Health Catalyst • Committed Member

Charter Consensus

11

Vote Charter Section

Comment Name • Org • Role

Yes(with comments)

Scope Statement

Continued On another topic, and I'm not sure how to incorporate this in the context of the charter, but to the degree that we can influence the commercial content providers for clinical practice guidelines (e.g., Zynx, BMJ) to follow a standardized knowledge representation format, the benefits to the industry would be significant. Having a standardized, computable format would allow us to parse and load that data into EMRs for order sets and CDS, with much less human intervention as what is currently required (which is error prone and a huge barrier to adoption). It would also allow for easier transition from one content provider to another, thus increasing a sense of competition that would drive licensing costs down, quality up, and innovation. Finally, a standard, computable format would greatly facilitate the development of analytics to support variability of care and outcomes analysis.

Dale Sanders • Health Catalyst • Committed Member

Charter Consensus

12

Vote Charter Section

Comment Name • Org • Role

Yes(with comments)

General Comment

A statement about whether or not backward compatibility to eCQM and CDS specific standards will be supported appears to be missing.

Heather Patrick • DB Consulting Group • Committed Member

Yes(with comments)

Timeline To identify, define, and harmonize electronic standards that promote integration between CDS and eCQM is a good goal and we support that. We are not able to support the overly aggressive timeline as it is likely going to impact the quality of the deliverable that can lead to re-work

Kalyani Yerra•Siemens HealthCare•Committed Member

Yes General Comment

Very good discussion on the call, Thursday, April 10, 2014. Thompson Boyd • Hahnemann University Hospital • Committed Member

Yes(with comments)

General Comment

This is a well-formed charter for a very important and timely project in the health care industry. Successful completion of the timeline will require committed participation from members of all stakeholder groups, discipline in defining the scope of use cases and pilots and an agile and pragmatic approach to developing and documenting the data models and standards.

Julie Scherer • Motive Medical Intelligence • Committed Member

Yes(with comments)

Relevant Standards and Stakeholders

For standards, I would suggest that we look at the SDC new standards of forms and templates

Jaleh Mirza • College of American Pathologists • Committed Member

Charter Consensus

13

Vote Charter Section

Comment Name • Org • Role

Yes Randall Case • American College of Emergency Physicians • Committed Member

Yes Polina Kukhareva • University of Utah • Committed Member

Yes Charles Parker • Interface People • Committed MemberYes Bruce Bray • University of Utah • Committed MemberYes Kevin Heard•BJC HealthCare•Committed Member

Charter Consensus

Pilots

14

House-wide Venous Thromboembolism (VTE)

Prophylaxis

And

PPC 16 - VTE

15

PPC/HAC VTE

FY 2009/10 FY 2010/11 Apr-Dec 2012 Jan-Mar 20130

10

20

30

40

50

60

42

57

21

6

PPC 16

PPC 16

PPC - provider preventable conditionsHAC - hospital acquired condition

16

VTE iForm

• All patients assessed for deep venous thrombosis (DVT) prophylaxis as of January 2013

• Some patients that were discharged in January were admitted in December (iForm was only utilized by January admissions) still there was improvement, but still no “hard stop” for assessment/ recording decision-making for all patients

• All admissions from January 2013 forward VTE iForm is utilized to assess need for VTE prophylaxis

iForm - interactive form17

% VTE Prophylaxis for Inpatient

Apr-12

May

-12

Jun-12

Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-

13

Apr-13

May

-13

Jun-13

0102030405060708090

100IP VTE Prophylaxis

IP - inpatient18

% VTE Prophylaxis for Intensive Care

Apr-12

May

-12

Jun-12

Jul-1

2

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Mar-

13

Apr-13

May

-13

Jun-13

0102030405060708090

100

ICU VTE Prophylaxis

ICU - intensive care unit19

% Prophylaxis Utilized- Appropriate Care Score

April-Dec 2012 Jan-Mar 2013 April-June 20130

10

20

30

40

50

60

70

80

90

10089

100 98

70

95 96

82

97 96

21

6

ICU ProphylaxisIP ProphylaxisACSPPC/HAC

ACS - appropriate care score20

Hospital Acquired DVT’sper 1,000 Discharges

FY 09/10 FY 10/11 CY April-Dec 2012 1/13-6/130.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

0.9

1.3

1.5

1

Rate

21

VTE Prophylaxis Compliance and VTE PPC/HAC per 1000 patients

April-Dec. 2012 January-June 20130

20

40

60

80

100

120

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.61.5

1

% ICU Prophylaxis compliance % VTE ProphylaxisVTE PPC/HAC per 1000 pt.

Hospital Acquired DVT’s per 1,000 Discharges

22

Radiology

23

Point of Order CPOE

Confidential © National Decision Support Company 2012-2014

CDS Artifact – ACR Select

• Web-service version of American College of Radiology’s (ACR) Appropriateness Criteria ®– Evidence based, national standard appropriate use criteria,

created and maintained by the ACR using AHRQ methodology, including contribution from other medical specialty organizations

• Structured list of clinical indications from ACR Commons displayed at Point of Order– Structured reason for exam drives decision support

24Confidential © National Decision Support Company 2012-2014

ACR Select Platform

EHRcustomer2.acrselect.org

customer1.acrselect.org

API

Ordering Physician Access

DSN LOCALIZATION

PORTAL

PLATFORMAUC

Confidential © National Decision Support Company 2012-2014

Confidential © National Decision Support Company 2012-2014

EMR Accesses CDS Artifact at Point of Order

Enter structured reason for exam

ACR Select presents score of selected exams any alternates

User refines order based on feedback

Consult AUC

Record DSNConfidential © National Decision Support Company 2012-2014

EMR Integration

• Completed integration with Epic and Cerner• Working with major EHR vendors

– Configurable based on modality/care setting/physician etc. – Direct, API integration– All decision support data stored within EHR

Confidential © National Decision Support Company 2012-2014

CDS Quality Framework

• Define standard for structure for Radiology orders• Define standard for Integration of Radiology CDS at Point of

Order• Define associated quality measures (CQM)

29Confidential © National Decision Support Company 2012-2014

Logical Data Model Considerations

CQF Data Model Team

30

Use of Data Models in CDS and CQM Artifacts

"Laboratory Test, Result: High Density Lipoprotein(HDL) (result < 40 mg/dL)" during "Measurement Period"

Encounter, Performed: Emergency Department Visit(facility location arrival datetime)" during "Measurement Period"

Platelet count every other day beginning day 2 and discontinued on day 14

Acetaminophen 650 mg by mouth every 4 hours as needed for discomfort and/or fever

CDS - Clinical Decision SupportCQM - Clinical Quality Measurement

31

Use of Data Models in CDS and CQM Evaluation

<clinicalStatement xsi:type="vmr:Problem"> <templateId root="2.16.840.1.113883.3.1829.11.7.2.5"/> <problemCode codeSystem="2.16.840.1.113883.6.96“ code="195967001"> <displayName value="Asthma"/> </problemCode> <problemEffectiveTime> <low value<=“20130814”/> <problemEffectiveTime> <problemStatus codeSystem="2.16.840.1.113883.6.96" code="55561003"> <displayName value="Active"/> </problemStatus></clinicalStatement>

32

Key Requirements of Data Models for Artifacts• Easy to read and write expressions

– Helps write correct expressions• Scope is data available in EHR

– and other clinical systems• Allow the model to be extended

– Evolution of the standard specification– “Point-to-point” exchanges

• Be able to reason about the data in multiple ways– By types of actions, e.g., all procedure-related actions (e.g.,

proposals, orders, events)– By phase/mood: all orders (medications, procedures)– By subcategories: chemotherapy procedures versus radiation

therapy procedures

33

FHIR as the Data Model

• Use FHIR resources as the logical model

34

Using FHIR Resources as the Model

• Pros– Interoperability with

other domains– Leverage work done by

others• Resource definitions,

templates, tools

– Aims to represent data found most commonly in EHRs

– Highly extensible– Includes physical model

• Cons– Expressions will be more

verbose– Hazards in creating correct

logic due to modeling approach

• Negation is part of class attributes

• Inconsistent modeling

– Little semantic structure to the model

• Limits the ability to reason

– Currently, many gaps in the scope of the model

– Expressions about extensions will be complex

35

Example in FHIR – Diagnosis Active: Asthma

Condition C where C.code.system="2.16.840.1.113883.6.96" and C.code.code ="195967001" and C.status=confirmed and C.startDate <= 2013-08-14 and not(C.abatement isA Boolean and C.abatement=true) and not(C.abatement isA date and C.abatement<#NOW) and not(C.abatement isA age and C.abatement<#CURRENT-SUBJECT-AGE)

Condition is active

36

Alternative Approach to Logical Model

• Leverage QIDAM/VMR to create a layer or view on top of FHIR– Deterministic mapping to FHIR

• This model will have– Consistent, intuitive naming– Separation of negations, unknowns into their own classes– Add compositional structure– More complete scope

• It builds upon work in CDS and CQM domains– VMR– QDM

37

Benefits of a Harmonized Approach

• Pros– Expressions are easy

to read and write– Expressions are

correct– More reasoning

power– Interoperates with the

broader healthcare domain

• Cons– Yet another model

• Effort to create and maintain

– Partly mitigated if built on FHIR

• Tooling

38

Example in Alternative Model – Diagnosis Active: Asthma

ConditionPresent C where C.code.system="2.16.840.1.113883.6.96" and C.code.code ="195967001" and C.status=Active and C.startDate <= 2013-08-14

Condition is active

39

Physical Model

• Artifacts – Will continue using their native format

• HQMF• HeD/CDS Knowledge Artifact specification

– References to data elements will be using names defined in the logical model

• Patient data– Since we have a deterministic mapping to FHIR, use the latter’s

JSON/XML serialization as the physical model• Adopt immediately for CDS services

– For the short- to medium-term, we may also define templates for QRDA that support the new logical model

• Migrate to FHIR model over the medium-to-long term for quality reporting

40

Participation in Model Development

• CQF Data Model call on Wednesday at 1 pm ET– http://www.anymeeting.com/Meliorix1– Phone Number: +1 770-657-9270, Participant Passcode: 217663

• HL7 Clinical Decision Support (CDS) Work Group call on Thursday at 3 pm ET– https://global.gotomeeting.com/join/383926805 – Dial +1 770-657-9270, Participant Code: 6870541

• HL7 Clinical Quality Information (CQI) Work Group call on Fridays at 1-3 pm ET (2-3 pm ET joint with CDS)– URL: https://www3.gotomeeting.com/join/111952694– Dial In: 1-770-657-9270– Access code: 217663– Meeting ID: 111-952-694

41

Next Steps

• Communicate your areas of interest for contributing via e-mail or via the wikihttp://wiki.siframework.org/Clinical+Quality+Framework+Join+the+Initiative

• Join us for the next Clinical Quality Framework meeting on April 24 from 11am-12:30pm ET

42

Questions and Open Discussion

43

Name E-MailMarc Hadley, Co-Coordinator mhadley@mitre.orgKen Kawamoto, Co-Coordinator kensaku.kawamoto@utah.eduBridget Blake, PM bridget@mitre.org

cqframework.info

Resources• Clinical Quality Framework S&I Initiative

http://wiki.siframework.org/Clinical+Quality+Framework+Initiative+Charter+and+Members

• Data Access Framework S&I Initiativehttp://wiki.siframework.org/Data+Access+Framework+Homepage

• FHIRhttp://www.hl7.org/implement/standards/fhir/

• Health eDecisions S&I Initiativehttp://wiki.siframework.org/Health+eDecisions+Homepage

• HL7 Clinical Decision Support Work Grouphttps://www.hl7.org/Special/committees/dss/index.cfm

• HL7 Clinical Quality Information Work Grouphttp://www.hl7.org/Special/committees/cqi/index.cfm

• HL7 Structured Documents Work Grouphttp://www.hl7.org/special/Committees/structure/index.cfm

• Query Health S&I Initiativehttp://wiki.siframework.org/Query+Health

• S&I Processhttp://wiki.siframework.org/Getting+Started+as+a+Volunteer

44

cqframework.info