Query Health: Distributed Population Queries Overview

Provide an overview of how Query Health is progressing How do the different parts of the Query Health solution fit together and their progress ? Use Cases and Requirements Standards and Specifications Reference Implementation Operational guidance and Pilots Session Objectives

Vision Enable a learning health system to understand population measures of health, performance, disease and quality, while respecting patient privacy, to improve patient and population health and reduce costs.

3 Distributed Query Outcomes Identify/Develop standards, specifications and Implementation Guides for distributed queries Deliver a robust, open source Reference Implementation that implement the standards and specifications Create operational guidelines and templates for Query Health pilots Pilot the Reference Implementation and provide feedback on standards and specifications

Why a Distributed Query ? Data Sources maintain HIPAA- mandated contractual control of their PHI Local content experts maintain a close relationship with the data Data Sources have the best understanding of their data and its uses; valid use and interpretation of findings requires input from the Data Sources. Easier to manage consent Lessens scale of breach / risk exposure / competitive exposure Accuracy, timeliness, flexibility, sustainability Don’t wait for a pendulum swing here: Privacy is a healthcare constant

Distributed queries unambiguously define a population from a larger set Questions about disease outbreaks, prevention activities, health research, quality measures, etc.

Distributed Query Networks Voluntary, No Central Planning Community of participants that voluntarily agree to interact with each other. There will be many networks; requestors and responders may participate in multiple networks. RequestorsParticipating Responders Query

Aggregated DataPatient Data Query & Results Reviewer Query & Results Reviewer Data Source How would a distributed query work? Information Requester 5. Sends Query Results to Information Requestor Firewall 3. Distribute Query to Data Sources 1. EHR / Clinical Record (Patient Data) 1. EHR / Clinical Record (Patient Data) 2. Query Health Data Element Mapping Note: All patient level data stays behind the firewall. Translate patient data 4. Execute Query, format & return Results Responding Organization

8 What are we Standardizing ? What data can be queried ? How are queries represented ? How are results represented ? How are queries and results exchanged ?

9 Query Health Supporting Artifacts Data Use Agreement Template for Pilots Health IT Policy Committee and Tiger Team recommendations for ONC pilots Reference Implementation Foundation Components

Vocabulary & Code Sets Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and government priorities Content Structure Queries & Responses Privacy & Security RI Foundation: Distributed Query Solutions SNOMED-CT Clinical Element Data Dictionary i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet LOINC ICD-10 RxNorm 10 Query Health Standards and RI Foundation Components Components The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Concept Definitions and Value Sets

The Data Clinical Element Data Dictionary (CEDD) 11 – Demographic – Patient Contact Information – Payer Information – Healthcare Provider – Allergies & Adverse Reactions – Encounter – Surgery – Diagnosis – Medication – Procedure – Immunization – Advance Directive – Vital Signs – Physical Exam – Family History – Social History – Order – Result – Medical Equipment – Care Setting – Enrollment – Facility ONC S&I Framework deliverable Standards independent

CEDD Cont’d 12 Data Element Name Data Element DefinitionData Element Format Expected Values/Cardinality Expected Vocabulary Guidelines Diagnosis Name The name of the diagnosis. Can also be used to capture a local code if the standard code is not mapped TextRequired Diagnosis FlagPrincipal diagnosis flagText Diagnosis TypeDescribes the typeCoded ValueRequiredSNOMED-CT Diagnosis DateCaptures the date of the diagnosisDate Diagnosis CodeUsed to capture a specific diagnosis codeCoded ValueRequiredSNOMED-CT Data Element Definition: Data Element Implementation Guidance – i2B2 S&I CEDD Defined ObjectS&I CEDD Data Elementsi2b2 CRC Dimensioni2b2 Dimension Data Element Implementation Guidelines Diagnosis Diagnosis CodeObservation Factconcept_cdDiagnosis is represented in i2b2 using the ICD-9 CM ontology The diagnosis concept code is used to join to other information, such as diagnoses, procedures, and medications, which also use concept codes.

CEDD alignment with NQF’s QDM 13

CEDD and C2C Outputs 14 1.Healthcare Industry has a significant gap in creating, managing and publishing “Value Sets” mapped to common concepts. – Community recommends to the HITSC to work with organizations such as NLM, NQF and others to set up the above capability. 2.For Query Health, the suggestion was to start with NQF CQM based Value Sets and improve from there. – This is a very good source as evidenced by the community and Query Health will start from these value sets. 3.In order to share value sets in a standard way, Query Health will adopt the IHE SVS Restful web service approach and will pilot that using the NQF and i2B2 Value Sets. 4.The CEDD is a significant specification to promote common definitions of queries across multiple Data Sources – Enhance the CEDD to include the vocabulary mapping, value sets for elements where applicable and map to the reference implementation frameworks of i2B2, hQuery and PopMedNet to ensure completeness 5.Multiple tools and interfaces can be used for Query Composition, but simple intuitive ways are necessary and the concept hierarchy representation of i2B2 has been proven to work in the real world. – Adopt i2B2 approach and create the hierarchy for Query Health pilots.

Vocabulary & Code Sets Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and government priorities Content Structure Queries & Responses Privacy & Security RI Foundation: Distributed Query Solutions SNOMED-CT Clinical Element Data Dictionary i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet LOINC ICD-10 RxNorm 15 Query Health Standards and RI Foundation Components Components The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Concept Definitions and Value Sets

The Query New HQMF Health Quality Measure Format HQMF newly modified to support the needs for dynamic population queries: – More executable – Simplified Advantages for query – Avoids “yet another standard” – Secure (vs procedural approach) – Works across diverse platforms Benefits – Speed and Cost

What are the major modifications Addition of business names to criteria and section elements to translate HQMF to executable code Inclusion of Variable definitions which allow for re-use of definitions within HQMF and also allow for easier translation to executable code Addition of Precondition conjunctions Complete List at y+Health+-+Query+Format y+Health+-+Query+Format

Vocabulary & Code Sets Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and government priorities Content Structure Queries & Responses Privacy & Security RI Foundation: Distributed Query Solutions SNOMED-CT Clinical Element Data Dictionary i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet LOINC ICD-10 RxNorm 18 Query Health Standards and RI Foundation Components Components The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Concept Definitions and Value Sets

The Results New QRDA Quality Reporting Document Architecture – Category I – Patient Level – Category II – Patient Populations – Category III – Population Measures Query Health will use new definitions of Categories II and III – Not yet specified and balloted – Needs implementation guide – Needs to align with eMeasures

Vocabulary & Code Sets Develop modular, testable portfolio of Query Health standards and specifications that can adopted by the industry, and support key HITECH and government priorities Content Structure Queries & Responses Privacy & Security RI Foundation: Distributed Query Solutions SNOMED-CT Clinical Element Data Dictionary i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet LOINC ICD-10 RxNorm 20 Query Health Standards and RI Foundation Components Components The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Concept Definitions and Value Sets

The Query Envelope Query agnostic Content agnostic Metadata facilitates privacy guidance from HIT Policy Committee RESTful interface specification for the Existing RI component integration

Query Health Technical Approach - Putting it all together 22

Query Health Technical Approach – Reference Implementation Components PopMedNet Components Query/Results Standards Components i2B2 Components hQuery Components hQuery Query Builder UX HQMF Query Builder UX PMN Portal PMN Data Client HQMF to Procedural Translator hQuery Execution Enginei2B2 Execution Engine Data Sources Native to QRDA Translator i2B2 Query Builder UX Results Viewer hQuery CIM (JSON) i2B2 CIM (STAR Schema) C32 or ETL Policy Enablement Components New HQMF JavaScript SQL Native Formats QRDA (Category III Report) Query Envelope Requesting Organization Responding Organization

Demonstration Distributed Query Execution What you’ll see – Life cycle of a Distributed Query (1 requestor, 2 data providers) – Policy Enablement Layer (control of queries execution and results by data providers) – RESTful interface – Query Envelope metadata for work flow integration and policy enforcement – Integration of hQuery (Query execution) and PopMedNet (policy enablement) – Open source components Presenting – Marc Hadley, MITRE Corporation – Rob Rosen, Lincoln Peak 24

Demonstration Query Language What you’ll see – Query Composition using i2B2 query builder – Query representation of i2B2 using internal formats and ontologies – Translation of composed Query to new HQMF – Translation of new HQMF to Java script – Open source components Presenting – Jeff Klann, Partners Healthcare – Marc Hadley, MITRE 25

Current Status of Standards, Specifications and Supporting Artifacts 26 ArtifactCurrent StatusLink CEDD SpecificationConsensus Approvedhttp://wiki.siframework.org/file/view/Query+Health+CEDD_Version+1+0.docx/ /Query%20Health%20CEDD_Version%201%200.docx Query EnvelopeFirst Round of Consensus voting completed - Resolving Consensus votes Query Format (HQMF Implementation Guide) HQMF Schema Changes completed. Implementation Guide under review and comments Schema Location: IG: Query Results (QRDA Category II and III Implementation Guide) QRDA proposed changes under review and comments IG: DUA TemplateConsensus Approvedhttp://wiki.siframework.org/file/view/Query%20Health%20DUA%20- %20Final%20for%20Consensus%20-%20Updated% doc Concept to Code WG Recommendations Consensus Approvedhttp://wiki.siframework.org/file/view/SIFramework_QH_ConcepttoCode s_V1.0.ppt

Current Status of RI 27 ArtifactCurrent StatusLink Base PopMedNet 3.0 PlatformCompletedhttp:// PopMedNet Plug-in RESTful InterfacesCompleted. Base i2B2 PlatformExisting Platformhttps:// i2B2 XML to HQMF TranslatorFirst Version Completed (Able to create HQMF queries for encounters, meds, labs, problems, diagnosis, demographics etc) y-health i2B2 HQMF to Native TranslatorIn-Progress i2B2 – PopMedNet IntegrationIn-Progress hQuery Base PlatformCompletedhttp://github.com/hquery HQMF to Java Script TranslatorFirst Version Completed (Able to translate i2B2 and sample HQMF queries.) qmf2js/tree/query-health-dev hQuery Composer to HQMFNot started hQuery – PopMedNet IntegrationFirst Version Completedhttp://github.com/hquery HQMF to SQL Translator (PopMedNet, CDC and other Vendors) Initial Prototype. y-health QRDA TranslatorsNot started Implement C2C RecommendationsIn-Progress PopMedNet Enhancements for Query Envelope Not started

NYS DOH NYC PCIP Information Requestors Data Sources Axolotl RHIO Inter- systems RHIO eCW EHR Sends Query to Data Sources Distributes Query Results to Information Requestor New York City / New York State Pilot Sends Query to Data Sources Distributes Query Results to Information Requestor

Mini-Sentinel/FDA Pilot 1- User creates and submits query (a computer program) 2- Data partners retrieve query 3- Data partners review and run query against their local data 4- Data partners review results 5- Data partners return results via secure network 6 Results are aggregated PopMedNet

Top Level Roadmap

The Way Ahead for Query Health

The path to critical mass 32 Today, distributed queries are generally limited to – Organizations with large IT & research budgets – Some exceptions (e.g., NYC PCIP, MDPHNet) Missing: Primary Care, FQHCs, CAHs, HIEs, etc… In other words, most places where clinical care is delivered and recorded Path to critical mass depends on – Query Health Standards – Health IT vendor participation Health IT vendors AllscriptsAmazing Charts AZZLYCerner dbMotionClinicalWorks EpiceRECORDS IBEZAInterSystems MedicityMicrosoft National Health Data Systems NextGenRelayHealth Siemens Check back - more to come at QueryHealth.org Health IT vendors AllscriptsAmazing Charts AZZLYCerner dbMotionClinicalWorks EpiceRECORDS IBEZAInterSystems MedicityMicrosoft National Health Data Systems NextGenRelayHealth Siemens Check back - more to come at QueryHealth.org

Agenda for Thursday / Friday 33 SessionTrack 1Track 2 Thursday Morning (8am – 10am) RI Coding and Enhancements (HQMF Translators, Value Sets, NY DOH Pilot – i2B2 ontology mapping) HQMF Sample Representation (Need to have XML Spy or Oxygen or some eclipse editor) (Samples/Schemas from Google Code Repository) Thursday Morning (10:30am – 12) RI Coding and Enhancements (HQMF Translators, Value Sets, NY DOH Pilot – i2B2 ontology mapping) QRDA Sample Representation (Need to have XML Spy or Oxygen or some eclipse editor) (Samples/Schemas from Google Code Repository) Thursday Afternoon (1:30 – 3:30 pm) HQMF IG Review (Discuss pending issues) CEDD Specification Review and Mapping activities (IG cleanup, Implementation Guidance) Thursday Afternoon (4 – 6pm) HQMF IG Review (Discuss IG) CEDD Specification Review and Mapping activities (IG cleanup, Implementation Guidance) Friday Morning (8-9am) RI Round Table (Ask the RI team questions about the RI components) QRDA IG Review Friday Morning (9 – 10:30 am) Pilots Discussion (NY and FDA Pilot next steps planning session, timelines) QRDA IG Review Friday Morning (11 – 12 noon) Wrap Up

Query Health Recap An ONC-sponsored S&I Framework open government initiative Standards and specifications for distributed population queries. “Send questions to the data” Data sources including EHRs, HIEs, PHRs, payers’ clinical record or any other clinical record. Voluntary collaborative networks Declarative questions build on NQF / CMS work on population measures Aggregate responses – Patient level information secure – Support questions related to disease outbreak, quality, CER, post-market surveillance, performance, utilization, public health, prevention, resource optimization and many others. Vocabulary & Code Sets Content Structure Queries & Responses Privacy & Security RI Foundation: Distributed Query Solutions SNOMED-CT Clinical Element Data Dictionary i2b2 The Results New QRDA 2 & 3 The Results New QRDA 2 & 3 PopMedNet LOINC ICD-10 RxNorm The Question New HQMF The Question New HQMF Query Envelope Privacy Policy Enablement hQuery Concept Definitions and Value Sets