Clinical Quality Framework cqframework.info All Hands Meeting April 17, am-12:30pm ET

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. Send your “chat” to All Panelists in order to ensure the comments are addressed publicly. Should you need to take another call, please leave the meeting and rejoin (i.e., please do not put the meeting line on hold). 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 2

Goals 3 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 4 TopicPresenter WelcomeKen Kawamoto, CQF Co-Coordinator Charter ConsensusKen Kawamoto, CQF Co-Coordinator PilotsChris Snyder, Peninsula Regional Medical Center Bob Cooke, National Decision Support Company Marc Hadley, CQF Co-Coordinator VTE Prophylaxis Radiology Chlamydia Screening Logical Data Model Considerations Marc Hadley, CQF Co-Coordinator Aziz Boxwala, Standards Sub-Team Co-Lead Next StepsKen Kawamoto, CQF Co-Coordinator Questions and DiscussionKen Kawamoto, CQF Co-Coordinator

Welcome 5 Announcements, Meeting Schedules, Agendas, Minutes, Reference Materials, Use Cases, Project Charter, and General Information are posted on cqframework.infocqframework.info All-Hands meetings are held weekly on Thursdays from 11am- 12:30pm ET Dial In: Access code: CQF Data Model meetings are held weekly on Tuesdays from 1- 2pm ET Dial In: Participant Passcode:

Welcome 6 Voluntary 2015 Edition Electronic Health Record Certification Criteria: Interoperability Updates and Regulatory Improvements; CorrectionVoluntary 2015 Edition Electronic Health Record Certification Criteria: Interoperability Updates and Regulatory Improvements; Correction Provide formal comments via regulations.gov until 4/28/14. regulations.gov Health Level Seven International (HL7) –ListservListserv –MembershipMembership

Charter Consensus 7

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 8

Charter Consensus 9 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

10 VoteCharter Section CommentName 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

11 VoteCharter Section CommentName 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

12 VoteCharter Section CommentName 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) TimelineTo 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 YerraSiemens HealthCareCommitted Member YesGeneral 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

13 VoteCharter Section CommentName Org Role YesRandall Case American College of Emergency Physicians Committed Member YesPolina Kukhareva University of Utah Committed Member YesCharles Parker Interface People Committed Member YesBruce Bray University of Utah Committed Member YesKevin HeardBJC HealthCareCommitted Member Charter Consensus

Pilots 14

House-wide Venous Thromboembolism (VTE) Prophylaxis And PPC 16 - VTE 15

PPC/HAC VTE PPC - provider preventable conditions HAC - hospital acquired condition 16

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 form 17

% VTE Prophylaxis for Inpatient IP - inpatient 18

% VTE Prophylaxis for Intensive Care ICU - intensive care unit 19

% Prophylaxis Utilized- Appropriate Care Score ACS - appropriate care score 20

Hospital Acquired DVT’s per 1,000 Discharges 21

VTE Prophylaxis Compliance and VTE PPC/HAC per 1000 patients Hospital Acquired DVT’s per 1,000 Discharges 22

Radiology 23 Point of Order CPOE Confidential © National Decision Support Company

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 24 Confidential © National Decision Support Company

ACR Select Platform EHR customer2.acrselect.org customer1.acrselect.org API Ordering Physician Access DSN LOCALIZATION PORTAL PLATFORM AUC Confidential © National Decision Support Company

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 ACR Select presents score of selected exams any alternates User refines order based on feedback Consult AUC Record DSN Confidential © National Decision Support Company

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

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) 29 Confidential © National Decision Support Company

Logical Data Model Considerations CQF Data Model Team 30

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 Support CQM - Clinical Quality Measurement 31

Use of Data Models in CDS and CQM Evaluation 32

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 33

FHIR as the Data Model Use FHIR resources as the logical model 34

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 35

Example in FHIR – Diagnosis Active: Asthma Condition C where C.code.system=" " and C.code.code =" " and C.status=confirmed and C.startDate <= 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 36

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 37

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 38

Example in Alternative Model – Diagnosis Active: Asthma ConditionPresent C where C.code.system=" " and C.code.code =" " and C.status=Active and C.startDate <= Condition is active 39

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 40

Participation in Model Development CQF Data Model call on Wednesday at 1 pm ET – –Phone Number: , Participant Passcode: HL7 Clinical Decision Support (CDS) Work Group call on Thursday at 3 pm ET – –Dial , Participant Code: HL7 Clinical Quality Information (CQI) Work Group call on Fridays at 1- 3 pm ET (2-3 pm ET joint with CDS) –URL: –Dial In: –Access code: –Meeting ID:

Next Steps Communicate your areas of interest for contributing via or via the wiki Join us for the next Clinical Quality Framework meeting on April 24 from 11am-12:30pm ET 42

Questions and Open Discussion 43 Name Marc Hadley, Ken Kawamoto, Bridget Blake, cqframework.info

Resources Clinical Quality Framework S&I Initiative Data Access Framework S&I Initiative FHIR Health eDecisions S&I Initiative HL7 Clinical Decision Support Work Group HL7 Clinical Quality Information Work Group HL7 Structured Documents Work Group Query Health S&I Initiative S&I Process 44 cqframework.info