Clinical Quality Framework cqframework.info All Hands Meeting June 2, 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 Welcome & AnnouncementsSwapna Bhatia, Project Support IOM DIGITizESandy Aronson & Grant Wood, IOM DIGITizE HumanaAngelica Garcia-Gutierrez, Transcend Insights Blue Cross Blue ShieldLenel James, Blue Cross Blue Shield Next StepsKen Kawamoto, 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 *New Time* CDS-on-FHIR/CQF Office Hours meetings are held weekly on Wednesday from 12pm to 1pm ET Dial In: Participant passcode: CQF Data Model meetings are held weekly on Wednesdays from 1pm to 2pm ET NQM-8ENJ&rnd= NQM-8ENJ&rnd= Dial In: Participant passcode: Clinical Quality Framework (CQF) All Hands meetings are held bi-weekly on Thursdays from 11am to 12:30pm ET Dial In: Access code: CQF Wiki: cqframework.info 4

Cooking with CQL Announcements 5 CMS invites you to a "Cooking with CQL: or How to Incorporate CQL into Health Quality Measure Format (HQMF) for Electronic Clinical Quality Measures (eCQMs) webinar. Each Cooking with CQL session will feature a specific topic. This course will walk through how to express a measure in CQL and provide an interactive opportunity for measure developers. Register for the webinar taking place on Thursday June 9, 2016 at 4:00PM - 5:00PM EDT: eb92296c eb92296c84 If you have any questions or need additional information, please contact Amira Elhagmusa at

6 IOM DIGITizE Sandy Aronson & Grant Wood

Display and Integrating Genetic Results Through the EHR (DIGITizE) Update

DIGITizE’s Current Objectives Pilot Existing Implementation Guide – Abacavir – HLA-B and TMPT – Azathiopurine focused – Thank you Bryn porting the guide to the FHIR format! Establishing New Guides – Lynch Syndrome with CSER – FH

Pilot Status Pilot WG Established (Grant Wood and Brad Strock Co-chairs) Multiple pilot sites meet yesterday to share status Different sites encounter challenges at different times - cross site sharing of techniques and best practices has begun

Pilot Sites that Met Yesterday Intermountain HealthCare Partners HealthCare University of Utah Duke St. Jude Mission Health Children’s Hospital Boston Johns Hopkins will also be participating but could not make the call

General Status Sites working through internal processes associated with standing up production Clinical Decision Support Clarity of rules and simplicity of requirements is making these processes easier Different architectural/messaging strategies being employed – will be interesting to assess differences over the course of the rollouts

Some Initial Issues/Questions Sharing the process of policy making and testing in developing CDS rules Careful review of alerts to avoid disrupting workflow Clinician involvement and feedback will be key Some sites further along, but adoption of standards a question Standardizing rules, even within the same EHR vendor, may be an issue Two sites implementing FHIR, others V2

13 Transcend Insights: Humana Angelica Garcia-Gutierrez

June, Update on the use of CQL and QUICK for the representation of HEDIS Measures.

Frameworks CQL  Provide a clinically focused, author friendly, and human- readable language for the representation of Clinical Quality Measures work/clinical_quality_langu age QUICK 15  Data Model that represents patient-centric concepts Auto-generated from the HL7 Quality Improvement Core (QICore) FHIR Profiles y/quick

HEDIS 16  HEDIS 2016 is published across a number of volumes and includes 88 measures across 7 domains of care: – Effectiveness of Care. – Access/Availability of Care. – Experience of Care. – Utilization and Risk Adjusted Utilization. – Relative Resource Use. – Health Plan Descriptive Information. – Measures Collected Using Electronic Clinical Data Systems.

HEDIS Measures with CQL Representation 17  Childhood Immunizations (CIS) -DTaP/DT – Children two years of age who have received four diphtheria, tetanus and acellular pertussis (DTaP/DT) vaccines by their second birthday.  Cervical Cancer Screening (CCS) – Women age 21 to 64 who had cervical cytology performed every 3 years. – Women age 30 to 64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.  Comprehensive Diabetes Care (CDC) -Retinal Exam – Patients 18 to 75 years of age with diabetes (type 1 and type 2) who have a claim for a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year or a negative retinal exam (no evidence of retinopathy) by an eye care professional documented in claims data in the year prior to the measurement year.  Osteoporosis Management in Women who had a Fracture (OMW) – Women 67 years of age and older who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture.

Current Challenges using CQL and QUICK 18  QUICK: Difficult to navigate references  Use case: Count the number of times a given medication was dispensed in the same period of time, and that was prescribed by different practitioners (use NPI)  In order to access the NPI (National Provider Identifier) from the QI-CORE MedicationDispense profile:  MedicationDispense.authorizingPrescription (Reference QICORE-MedicationOrder). prescriber(Reference QI-CORE-Practitioner).id  CQL: List Operators include First and Last, but not Second, Third or Fourth (per QDM).  Second= “Valid Outpatient Visit”[ IndexOf(First(“Valid Outpatient Visit” V sort by V.date asc)+1) ]  Unable to directly use CQL-to-ELM Conversion Tool  HEDIS Measures data source is Claim/Encounter Data  QI-CORE profiles for FHIR Claim and Coverage resources do not exist  QUICK model info that the CQL-to-ELM translator is using is out of date

Measure Library for Comprehensive Diabetes Care – Retinal Screening 19 Library CCD_RetinalScrrening_QUICK version ‘1' using QUICK valueset "Outpatient": ' ' valueset "Observation" :' ' valueset "ED":' ' valueset "Nonacute Inpatient":' ' valueset "Diabetes":' ' valueset "EYE_CARE_PROFESSIONAL":'TBD' valueset "Diabetic Retinal Screening":' ' valueset "Diabetic Retinal Screening Negative":' ' valueset "Acute Inpatient":' ' parameter CutoffDate DateTime parameter "One Year Prior and during Measurement Period" default Interval(CutoffDate - 2 years, CutoffDate] parameter "Measurement Period" default Interval(CutoffDate - 1 years, CutoffDate] context Patient define "In Demographic": AgeInYearsAt(CutoffDate) >= 18 and AgeInYearsAt(CutoffDate) <= 75 define "Members with Diabetes by Pharmacy Data": [MedicationDispense: type in "CDC-A"] M where M.whenHandedOver during "One Year Prior and during Measurement Period”

Measure Library for Comprehensive Diabetes Care – Retinal Screening 20 define "Outpatient and Nonacute Inpatient with Diabetes by Claim Data": from [Claim: diagnosis in "Diabetes"] C where C.item.servicedDate during "One Year Prior and during Measurement Period" and ( C.item.service in "Outpatient" or C.item.service in "Observation" or C.item.service in "ED" or C.item.service in "Nonacute Inpatient") define "Acute Inpatient with Diabetes by Claim Data": from [Claim: diagnosis in "Diabetes"] C where C.item.servicedDate during "One Year Prior and during Measurement Period" and C.item.service in "Acute Inpatient" define "Denominator Reason 1": if exists("Members with Diabetes by Pharmacy Data") then {Last("Members with Diabetes by Pharmacy Data" C sort by C.whenHandedOver asc)} else null define "Denominator Reason 2": case when Count("Outpatient and Nonacute Inpatient with Diabetes by Claim Data" C return C.item.servicedDate) >= 2 then { Last("Outpatient and Nonacute Inpatient with Diabetes by Claim Data" C sort by C.item.servicedDate asc), "Outpatient and Nonacute Inpatient with Diabetes by Claim Data"[ IndexOf( "Outpatient and Nonacute Inpatient with Diabetes by Claim Data", Last("Outpatient and Nonacute Inpatient with Diabetes by Claim Data" C sort by C.item.servicedDate asc))-1] } when exists("Acute Inpatient with Diabetes by Claim Data") then {Last("Acute Inpatient with Diabetes by Claim Data" C sort by C.item.servicedDate asc)} else null end denominator "Is Eligible": "In Demographic" and exists "Denominator Reason 1” or exists "Denominator Reason 2”

Measure Library for Comprehensive Diabetes Care – Retinal Screening 21 //--Numerator define "Num Reason1: Diabetical Retinal Screening by an Eye Care Professional": from [Claim: item.service in "Diabetic Retinal Screening"] C where C.item.servicedDate during "Measurement Period" and C.asserter.practitioner.practitionerRole.specialty in "EYE_CARE_PROFESSIONAL" define "Num Reason2: Diabetical Retinal Screening by any Provider": from [Claim: item.service in "Diabetic Retinal Screening With Eye Care Professional"] C where C.item.servicedDate during "Measurement Period" define "Num Reason3: Diabetical Retinal Screening Negative by any Provider": from [Claim: item.service in "Diabetic Retinal Screening Negative"] C where C.item.servicedDate during "Measurement Period" define "Is Compliant": exists("Num Reason1: Diabetical Retinal Screening by an Eye Care Professional") or exists "Num Reason2: Diabetical Retinal Screening by any Provider" or exists "Num Reason3: Diabetical Retinal Screening Negative by any Provider" define "Compliance Date": Max ({ Last ("Num Reason1: Diabetical Retinal Screening by an Eye Care Professional" c sort by c.item.servicedDate).item.servicedDate, Last ("Num Reason2: Diabetical Retinal Screening by any Provider” c sort by c.item.servicedDate asc).item.servicedDate, Last ("Num Reason3: Diabetical Retinal Screening Negative by any Provider" c sort by c.item.servicedDate asc).item.servicedDate })

Measure Library for Comprehensive Diabetes Care – Retinal Screening 22 define "Most Recent Compliance Fact": if "Compliance Date" = Last ("Num Reason1: Diabetical Retinal Screening by an Eye Care P`rofessional" c sort by c.item.servicedDate).item.servicedDate then Last ("Num Reason1: Diabetical Retinal Screening by an Eye Care Professional" c sort by c.item.servicedDate) else if "Compliance Date" = Last ("Num Reason2: Diabetical Retinal Screening by any Provider" c sort by c.item.servicedDate asc).item.servicedDate then Last ("Num Reason2: Diabetical Retinal Screening by any Provider" c sort by c.item.servicedDate asc) else if "Compliance Date" = Last ("Num Reason3: Diabetical Retinal Screening Negative by any Provider" c sort by c.item.servicedDate asc).item.servicedDate then Last ("Num Reason3: Diabetical Retinal Screening Negative by any Provider" c sort by c.item.servicedDate asc) else null define "Numerator Facts": { complianceFlag: "Is Compliant", complianceDate: "Compliance Date", claim: "Most Recent Compliance Fact" } //--Optional Exclusions define "Gestational or Steroid Induced Diabetes": [Claim: item.service in "Diabetes Exclusions"] C where C.item.servicedDate during "One Year Prior and during Measurement Period" define "Has Optional Exclusions": exists "Gestational or Steroid Induced Diabetes" and not exists "Outpatient and Nonacute Inpatient with Diabetes by Claim Data" and not exists "Acute Inpatient with Diabetes by Claim Data" define "Optional Exclusions Facts": "Gestational or Steroid Induced Diabetes"

Next Steps Follow up with the CQI Workgroup for possible additions of QI-CORE Profiles for FHIR Claim and Coverage Resources. CQL-to-ELM Conversion Tool – Follow up with Bryn Rhodes on having the tool using an updated version of the QUICK data model. Collaborate with CQF on the development of tools that simplify Reference navigation. Continue to write CQL Representations of HEDIS Measures.

24 Blue Cross Blue Shield Lenel James

Payer Extract IG - Connectathon Summary Using the CQF IG to Describe and Extract Data

Payer Extract Goals Determine feasibility of CQF-Based approach to communicating data elements required for calculating payer quality measures Engage payers and vendors at the upcoming connect-a-thon to test the approach Incorporate feedback from the connect-a-thon into the CQF IG Assess the results and course-correct as appropriate

Data Extraction EHR Data Payer Payer Extract Processing EHR FHIR Endpoint Payer Extract Endpoint

Data Element Definitions

Sample Data

MeasureReport - Individual Level

MeasureReport

Evaluated Resources Bundle

Subscribe to Clinical Quality Framework Please visit the “Join the Initiative” section of the CQF Wikipage to subscribe to our list serve: – ework+Join+the+Initiative ework+Join+the+Initiative 33

Next Steps Join the Initiative Engage in Workgroups ( Pilots – Co-Coordinator, Ken KawamotoKen Kawamoto – Co-Coordinator, Floyd EisenbergFloyd Eisenberg Standards Development – Subject Matter Expert, Bryn RhodesBryn Rhodes Join us for the upcoming Clinical Quality Framework All Hands meeting: June 16, 2016 CQF Wiki: cqframework.info 34

Questions and Discussion Name Ken Kawamoto, Floyd Eisenberg, Swapna Bhatia, Initiative cqframework.info CQF Wiki: cqframework.info 35