1. Clinical Reasoning Update
Connectathon 19
HL7 WGM Baltimore, MD
September 29-30, 2018

2. Connectathon

3. QDM -> QI-Core
Test quality reporting submission using the FHIR MeasureReport resource for a focused set of program measures and based on the Cypress tooling
Support evaluation of CMS program measures in a FHIR environment using:
Translation of QDM-based CQL measures to FHIR-based CQL
Evaluation of QDM-based CQL measures through runtime transformation

4. CQF Measures https://github.com/cqframework/cqf-measures
Github repository housing an IG specifically for this track
Will contain 2 versions each of the following 3 measures:
Breast Cancer Screening (CMS125v7)
Cervical Cancer Screening (CMS124v7)
Colorectal Cancer Screening (CMS130v7)
Will use the May2018 ValueSets (not the addendum)
One version is a FHIR packaging of the QDM-based measure
The other is a FHIR-based version of the measure
Test data for these is posted here:

5. Participating Systems

6. Quality Measure Evaluation
CQL Engine
FHIR Server 1 2 3
FHIR DataProvider 4
CQL Engine evaluates the retrieve [Procedure: Colonoscopy]
FHIR DataProvider transforms this to a FHIR url: [base]/Procedure?code=:in[valueset-url]
FHIR server returns all procedures satisfying the code condition
CQL Engine evaluates additional criteria to satisfy the query (status = 'active', performed ends...)

7. QDM Quality Measure Evaluation
CQL Engine
FHIR Server 1 2 3
FHIR DataProvider 5 4
CQL Engine evaluates the retrieve ["Procedure, Performed": "Colonoscopy"]
FHIR DataProvider transforms this to a FHIR url: [base]/Procedure?code=:in[valueset-url]
FHIR server returns all procedures satisfying the code condition
FHIR DataProvider uses a StructureMap to transform results to "QDM" objects
CQL Engine evaluates additional criteria to satisfy the query (relevantPeriod ends...)

8. Notable Achievements
Calculation of QDM-based CMS Measures against FHIR source data
Calculation of FHIR-based CMS Measures
Used the Crucible testing engine to compare MeasureReport results from different systems
Successful submission of DaVinci MedRec event using $submit-data

9. Vendor Feedback – QDM->QI-Core Mapping
Colorectal Cancer Screening
FOBT where effective during Measurement Period
The QDM used authorDatetime, which QDM-to-QICore mapping says maps to Provenance
That mapping is right in general, but in this case, the authorDatetime in QDM was actually being used to approximate "specimen collection", but what the measure is really looking for is "specimen collection"
This means the QDM implementation will be inconsistent
some systems will implement as "when recorded", some as "when collected"
It also means the mapping can't be encoded in this case
Translations
Interventions - Difficult to know how this maps to FHIR resources
Had to map some codes/code systems such as Administrative Gender
Encounter Mapping
"Encounter, Performed".code should map to Encounter.type, not Encounter.class

10. Vendor Feedback – eCQM Specifications
Measure CQL would be easier to read if terminology declarations were right-aligned:
In the human readable, the terminology section should just be a table with hyperlinked value set references

11. Vendor Feedback – QDM vs QI-Core
Feedback from Athena Health:
We're translating FHIR resources to QDM to support evaluating QDM-based measures. All of this would be much easier if we had FHIR-based measure and could just evaluate them directly.
Feedback from DynamicHealthIT:
Since we started with a working measure calculator our biggest challenge was converting the FHIR resources into native QDM data elements consumable by the measures.

12. FHIR Quality Reporting Breakout
What versions of FHIR/USCore/QICore would you expect quality reporting to be focused on?
STU2 - 0
STU3 - 7
R4 - 0
What roles
Providers/Patients/Hospitals
Collectors/Aggregators/Reporters
Reporting Sinks
Should the system support MeasureReport or BulkJSON
Whether you are required to share the evidence or the conclusion is independent of the format of the response
Should the approach be pull or push?
could be any of the above, depends on lots of factors including timeliness of results, business relationships, quality improvement objectives, etc.
Is there interest in a bridge approach?
Yes, so long as there is a drive towards a single stack
Use OAuth?
Yes
How do we specify programs?
How do we specify provider attribution?

13. Ballot and R4 Next Steps

14. Ballot 14 Comments on CDS Resources 2 Comments on CQI Resources
2 Negative, 12 Affirmative
2 Comments on CQI Resources
2 Affirmative

15. R4 STU Next Steps Resolve and apply ballot comments
Apply QA changes for maturity goals:
Resource
Current FMM
Target FMM
ActivityDefinition 2 3
DetectedIssue 1
EventDefinition
GuidanceResponse
Library
PlanDefinition
RequestGroup
RiskAssessment
Measure
MeasureReport

16. Timeline
Key Dates:
: Final reconciliation package posted for STU ballot
: Final content freeze for R4 publication
: IG content freeze and QA period start
– : QA changes applied
– : Recirculation ballot
Before : R4 publication

17. Questions?