Download - Clinical Quality Framework cqframework.info All Hands Meeting April 17, 2014 11am-12:30pm ET
Clinical Quality Framework
cqframework.info
All Hands MeetingApril 17, 2014
11am-12:30pm ET
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From S&I Framework to Participants:Could you please explain how the terminologies are used in this instance?
All Panelists
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Goals
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• 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
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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
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• 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
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• 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
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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
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Charter Consensus
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• 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
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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
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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
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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
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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
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House-wide Venous Thromboembolism (VTE)
Prophylaxis
And
PPC 16 - VTE
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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
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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
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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
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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
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Radiology
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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)
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Logical Data Model Considerations
CQF Data Model Team
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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
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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>
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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
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FHIR as the Data Model
• Use FHIR resources as the logical model
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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
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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
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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
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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
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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
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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
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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
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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
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Questions and Open Discussion
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Name E-MailMarc Hadley, Co-Coordinator [email protected] Kawamoto, Co-Coordinator [email protected] Blake, PM [email protected]
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
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cqframework.info