Clinical Quality Framework cqframework.info All Hands Meeting January 28, am-12:30pm ET 2 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. 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 CQF Wiki: cqframework.info 2 Send your chat to All Panelists in order to ensure the comments are addressed publicly. This meeting is being recorded. Should you need to take another call, please leave the meeting and rejoin (i.e., please do not put the meeting line on hold). Agenda TopicPresenter WelcomeSwapna Bhatia, Project Administrative Support Interview Study to Identify Barriers and Potential Solutions to CDS-eCQM Integration Ken Kawamoto, CQF Co-Coordinator Orlando HL7 Work Group Meeting UpdateKen Kawamoto, CQF Co-Coordinator Floyd Eisenberg, CQF Co-Coordinator Bryn Rhodes, CQF Subject Matter Expert CDS-on-FHIR Connect-a-Thon Implementation Experience Bryn Rhodes, CQF Subject Matter Expert CDS-on-FHIR HarmonizationBryn Rhodes, CQF Subject Matter Expert Next StepsFloyd Eisenberg, CQF Co-Coordinator Questions and DiscussionFloyd Eisenberg, CQF Co-Coordinator CQF Wiki: cqframework.info 3 Welcome Announcements, Meeting Schedules, Agendas, Minutes, Reference Materials, Use Cases, Project Charter, and General Information are posted on cqframework.info cqframework.info Clinical Quality Framework (CQF) All Hands meetings are held bi-weekly on Thursdays from 11am to 12:30pm ET https://siframework1.webex.com/siframework1/onstage/g.php?t=a&d= Dial In: Access code: CQF Data Model meetings are held weekly on Wednesdays from 1 to 2pm ET https://meetings.webex.com/collabs/#/meetings/detail?uuid=M8UL81KQZZKHCW46R28OYGI NQM-8ENJ&rnd= https://meetings.webex.com/collabs/#/meetings/detail?uuid=M8UL81KQZZKHCW46R28OYGI NQM-8ENJ&rnd= Dial In: Participant passcode: CDS-on-FHIR/CQF Office Hours meetings are held weekly on Wednesdays from 11am to 12pm ET https://global.gotomeeting.com/meeting/join/ Dial In: Participant passcode: CQF Wiki: cqframework.info 4 Welcome Bonnie Users Group CMS and ONC invite you to join the new Bonnie Users Group. Bonnie is a tool for testing electronic clinical quality measures (eCQMs). The purpose of this user group is to create a community of Bonnie users that can benefit from one anothers experience and questions, and to allow the development team to easily reach out to the community regarding new releases, proposed features, and focus group opportunities To join: Navigate to https://groups.google.com/forum/#!forum/bonniehttps://groups.google.com/forum/#!forum/bonnie Sign into a google account, or create one You can create a google account tied to an existingaddress: under Choose your username click I prefer to use my currentaddress. Click Join group Adjust your preferred settings in the pop-up dialog to indicate how you wish to receive group messages. You can change these settings later Click Join this group Contact us with questions at CQF Wiki: cqframework.info 5 Interview Study to Identify Barriers and Potential Solutions to CDS-eCQM Integration Ken Kawamoto, CQF Co-Coordinator CQF Wiki: cqframework.info 6 Interview Study Univ. of Utah researchers are seeking to interview experts in CDS and eCQM to better understand how CDS and eCQM can be integrated to improve care 1 hour interview, $40 Amazon gift certificate Please contact if CQF Wiki: cqframework.info 7 Orlando HL7 Work Group Meeting Update Ken Kawamoto, CQF Co-Coordinator Floyd Eisenberg, CQF Co-Coordinator Bryn Rhodes, CQF Subject Matter Expert CQF Wiki: cqframework.info 8 Highlights Successful CDS on FHIR Connect-a-Thon Agreement reached to make GAO FHIR profile a knowledge module of CQIF CDS and CQI Work Groups had a joint session with the Clinical Information Modeling Initiative (CIMI) Work Group and developed a joint plan for developing CIMI models to meet Quality use cases CDS and eCQM FHIR projects will be officially merged into a single project jointly sponsored by CDS and CQI Work Groups A new project will be started to harmonize Clinical Quality Language (CQL) and FHIRPath for use in FHIR CQF Wiki: cqframework.info 9 Clinical Quality Framework IG Combines CDS-on-FHIR IG and eCQM Profile CDS/CQI WGs both primary sponsors Seeking co-sponsorship from FHIR Infrastructure and SOA Incorporates feedback from: Ballot comments from the September cycle for both prior IGs Implementation feedback from the Connectathon Alignment feedback and discussions from other groups: FHIR Infrastructure Patient Care/OO/MnM/Pharmacy/Workflow discussions HSPC Clinical Informatics WG Goal is a May STU Ballot CQF Wiki: cqframework.info 10 CQL/FluentPath FluentPath (aka FHIRPath) is a path traversal language proposed for use within the FHIR specification invariant definitions search parameters CQL has overlapping requirements A new PSS with ITS as primary sponsor and FHIR-I, CDS, and CQI as co-sponsors will expand CQL to add path traversal functionality: Backwards compatible (all existing CQL expressions will still be valid) Profiles can be used to restrict functionality for use in particular settings Within FHIR Specification, FluentPath For Quality Domains, full CQL with strict type-checking CQF Wiki: cqframework.info 11 CDS-on-FHIR Connect-a-Thon Implementation Experience Bryn Rhodes, CQF Subject Matter Expert CQF Wiki: cqframework.info 12 S&I Framework Clinical Quality Initiatives Health eDecisions Focused on Sharing and Evaluating decision support artifacts Resulted in Knowledge Artifact Specification Decision Support Service R2 & IG vMR R2 & related Templates Clinical Quality Framework Focused on Alignment/Harmonization with Quality Measurement Resulted in Conceptual Metadata Model Clinical Quality Language CQIF IG eCQM FHIR Profile CQF Wiki: cqframework.info 13 Clinical Quality Improvement Framework IG Goals Use Case 1: Artifact Structure DecisionSupportServiceModule and DecisionSupportRule Library OrderSet DocumentationTemplate (profile of Questionnaire) Use Case 2: Evaluation DecisionSupportServiceModule/ecrs-cdc- immunizations/$evaluate API Independence as a primary design goal Use Case 3: Distribution Sharing artifact definitions Discovery of Data Requirements Module search functionality CQF Wiki: cqframework.info 14 Connect-a-thon 11 Use Case 2 Partners Healthcare Exposed a FHIR endpoint using CQIF resources as an adapter to their production ECRS rule system Exposed CDC Immunization Guideline Module University of Utah Health Care Also Exposed a FHIR endpoint as an adapter Exposed Colorectal Screening Module using OpenCDS (www.opencds.org) FHIR logical model, flow diagrams, guided ruleswww.opencds.org Also exposed simple GAO Assessment Prototype/Example Implementation Built on Furores Spark and FHIR-NET-API Echo implementation Adapter implementations (for ECRS and CDS-Hooks) CQF Wiki: cqframework.info 15 ECRS CDC Immunization Partners Healthcare Exposed a FHIR endpoint but retained their current model Data is passed to and from the service using in-line XML in FHIR parameters Example implementation was used as an Adapter Input data was transformed from FHIR ECRS input Result was transformed from ECRS Recommendation to FHIR ImmunizationRecommendation in a GuidanceResponse CQF Wiki: cqframework.info 16 CDS-Hooks Adapter Example implementation was extended to implement $cds-hook Defined cdc-immunization activity Expects Patient/Immunziation resources as preFetchData Repackages Parameters in the format expected by $evaluate Executes the call to the ECRS-CDC-Immunization Module Repackages results as a suggestion card CQF Wiki: cqframework.info 17 What worked well? Able to quickly expose functionality from various sources Partners Healthcare, University of Utah Flexible module and API definition enabled multiple scenarios Echo Quick and dirty plumbing tests Adapter Marshalling between existing services w/ different information models Bridge Routing calls between existing FHIR services w/ different operations FHIR Stack and Tooling enabled rapid development of diverse scenarios First Class Resources Much easier to understand and use than the Basic profiles in the previous ballot CQF Wiki: cqframework.info 18 What didnt work well? Difficulty of managing contained resources From a development perspective, location of the resource is painful Difficulty of dealing with extensions From documentation to development, still painful to deal with extension data Structures are often verbose and difficult to deal with in Java/C# Cardinality of elements Extraneous properties Constructing resources is often difficult (should be more fluent) There is some of this, but it should be more prevalent In general, more helper functions throughout the APIs For example, accessing parameter values is quite involved CQF Wiki: cqframework.info 19 Where to next? Interface generation based on profile definitions? Allows for purpose-built representations of particular structures Could reduce cardinality where possible Could make reference location transparent (largely) Could eliminate difference between extensions and first-class properties Could be used in both Java and C# implementations CQF Wiki: cqframework.info 20 CDS-on-FHIR Harmonization Bryn Rhodes, CQF Subject Matter Expert CQF Wiki: cqframework.info 21 Metadata Harmonization ModuleMetadata has elements that are conceptually the same as the various conformance resources, but represented differently ModuleMetadata is defined as a resource but is really a data type We will change this to be a data type that can be used by all the DSS resources FHIR conformance resources may also use this new data type CQF and FHIR Metadata representations will be merged CQF Wiki: cqframework.info 22 Metadata Changes to CQF Add url - Same definition as conformance resources Version Documentation will be updated to indicate version is optional only for draft/test/generated resources, required for publication Status Test status will be removed in favor of experimental flag Coverage - (UseContext) (Proscriptional) Drop Description (is Value.Text) Add Jurisdiction to Focus Type Change Focus Type to Coding Keyword - Get rid of it (collapse to Topic) CQF Wiki: cqframework.info 23 Metadata Changes to CQF Contributor Moved all contributors to be represented in Provenance In general this type of information should only be included in the resource if it is essential to the understanding of the resource. Publisher/Steward Use FHIR simplified representation for the publisher in the Resource directly, provenance for the full organization definition Collapsed Steward to Publisher and clarified documentation Related Resource Simplified representation Clarified resource types: Documentation Additional supporting docs Justification Summary of justification Citation Bibliographic references CQF Wiki: cqframework.info 24 DecisionSupportServiceModule vs OperationDefinition? Pros Becomes part of the FHIR-spec directly Cons Lose the ability to define generic parameters common to all decision support (could resurrect GuidanceRequest) Lose scoping, the ability to define operations within a unique scope for decision support Lose the ability to search for knowledge modules independent of other types of operations within the service CQF Wiki: cqframework.info 25 DecisionSupportServiceModule vs OperationDefinition Recommendation Continue to model DSS and quality measure evaluation as operations against the resources directly Introduce a new batch-level DSS operation to enable multiple evaluations per call 26 Definitional Structures within FHIR Recognizing that this is a general, infrastructure level problem that has lots of applications throughout FHIR, want to take a consistent approach to the solution CDS KAS Approach Use an expression entirely DecisionSupportRule Approach Use a Resource to represent the static components with customization expressions to represent the dynamic components StructureDefinition Approach Point to a StructureDefinition to represent the static components, customize everything else Introduce a definitional status on the intent resources Introduce definitional versions of each of the intent resources CQF Wiki: cqframework.info 27 Next Steps Incorporate changes to the Base Resources Changes from FHIR Infrastructure Changes from Connect-a-thon Feedback Continue incorporating changes from Ballot Changes from reconciling approach with GAO Incorporate eCQM Profile Content Expand Measure resource Add MeasureResponse resource Incorporate ballot feedback CQF Wiki: cqframework.info 28 Seeking Input on Observation Status Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. 29 Medicare Benefit Policy Manual. (Chapter 6, Section 20.6) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06.pdf Seeking Input on Observation Status Seeking input on how EHRs handle transition from Emergency Department to Observation Status to Admission within a single episode of care Purpose to evaluate the single episode from facility arrival time to treatment to facility departure time 30 Single Episode of Care 1 Facility Emergency Department Observation Status Hospital Admission Seeking Input on Observation Status Method to Determine the Following Times 31 ED Arrival Time Departure Time Observation Arrival Time Departure Time Hospital Admission Arrival Time Departure Time Admission Time Discharge Time Admission Time Discharge Time Admission Time Discharge Time Next Steps Engage in workgroups (www.cqframework.info)www.cqframework.info Pilots Co-Coordinator, Ken KawamotoCo-Coordinator, Ken Kawamoto Standards Development Subject Matter Expert, Bryn RhodesSubject Matter Expert, Bryn Rhodes Join us for the upcoming Clinical Quality Framework All Hands meetings: 2/11 CQF Wiki: cqframework.info 32 Questions and Discussion Name Ken Kawamoto, Floyd Eisenberg, Swapna Bhatia, Initiative cqframework.info CQF Wiki: cqframework.info 33