cql4cds webinar - amazon web services
TRANSCRIPT
CQL4CDS Webinar
CQL Primer
Clinical Quality Language
• Health Level 7(HL7) standard designed to:• Enable automated point-to-point sharing of executable clinical knowledge• Provide a clinically focused, author-friendly, and human-readable language
• Currently a Standard for Trial Use (STU) publication• Approved normative, awaiting publication (http://build.fhir.org/ig/HL7/cql)• Currently published STU4 (http://cql.hl7.org)
Components of Sharing Logic
Value > 100
SNOMED-CTLOINCRxNorm
EncounterMedicationObservation
Logic
Model Terms
Definitions:SNOMED CT – Systematized Nomenclature of Medicine – Clinical TermsLOINC – Logical Observation Identifiers Names and Codes
2/25/21 Clinical Quality Language: Deep Dive 4
CQL Architecture
Definitions: SQL – Structured query language
2/25/21 Clinical Quality Language: Deep Dive 5
Conceptual Knowledge Architecture
http://hl7.org/fhir/uv/cpg/documentation-approach-12-conceptual-knowledge-architecture.html
Knowledge Capabilities
http://hl7.org/fhir/uv/cpg/profiles.html#artifact-profiles
Knowledge Level
Description Example
L1 Narrative Guideline for a specific disease that is written in the format of a peer-reviewed journal article
L2 Semi-structured
Flow diagram, decision tree, or other similar format that describes recommendations for implementation (HUMAN READABLE)
L3 Structured Standards-compliant specification encoding logic with data model(s), terminology/code sets, value sets that is ready to be implemented (COMPUTER/MACHINE READABLE)
L4 Executable CDS implemented and used in a local execution environment (e.g., CDS that is live in an electronic health record (EHR) production system) or available via web services
Translating Knowledge to Execution
Adapted from: Boxwala, AA, et al.. A multi-layered framework for disseminating knowledge for computer-based decision support. J Am Med Inform Assoc 2011(18) i132-i139.
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
L1 L2 L3 L4
L1L2
L3L4
WaterfallGDP, KE, CDS, &Implementation
AgileIntegratedCross-functionalCPG-IG Approach
- Shared Tooling- Shared Information- Incremental- Concurrent Development- Iterative, Rapid Feedback- Test-Driven- Reuse Content
Levels of Representation ReconceptualizedFramework for Describing Nature of Representation (NOT Process)
Tradition Knowledge Engineering Approach:•Process Steps that mimicked Progression of Levels-•L2 only on Final L1•L3 only on completion of L2
Agile KE:•Concurrent, iterative, integrated, and cross-functional•Different Expertise work on Different Levels concurrently•Knowledge Increments across Levels
CQL Specification Target Audiences
• Authors – Clinical domain experts and clinical artifact authors• Developers – Authors building more complex artifacts as well as
shared libraries• Integrators – Health-IT professionals integrating quality artifacts• Implementers – Systems analysts, architects or developers building
language processing applications
2/25/21 Clinical Quality Language: Deep Dive 11
Delivery/Enablement
http://hl7.org/fhir/uv/cpg/documentation-approach-03-conformance-levels.html
Direct (Ingestion and/or Translation)
http://hl7.org/fhir/uv/cpg/documentation-approach-10-mechanisms-of-integration.html
Reasoning-as-a-Service
http://hl7.org/fhir/uv/cpg/documentation-approach-10-mechanisms-of-integration.html
Real-time Data Enrichment and Delivery
http://hl7.org/fhir/uv/cpg/documentation-approach-10-mechanisms-of-integration.html
As an Application
http://hl7.org/fhir/uv/cpg/documentation-approach-10-mechanisms-of-integration.html
DEQMQI CORE
FOUNDATION CONFORMANCE ADMINISTRATION CLINICAL REASONING
EBM-ON-FHIRCPG-ON-FHIRUS CORE QM
HEDIS
CDC OPIOID PRESCRIBING
WHO ANC
Spec
ifica
tion
IGs
Cont
ent I
Gs
FHIRPATH CQL
Mod
el IG
s
IPS
CDS HOOKS SMART
SDC
WHO CORE
WHO FP WHO STIECQMPROGRAMS
MME CALCULATION
Open Source Stack
Content IG Walkthrough
https://github.com/cqframework/content-ig-walkthrough
Examples
USPTF Lung Cancer Screening
• Built as part of a University of Utah project on Lung Cancer Screening• CQL and FHIR-based representation• Uses US-Core Smoking Status• Uses GEM as an intermediate/L2 representation
Funded by a grant from the Agency for Healthcare Research and Quality (AHRQ): AHRQ grant R18 HS026198http://build.fhir.org/ig/cqframework/lcs-cds/
USPTF Lung Cancer Screening – L1
USPTF Lung Cancer Screening – L2
USPTF Lung Cancer Screening – L3
WHO Antenatal Care
• Built as part of the WHO Smart Guideline Initiative• Part of a family of guides• WHO Core – Provides common profiles used by multiple guides• WHO Family Planning• WHO Sexually Transmitted Infection• WHO Antenatal Care
WHO Digital Accelerator Kits/Computable Guidelines
https://www.who.int/publications/i/item/9789240020306
Focused on supporting adoption, Digital Accelerator Kits provide:• Generic Personas• User Scenarios• Business Processes & Workflows• Core Data Elements• Decision Support Logic• Indicators & Monitoring• Functional Requirements
WHO Antenatal Care – L2 – Data Elements
WHO Antenatal Care – L2 – Decision Tables
WHO Antenatal Care – L3
Concepts, DataElements, Decisions
DataElements
Decisions
CDC Opioid Prescribing Support
CDC Opioid Prescribing Guideline
AHRQ Pain Management Summary Opioid eCQMs AHRQ Chronic Pain ManagementCDC Opioid Prescribing IG
Opioid-related Projects
https://www.cdc.gov/drugoverdose/prescribing/guideline.html
CDC Opioid Prescribing Guideline
https://github.com/AHRQ-CDS/AHRQ-CDS-Connect-PAIN-MANAGEMENT-SUMMARY
AHRQ Pain Management Summary
AHRQ Pain Management Summary
https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS460v2.html
Opioid eCQMs
Opioid eCQMs
AHRQ Chronic Pain Management
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
SDC
Chronic Pain Management
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
• ExtractableQuestionnaire to submit questionnaire results as Assessments to the EHR
• Assessments are incorporated into the Pain Management Summary
• Decision support capability added from the Opioid IG (including MME calculation)
Enable Shared Decision Making Through:
AHRQ Chronic Pain Management
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
http://build.fhir.org/ig/cqframework/opioid-cds-r4/
CDC Opioid Prescribing IG
Patient selectOpioid review useful?
Stop
Receiving both opioid analgesics with ambulatory
misuse potential and benzodiazepine medications?
Avoid prescribing opioid pain
medication and benzodiazepine
concurrently
Will revise
Benefits outweigh risks, snooze 3
months
N/A- see comment, snooze 3 months
Yes
No
Yes
No
No
Yes
Order exists for opioid analgesics with ambulatory
misuse potential?
Order exists for benzodiazepine medications?
ExclusiveGatewayIndicated
Do both actions
conclude true?
EHR Triggering Event
Calculation LogicConfigurable calculation logic
Sub-routine calculation logic
User Interaction
Optional Sub-routine logic
Recommendation #11 – L2
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
L3 – Terminology
L3 – Profiles (Data Elements)
Requirements to Running CodeT1
–Da
taT2
–Lo
gic
T3 –
Form
s
L1 – Narrative L2 – Semi-Structured L3 – Structured L4 – Executable
Case ExamplesPaper FormsUser StoriesPersonas
Guideline narrativeEvidence SummariesTables & Figures
GlossariesDomain ConceptsIndicator descriptions
Wire FramesFlow Diagrams Questionnaire (SDC)
User-interface FormsVisualizationsInteraction Model
WorkflowsDecision TreesTriggers
TerminologiesData DictionaryIndicators
Library (CQL)ActivityDefinitionPlanDefinition
CodeSystemValueSetStructureDefinitionMeasure
Application ServicesHealth Record SystemsDecision Services
Systems of RecordRegistries and ExchangesData Services
L3 – Logic (CQL Libraries)
Patient selectOpioid review useful?
Stop
Receiving both opioid analgesics with ambulatory
misuse potential and benzodiazepine medications?
Avoid prescribing opioid pain
medication and benzodiazepine
concurrently
Will revise
Benefits outweigh risks, snooze 3
months
N/A- see comment, snooze 3 months
Yes
No
Yes
No
No
Yes
Order exists for opioid analgesics with ambulatory
misuse potential?
Order exists for benzodiazepine medications?
ExclusiveGatewayIndicated
Do both actions
conclude true?
EHR Triggering Event
Calculation LogicConfigurable calculation logic
Sub-routine calculation logic
User Interaction
Optional Sub-routine logic
L3 – Recommendation
Patient selectOpioid review useful?
Stop
Receiving both opioid analgesics with ambulatory
misuse potential and benzodiazepine medications?
Avoid prescribing opioid pain
medication and benzodiazepine
concurrently
Will revise
Benefits outweigh risks, snooze 3
months
N/A- see comment, snooze 3 months
Yes
No
Yes
No
No
Yes
Order exists for opioid analgesics with ambulatory
misuse potential?
Order exists for benzodiazepine medications?
ExclusiveGatewayIndicated
Do both actions
conclude true?
EHR Triggering Event
Calculation LogicConfigurable calculation logic
Sub-routine calculation logic
User Interaction
Optional Sub-routine logic
L3 – Recommendation (cont)
Patient selectOpioid review useful?
Stop
Receiving both opioid analgesics with ambulatory
misuse potential and benzodiazepine medications?
Avoid prescribing opioid pain
medication and benzodiazepine
concurrently
Will revise
Benefits outweigh risks, snooze 3
months
N/A- see comment, snooze 3 months
Yes
No
Yes
No
No
Yes
Order exists for opioid analgesics with ambulatory
misuse potential?
Order exists for benzodiazepine medications?
ExclusiveGatewayIndicated
Do both actions
conclude true?
EHR Triggering Event
Calculation LogicConfigurable calculation logic
Sub-routine calculation logic
User Interaction
Optional Sub-routine logic
Questions
ActivityDefinition for a list of medications
ValueSet for “Named Events” in TriggerDef
• Various contexts• CDS Hooks `hook definitions`
• Needs a CodeSystem in terminology.hl7.org• CPG Activity Types
• http://hl7.org/fhir/uv/cpg/CodeSystem-cpg-activity-type.html• Content-specific activities
• http://build.fhir.org/ig/who-int/anc-cds/documentation.html#routine-anc-contact• US Public Health `named events`
• http://build.fhir.org/ig/HL7/case-reporting/CodeSystem-us-ph-triggerdefinition-namedevents.html
• http://build.fhir.org/ig/HL7/case-reporting/StructureDefinition-us-ph-namedEventType.html
Calculation Services?
http://build.fhir.org/ig/cqframework/opioid-mme-r4/#usage
Exposing Calculation Services•CPG Library EvaluateEvaluates the contents of a library and returns the results as a Parameters resource.
•CPG CQLEvaluates a CQL expression and returns the results as a Parameters resource.
Code System Supplement Configuration
http://build.fhir.org/ig/cqframework/opioid-mme-r4/conversion-factors.html#conversion-factors
Code System Supplement Configuration
http://build.fhir.org/ig/cqframework/opioid-mme-r4/conversion-factors.html#usage
Concepts Configuration
• Pain Management Summary has a “Factors_To_Consider...” Library• Significant amount of content useful for summarizing and presenting relevant
information for Pain Management
• Chronic Pain Management project• Re-use as much as possible• Needed additional capability• Needed to accommodate different perspective on the same concepts
Refactored to create a Concepts library
Created a new Version to change value sets
Static vs Dynamic Version Binding (manifest)
http://build.fhir.org/ig/HL7/cqf-measures/measure-terminology-service.html
Unit Testing
https://github.com/cqframework/atom_cql_support#using-the-cql-support-in-atom
Profile-informed Authoring
• Using profile definitions in FHIR to enable more domain-focused CQL• Focuses on
• Primitives• Choices• Slices• Simple Extensions• Complex Extensions
• Implemented as a lossless mapping• Means no run-time impact, implementations see “pure FHIR”
• Case Features• Asserted vs Inferred Data Elements
Primitives
Slices
Simple Extensions
Complex Extensions
Retrieve Enhancements
• Includes/Reverse Includes• Profile-based Retrieve• Multi-factor Retrieves• Related-context Retrieve
Current Status
• Clinical Quality Language• ANSI Approved Normative/publication in progress (https://cql.hl7.org/)
• FHIR Clinical Guidelines (CPG-on-FHIR)• Published STU1 (v1.0.0) (http://hl7.org/fhir/uv/cpg/)
• CDS Hooks• Published STU1 (v1.0) (https://cds-hooks.hl7.org/1.0/)• 1.1 Ballot in reconciliation (targeting May publication)• https://cds-hooks.hl7.org/ballots/2020Sep/• Hook Definitions (patient-view balloted, targeting April publication)
https://confluence.hl7.org/display/CDS/Standards
What’s Next...
• FHIR R5• Clinical Reasoning Module (promoting universally applicable conformance and
guidance)• CPG-on-FHIR Next
• Terminology Service• Knowledge Repository Service• Version Manifest
• Content IGs To Be Published...• Opioid MME, Opioid Guidance, Lung Cancer Screening• WHO Core, FP, STI, and ANC• Others...
• Authors, Authors, Authors, Authors• BPM+ Collaboration/Mapping/Coordination
Get Involved!
• Adapting Clinical Guidelines for the Digital Age• CPG-on-FHIR Project
• Clinical Quality Framework Initiative• Clinical Decision Support and Clinical Quality Information HL7 Work Groups
• WHO SMART Guidelines Initiative• EBM-on-FHIR (COKA) Initiative• CQL FHIR Zulip Stream• CQFramework Repository• eCQI Resource Center