Quality Reporting HIT Standards Project The Quality Reporting Document Architecture: Phase I

1. Quality Reporting HIT Standards Project The Quality Reporting Document Architecture: Phase I September 2007

2. Overview • Sample • Project proposal with SDTC

3. QRDA: Project Goal Quality Reporting Document Architecture Develop an electronic data standard report for healthcare information systems to use in communicating patient level quality measurement data across disparate systems.

4. Participants: A Private Collaborative Founders Primary Benefactor For Phase One HL7 Sponsor Project Management

5. HospitalCommunity PhysicianCommunity Alliance for Pediatric Quality Four national pediatric organizations aligned to improve the qualityof health care for America’s children. • 200+ children’s hospitals and 60,000 pediatricians using the same play book to improve care • Alignment of physicians and hospitals is essential to improvement progress • Combined expertise and spheres of influence will accelerate improved quality for children

6. AllianceGoals & Strategies Our Strategies • Work for consensus – speak with one voice for improvement in quality for children; advance pediatric improvement initiatives, measures and data/health information technology • Endorse and promote projects that advance pediatric quality and health information technology • Convene stakeholders • Advocate in media and legislature • Promote meaningful pediatric improvement and measures • Promote initiatives using measures for improvement • Spread use of measures for improvement and public reporting • Develop a comprehensive catalogue of pediatric improvement priorities and measures • Ensure health information technology works for children • Seek industry-wide adoption of data standards for pediatrics • Promote integration of child health EHR-S standards into vendor systems • Endorse pediatric data standards that make comparability possible • Explore opportunities for collecting and sharing data

7. Using Data for Quality Performance Measurement Problem* • Time-consuming and problematic operations for data acquisition from electronic systems • Multiple and disparate systems within health care organizations complicate data mining and coordination of efforts • Resource-intensive data mapping efforts to link systems and performance measurement data requirements • Conflicts or differences between administrative data sets • Physicians and providers struggle to meet increasing demands for performance data *Source: Agency for Healthcare Research & Quality Opportunity • Support efficient collection, aggregation and reporting of quality measurement information • Among providers within a healthcare system • Among providers from different healthcare systems • Among providers and requestors of quality data (e.g. quality improvement organizations, payers, accrediting orgs, etc.) • Support adoption of quality measurement • Among developers of health information technology systems • Among providers and payers

8. Status Quo in Quality Measure Reporting Requestors of Quality Data Prepare data for analysis Data Entry 100% manual process: data abstraction and data mining QualityImprovement Organizations Accrediting Organizations Payers Paper Medical Records Key-boarding or manual entry Proprietary data formats Electronic Medical Records Provider sends patient level measure data in multiple formats; data prepared for analysis and submitted in multiple formats

9. QRDA Immediately Simplifies Quality Measure Reporting Requestors of Quality Data Prepare data for analysis Data Entry semi-automated: data abstraction and data mining QualityImprovement Organizations Accrediting Organizations Payers Paper Medical Records Key-boarding or manual entry QRDA QRDA-compatible QRDA valid? Electronic Medical Records Semi-automated data entry; single, open data format for collection and analysis; compatible with EMR exchange documents (CCD, CDA); point-of-collection validation

10. Future: QRDA Streamlines Quality Measure Reporting Requestors of Quality Data Prepare data for analysis Data Entry semi-automated: data abstraction and data mining QualityImprovement Organizations Accrediting Organizations Payers Paper Medical Records Key-boarding or manual entry QRDA QRDA-compatible QRDA Electronic Medical Records Fully-automated data entry, ready for collection and analysis

11. Leverage and Harmonize With Others Collaborative for Performance Measure Integration with EHR Systems (The Collaborative) • American Medical Association, National Committee on Quality Assurance • Addressing performance measure functionality and integration with EHRs • Facilitating integration, calculation and reporting of measures within vendor products for reporting American Health Information Community (AHIC), Health Information Technology Standards Panel (HITSP), Certification Commission for Health Information Technology (CCHIT) • Promoting automation of quality data reporting • Developing quality use cases • For possible vendor certification of the QRDA standard Integrating the Healthcare Enterprise • Building Technical Framework for coordination of quality data submission, aggregation and feedback • Driving vendor adoption of standards Health Level Seven • Vehicle for publishing the QRDA standard • Working with Clinical Interoperability Council, Electronic Health Record Technical Committee, Government SIG, Pediatric Data Standards SIG, Structured Documents Technical Committee, and more

12. Related Efforts NCQA, AQA, APQ....: measure definition Measure Development AHIC, HITSP Use Cases eMeasure Definition The Collaborative: eMeasure definition ok? ok? ok? IHE: multi-party choreography using HL7 messages, services feedback QRDA QRDA QRDA Aggregators, Requestors

13. Related Efforts • Coordination Points: preliminary work shows that • QRDA maps to The Collaborative Work Group B data export requirements • QRDA can be payload in IHE PEQD multi-party choreography • Combined efforts of The Collaborative, IHE, QRDA and SDOs support AHIC and HITSP use cases • Coordination Priorities: future • Electronic measure definitions drive data entry as well as validation • Integrate into national exchange framework

14. QRDA Project Overview Phase One: • Define project opportunity • Select standards development expert for support • Secure endorsement and funding • Recruit volunteers • Develop prototype QRDA-compliant reports • Describe relationship to other projects • Make recommendations for moving forward • Secure endorsement and funding for Phase Two Phase Two: • Ballot and publish QRDA Draft Standard for Trial Use through HL7 • Training material and support for vendors adopting the QRDA for pilot measures; Guidelines on prioritized reporting measures • Conduct proof of concept demonstrations 3 months TBD

15. Benefits of Standardized Electronic Quality Measurement Data Transmission • Leverage existing electronic health record data • Improve information technology return on investment • Eliminate manual data collection (QRDA-compliant EMRs) • Promote adoption of electronic health records • Reduce the data collection, aggregation and reporting burden for health care providers

16. Project Proposal: Quality Reporting Document Architecture • “Health care institutions routinely collect and report performance measure data to improve the quality of care provided to patients. Measure data conforms to the requirements of defined "quality measures" which are written and maintained by institutions concerned about health care quality. This project will define and bring to ballot a set of specifications for reporting quality data in conformance with defined quality measures.” • Project initiation: Sept, 2007 • Initial ballot: Targeted for May, 2008 • See project proposal document

17. Project Fit With Alliance Mission Alliance for Pediatric Quality • Lead, shape and accelerate recognition and adoption of quality improvement • Promotes improvement priorities • Provides specific data elements for pediatric quality measures HL7 PeDSSIG With other HL7 committees, organizations and vendors within the HL7 enterprise • Maps data elements to HL7 RIM • Develops HL7 v3 Implementation Guideline for measure/s using QRDA standard Vendor EMR systems and other systems • Adopts HL7 implementation plan through system updates • Develops internal logic/algorithms to capture data elements for specific measure/s • Validates and tests accuracy of data output for specific measure CCHIT • Vendor certification of compliance to standards Reporting Facility Practice/Healthcare Institution • Purchases vendor that complies with HL7 standards • Receives functionality through vendor system • Participates in reporting to Improvement Organization(s) Requestors of Quality Data Or other central quality assurance bodies such as CHCA, NACHRI, etc. • Accepts QRDA data-submissions for benchmarking

18. Phase One: Volunteers

19. Primary Project Contacts Chad Bennett Iowa Foundation for Medical Care The Collaborative for Performance Measure Integration with EHR Systems cbennett@ifmc.org Crystal Kallem American Health Information Management Association (AHIMA) HL7 Structured Documents Technical Committee crystal.kallem@ahima.org Joy Kuhl Alliance for Pediatric Quality HL7 Pediatric Data Standards Special Interest Group joy.kuhl@chca.com Feliciano Yu, MD HL7 Pediatric Data Standards Special Interest Group The Children’s Hospital of Alabama fyu@peds.uab.edu

20. Quality Reporting HIT Standards Project The Quality Reporting Document Architecture: Phase I FOR DISCUSSION WITH PedsSIG September 2007

21. Strawmen samples • DOQ-IT CAD-1-7 --- Adult, ambulatory • Sample 1: Single visit, initial submission, first visit • Sample 2: Single visit, update, same as Sample 1, adds HbA1c result • Sample 3: Single visit, second visit • Sample 4: Both visits • JCAHO asthma measure (CAC) --- Pediatric, inpatient • Sample 5:

22. Strawmen samples

23. Strawman samples

24. DISCUSSION POINTS: Clinical Content-related Issues • Organization of clinical data both useful; develop alt QRDA stylesheet • as data set/list • comparable to source documents • alternate? • Single/multiple visits per document? defer to discuss w/Collaborative, vendors • If multiple, organize by finding or chronology? • Order/results useful to show as observation/result • Code “test has been ordered” as a result set; provide results as available? • Focus on pediatric use case: discussion • changes to use case? add alternative ICD-9 codes to indicate that also applicable (Greg to supply) • PMS Identifier: N/A? ok • Procedures: values implicit? ok • Contraindications: as JCAHO codes? show alternate representations w/in sample • Patient data: take from 1600 form; what is the minimum data required? to be analyzed • What is “the encounter”? discussion: discuss further: w/Collaborative, vendors, accepting systems’ guidelines • single visit? • series? • “episode”? • Update/replace useful to provide as-is, and update • where needed • replace vs append not resolved • Link to source document(s) / observations not discussed

25. DISCUSSION POINTS: Technical Issues • TECHNICAL ISSUES: • Templates discussion: need to refine usage model (what templates are reusable) • document (report) level • section level • entry level • Code sets discussion: provide translation examples • industry vs quality reporting • Display discussion: develop alt stylesheet • need for QRDA-specific display? • Validation many options possible, no further discussion • submission data set • other: inclusion/exclusion, ? • OIDs reviewed usage, application of • Link to source document(s) / observations not discussed • Display discussion: develop alt stylesheet • review: should codes be displayed? (e.g. “ICD-9....”); alternative stylesheets for MDs, for abstractors?

26. current work HL7 Structured Docs DMIM 2 RMIMs CDA-report CDA-R2 SPL MR Q report HAI H&P CCD AdmitH&P PedH&P diabetic asthma BSI SSI • Rules: • Relationship between DMIM/RMIMs: • blown out • constrained • where can XML change? • what can extend/constrain a model? • R2-body based CDA-reporting • DMIM for SD/R2 • CDA-R3

27. future work HL7 Structured Docs DMIM RMIMs CDA-report CDA-R3 SPL MR Q report HAI H&P CCD AdmitH&P PedH&P diabetic asthma BSI SSI • R2-body based CDA-reporting • DMIM for SD/R2 • CDA-R3 • or • DMIM • CDA-R3 • CDA-report • Rules: • Relationship between DMIM/RMIMs • where can XML change? • what can extend/constrain a model?