Clinical Quality Measures (CQMs) CoP

September 11, 2014

2:00 PM Eastern Time

Medicaid Electronic Health Record (EHR) Team (MeT)

Centers for Medicare and Medicaid Services (CMS)

This is an advance copy of the CQM presentation for your review only. This presentation is subject to change and should not be reproduced. The final version of the presentation will be posted to the Medicaid HITECH TA Web site at a later date.

Today’s CMS & MeT Resources

David Koppel: David.Koppel@cms.hhs.govCMS, Health Information Technology for Economic and Clinical Health (HITECH) Coordinator

Phone: (410) 786-3255

Izanne Leonard-Haak: Ileonardhaak@healthmanagement.comMeT, Team Member

Health Management Associates

2

PopHealth Guests

Presenter: Jackie Mulhall, eHealthConnecticut

Resources: • John Rancourt, Office of the National Coordinator

for Health Information Technology (ONC)• Linda Cramer, Wyoming Medicaid EHR program

3

Agenda

Poll

popHealth Presentation

Q & As/Discussion

Next CQM CoP

4

Participant Poll #1

Please click all that apply:• IT• Policy• Operations/Audit• Clinical/Quality• Provider Training/Outreach

5

popHealth Overview for CQM CoP

Jackie Mulhall, eHealthConnecticut

Acronyms

■ HL7 - Health Level Seven International

■ CDA – Clinical Document Architecture (An architecture with templates for clinical documents e.g. CCDs)

■ CCDA – Consolidated Clinical Document Architecture (Similar to CDA)

■ CCD – Continuity of Care Document (A summary document for a single patient)

■ QRDA – Quality Reporting Document Architecture

■ HQMF - Health Quality Measure Format (eMeasure)

■ eCQM – Electronic Clinical Quality Measure

■ CIPCI – Connecticut Institute for Primary Care Innovation

popHealth Overview

■ popHealth is an Open-Source Clinical Quality Measure database and reporting engine presented through a web-based interface

■ Centralized repository of clinical data

■ Data is sent from EHRs via nationally recognized standards

– Consolidated Clinical Data Architecture (C-CDA) Continuity of Care (CCD) Document

– QRDA (Quality Reporting Data Architecture) Cat 1 or 3 Document

■ Clinical Quality Measures (CQMs) are calculated for providers and presented through a web-based interface

– Drill down ability to the provider and patient-level data

■ Track trends in quality and health over time

■ Capture CQMs for Meaningful Use Reporting

■ September 2009 - popHealth started as a prototype, proof-of-concept for a Clinical Quality Measure (CQM) reporting module: popHealth v0.1

■ September 2010 - popHealth formally supported by ONC as a MU Stage 1 reference implementation

■ 2011 – popHealth certified■ January 2012 – v1.4 support for multi-provider with enhanced

functionality released■ December 2012 - v2.0 support for MU Stage 2 CQMs for EPs

released■ February 2013 – v2.1.2 with enhanced functionality released■ June 2014 - v3.0 with upgraded user interface (UI), enhanced

technical architecture, support for QRDA import released■ Spring 2014 - v3 certified■ Fall 2014 – transition to Open Source Community from ONC

History of popHealth

■ Entities are using popHealth in a variety of ways

■ Active User Community– Monthly user group meetings– Includes active users and interested users

■ Currently Managed by ONC, Moving to Open Source Community– Open Source Electronic Health Record Alliance (OSEHRA)

selected to manage Open Source Community– Process of moving to OSEHRA has begun, will take place

over the next few months

■ EHR Upgrades to 2014 CEHRT impacting popHealth– QRDA Documents becoming available but issues due to being a

new standard– CCD v1.1 not always working, additional testing required

Current Status

■popHealth Server – Ruby (version 2.1.1) on Rails (version 4.1.2 or higher)

■Database – MongoDB (version 2.0.1) *depends on the host server

■CQM Calculation – Leverages MapReduce framework in MongoDB

■popHealth Internal Measure Representation – Uses JSON and JavaScript

Technology Stack

■ popHealth is Open Source prototype software that was developed by MITRE through a grant from ONC

■ Pros

– No cost to purchase

– Active Open Source Community

– All users benefit from enhancements/contributions back to the Open Source Community

■ Cons

– “Free like a puppy”

– Documentation is lacking and support is voluntary through Open Source Community

– Requires skill set that is unusual:

HL7, QRDA standards Mongo DB Ruby on Rails JSON 

Implementation Challenges

CQM Reporting for Meaningful Use

■ Northwestern University Medical System– Feed data from various EHRs (through their data warehouse) to

popHealth for CQM reporting for all entities in health system

■ VA– MITRE working to connect popHealth to VA’s Corporate Data

Warehouse (CDW) for CQM reporting

■ Wyoming Medicaid– Database for QRDA Cat 3 data (CQM data) that is entered by

providers– Ability to rank providers into tiers for payment based on CQM rates– Future plans for eCQM submission by accepting QRDA Cat 3

documents

Current popHealth Use Cases

Current popHealth Use Cases

CQM Reporting for Other Purposes

■ eHealthConnecticut (CT Regional Extension Center)– FQHCs (CHCs) send CCD data to popHealth database– Centralized clinical database data from FHQCs– Use for CQMs and other clinical data reporting needs– Unexpected outcome is workflow improvement to resolve data

issues– Used for CQM measurement for CT DPH SHAPE grant

■ IL DPH– FQHCs (CHCs) send CCD data to popHealth database– Used for CQMs and popHealth dashboards to drive clinic

improvements in hypertension management

Consolidated CDA

■ Output of the effort to create one guide that could be used for implementation and analysis of documents within the CDA standard

■ The Consolidated CDA solution is a library of reusable CDA templates 

■ Templates can be utilized at multiple levels within a CDA document:– Level 1: Document Level Templates, such as CCD or Discharge

Summary, can be utilized to define a template for the document as a whole.

– Level 2: Section Level Templates, such as Allergies or Medications, can be utilized to define what specific information will be included in each section.

– Level 3: Entry Level Templates, such as specific Observations or Procedures, can be utilized to define how the information is encoded within each section.

■ Consolidated CDA has a document level template for CCD■ QRDA uses parts of C-CDA framework but is not a template

■ Part of C-CDA Architecture

■ Extensive clinical data– Allergies: RxNorm*, Systematized Nomenclature of Medicine (SNOMED)-CT*

– Care Goals, Social History, Medical Equipment: SNOMED-CT*

– Conditions: SNOMED-CT*, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), ICD-10-CM

– Encounters: Current Procedural Terminology (CPT)

– Immunizations, Medications: RxNorm*, Codes for Vaccine Administered (CVX*)

– Procedures: CPT, ICD-9-CM, ICD-10-CM, SNOMED-CT*

– Vitals, Results, Assessments: Logical Observation Identifiers Names and Codes (LOINC*), SNOMED-CT*

– Communications: SNOMED-CT

■ * preferred

■ All continuity of care entries are time-stamped

■ Results and vitals must be provided structured with units and values

Continuity of Care Document

QRDA Architecture

■ HL7 QRDA is a standard document format for the exchange of electronic clinical quality measure (eCQM) data.

■ QRDA reports contain data extracted from electronic health records (EHRs) and other information technology systems. QRDA reports are used for the exchange of eCQM data between systems for a variety of quality measurement and reporting initiatives.

■ QRDA makes use of CDA templates, which are business rules for representing clinical data consistently. Many QRDA templates are reused from the HL7 Consolidated CDA (C-CDA) standard.

■ Templates defined in the QRDA Category I and III enable consistent representations of quality reporting data to streamline implementations and promote interoperability.

QRDA Documents

■ A QRDA Category I report is an individual patient quality report. Each report contains quality data for one patient for one or more eCQMs, where the data elements in the report are defined by the particular measure(s) being reported. A QRDA Category I report contains raw applicable patient data (e.g., the specific dates of an encounter, the clinical condition) using standardized coded data (e.g., ICD-9-CM, SNOMED CT®). When pooled and analyzed, each report contributes the quality data.

■ A QRDA Category III report is a standard structure to use in reporting aggregate quality measure data. Each report contains aggregate quality data for one provider for one or more eCQMs necessary to calculate population measure metrics.

CCD vs. QRDA Cat I

CCD/CCD 1.1 ■ Clinical summary document

for patient history of procedures, encounters, allergies, medications, etc.

■ Main body of data contains different sections for different clinical data components e.g. medical history, procedures, medications, etc.

■ The data sections are larger and have more general templates for procedures, encounters, etc.

QRDA Cat 1 ■ QRDA reports are

generated based on a CQM request. The data contained in the QRDA file is specific to certain CQMs.

■ Main body of data is divided into three segments: - reporting measure(s) - reporting parameters (rep period) - patient data

■ Templates are more specific and thorough, with smaller general sub groups.

■ Newer standard – less tested

CCD and QRDA Comparison

Header (template IDs)

Author, Custodian,Informant, etc

Patient Information

Provider Information

Structured sections- Procedures- Medications- Problems/Allergies- Encounters- Results Etc.

Header (template IDs)

Author, Custodian,Legal Authenticator, etc.

Patient Information

Provider Information

Structured sections:- Procedures- Medications- Problems- Allergies- Encounters- Results Etc.

CCD (CDA) CCD 1.1 (CCDA)

Header (template IDs)

Author, Custodian, Legal Authenticator, etc

Patient Information

Provider Information

Three 'components'- Measures- Reporting parameters- Patient Data (aggregate of entries for various sections)

QRDA Cat 1

Data Flow for Population Health Management

Providers Collaborate on Patient Health

Population Health Reporting Tool

Electronic Medical Records Database for

Practice

Clinicians Enter Patient Data into

Electronic Medical Record (EMR)

Secure Transfer of Patient Data

popHealth Today for FQHCs in CT

popHealth Reporting Tool

Role-based web access MU Stage 1 and 2

Reports Overall measures with

ability to drill down HIPAA compliant Aggregated population

health reports

CCD Data

Aggregate Data

popHealth Database

FQHC 1 Data

FQHC 2 Data

FQHC 3 Data

FQHC 4 Data

FQHC 1 EHR

CCD DataFQHC 2 EHR

CCD DataFQHC 3 EHR

CCD DataFQHC 4 EHR

popHealth Reporting Tool

Provider CQMs DPH Reporting DSS/Medicaid Cat 3 Docs Comparison to cohort Grant CQMs PCMH ACO

CCD via Batch

Aggregate Data

popHealth Database

Provider Data

Hospital Data

FQHC Data

Other Data

EHR 1

CCD via DirectEHR 2

QRDA Cat 1EHR 3

QRDA via DirectEHR 4

popHealth Next Generation in CT

Main Dashboard

Individual Provider Statistics

Individual Provider Dashboard

Measure Criteria

List of Applicable Patients for a Measure

Patient Summary

Contact Information

Jackie Mulhall, DirectoreHealthConnecticut

c/o SMC Partners LLCHartford Square North

10 Columbus Boulevard, 9th FloorHartford, CT 06106

Phone: 203-695-1030 E-mails: jmulhall@smcpartners.com 

jmulhall@ehealthconnecticut.org

31

Question & Answers/ Discussion

32

Upcoming CQM CoP

Thursday, November 6, 20142:00 PM ET

33

David Koppel David.Koppel@cms.hhs.govCMS, HITECH Coordinator

Phone: 410 786-3255

Izanne Leonard-Haak Ileonardhaak@healthmanagement.com

MeT Team