1. eCQM Affinity Group Session #2 Technical Discussion – State eCQM Models, Data Types and Formats, Data Intermediary Services, and Data Quality supporting priority uses of eCQM information

2. Agenda Introductions Context Technical models – State eCQM Technical Models – Data types – Shared services through data intermediaries and governance – QRDA / C-CDA Next steps

3. Context ONC is convening the eCQM Affinity Group as collaborative peer sharing providing assistance for eCQM strategy development. The eCQM Affinity Group will discuss an end-to-end framework and state/regional examples discussing strategic planning, technical models, and implementation best practices. Federal trajectory for quality measurement to support Alternative Payment Models ONC Learning Event – eCQMS – National and State Usage and Issues in Support of Value-Based Payments eCQM Affinity Group #1 - Building Clinical Quality Measure Capacity Framework ONC Health IT Stack for Value-Based Payment Models

4. Context: eCQM Framework Build Capacity for Measurement Key Components Leverage new CEHRT and MU req’ts Promote HIT infrastructure development Develop measurement infrastructure for analysis, reporting Broaden Governance Key Components Identify multi-stakeholder governance structure Identify common objectives Identify value proposition for all stakeholder groups (payers, purchasers, providers, patients) Align around a model Common benefits – use quality measures for developing new VBP products Strengthen Technical Infrastructure Key Components Assess current technical assets in the state to build technical capacity for measurement Identify opportunities for shared technical services or common data intermediaries across organizations Evaluate current core capabilities, roadmaps, and expanding functions Assess needs of data users and sources Improve use of CQM information Key components Create reporting efficiencies Establish accurate source of key provider information Enhance data transparency improving availability of information for providers, health systems, purchasers, payers, and state Programmatic performance evaluation

5. Context: Affinity Group Objectives Discuss CQM framework supporting: – Strategic planning for innovation and value based payment models; – Discussing governance and policy to support building measurement capacity; – Understanding technical models and considerations for choosing appropriate technical model for your state; and – Supporting quality improvement activities improving health, quality of care, and reducing costs.

6. Context: eCQM Uses and Benefits UsesBenefits Clinical Quality Calculation and Measurement improving quality of care delivery Produces better value through higher quality and lower cost of care Measure for Payment – Pay for Value financial incentives for health care providers Rewards providers for lower cost and better outcomes Public Reporting for cost and quality transparency Provides transparency on quality of care supporting supports better decisions by consumers and purchasers Reuse collected data for clinical action and population health measurement Collect data once and reuse for clinical quality measurement and clinical action, such as Clinical Decision Support (CDS) and provider self-monitor progress Payment reform design, implementation, program monitoring and evaluation Builds more effective programs using available quality measures Assesses impact of payment reform programs on value Decision support and gap analysis of patient cohort Cohort identification and understanding of controlled and uncontrolled patient cohorts

7. State eCQM Technical Models Claims only HEDIS Manual chart review/surveys Current state Time-limited No clinical quality measure data Numerator Denominator Program reporting Can’t get to patient level Calculation within EHR Can’t measure across organizations w/out Master Pt. Index Multiple attribution issues Uses: Multiple reporting requirements Data intermediary Central aggregation Calculation Reporting - QRDA III/I; CCDA; but many custom queries Uses: Program Reporting Quality measurement Monitor progress Reuse of clinical data Integrated data Clinical/claims Central data calculation Coordinated governance Uses: Supports pay for value Quality measurement Population health measurement Oregon CQMR Michigan CQMRR at HIE Connecticut Indexing (Edge servers) MyHealth Access Network Tulsa, OK The Health Collaborative Cincinnati, OH Utah UHIN Medicaid EHR Incentive Program attestation

8. For discussion How do states identify end state goals and path to get there? Are there models missing? States using data intermediaries – What were steps taken to implement your model? – What were challenges? – Are you planning on scaling to other uses of the eCQM information?

9. Data type and sources supporting eCQMs Claims only, Clinical only, Integrated (Clinical and Claims) Figure source: Catalyst for Payment Reform. “CPR Employer-Purchaser Guide to Quality Measure Selection.” http://www.catalyzepaymentreform.org/how-we-catalyze/purchaser-strategy-and-tools/quality-measures October 2015

10. System Individual Organization Individual Practice Provider Patient Population Clinica l Coordinated CentralDecentralized Central/shared 1 1 3 3 Data Type Identity Management Unit of Measurement Claims Independent 2 2 4 4 eCQMs – Use Case #1 – Claims Only Governance AdvantagesDisadvantages Data easy to access-No use for clinical quality measurement -Value of data for clinical action goes down -No comparison across organizations Uses Clinical Quality Measurement Pay for ValueClinical action and population health measurement Pt Cohort Decision support & management Program requirements and evaluation Cost and quality transparency public reporting

11. System Cross Organization Cross Practice Provider Patient Population Clinica l Coordinated CentralDecentralized Central/sh ared 1 1 3 3 Data Type Identity Management Unit of Measurement Claims Independent 2 2 4 4 eCQMs – Use Case #2 – Claims Only & Shared Identifier Governance AdvantagesDisadvantages Data easy to access Measurement/com parison across organizations and practices -No use for clinical quality measurement -Value of data for clinical action goes down Uses Clinical Quality Measurement Pay for ValueClinical action and population health measurement Pt Cohort Decision support & management Program requirements and evaluation Cost and quality transparency public reporting

12. System Cross Organization Cross Practice Provider Patient Population Clinica l Coordinated CentralDecentralized Central/sha red 1 1 3 3 Data Type Identity Management Unit of Measurement Claims Independent 2 2 4 4 eCQMs – Use Case #3 – Clinical Only & Shared Identifier Governance AdvantagesConsiderations CMS program quality measurement requirements -Need for central or coordinated governance -Need to pool information and analyze for population health measurement Uses Clinical Quality Measurement Pay for ValueClinical action and population health measurement Pt Cohort Decision support & management Program requirements and evaluation Cost and quality transparency public reporting

13. Considerations for data intermediary services Identity Management supporting cross organization and provider calculation Data quality improvement services supporting practices with data capture may be professional services or technical solutions – Data completeness and consistency – address data gaps and missing data elements Central reporting –support reporting to payers Governance options – Decentralized – services provided separately and by separate organizations – Central – one data intermediary providing services (e.g., SDE, HIE, state) – Coordinated – one or more data intermediaries with virtual trust community and technical services Data Aggregation Reporting Services Notificatio n Services Consumer Tools Analytic Services Provider Portal Data Quality Pt. Prov/Attributi on Data Transport and Load (Warehouse/Repository) Data Extraction Identity Management Provider Directory/Registry Security Mechanisms Consent Management Governance Financing Policy/Legal Business Operations

14. Data quality

15. Patients with >1 clinical data sources

16. Discussion What are dependencies to getting to patient level data? How do you plan for gaps in EHR data and eCQM capabilities? How are states planning data quality improvement strategies?

17. QRDA Cat 1 and C-CDA for Quality Reporting QRDA Cat IC-CDA Intent for use Developed for collecting data required to calculate the 93 e-specified measures required for MU2 Developed to provide a longitudinal view of patient’s health information to support care coordination Perspective Ambulatory/hospital oriented: Aims to capture information on provider/hospital behaviors and processes and their impact on patient care and outcomes Patient oriented: Aims to capture information to provide a longitudinal view of a patient’s health and healthcare history Function Used for the exchange of eCQM data between systems for quality measurement and reporting initiative Primary function is to support care coordination but can be used for quality reporting Available DataQRDA I Is limited to data required for eCQM calculation C-CDA Includes additional data components that can support multiple functions Structured data and data quality Enforces structured data capture improving interoperability and comparisons Does not enforce the capture of structured data and may require additional data quality efforts (professional and technical) to ensure quality reporting Discussion

18. Clinical Data Format Discussion 1.What are opportunities and limitations to data types and data formats? 2.Are states planning for QRDA and/or C-CDA for eCQM? Or other data formats (e.g., ADTs, Lab results) 3.What challenges are states facing with QRDA and/or C-CDA? 4.Can states get to additional eCQM uses using C-CDA?

19. Next Steps Session #3 – Thursday, 12/17 – 11 am ET Session #4 – Thursday, 1/7 – 11 am ET Specific questions contact ONC Resource Center or submit TA request

20. Clinical Quality Measures (CQM) - Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care.1 Electronic CQM (eCQM) - CQMs that are specified in a standard electronic format and are designed to use data from Health IT systems for measurement. Common Definitions Sources: 1 http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/QualityMeasures/ index.html 2. Office of the National Coordinator, “ Health IT Enabled Quality: A Vision to Achieve Better Health and Health Care”, * http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html

21. Common Definitions QRDA is a standard document format for the exchange of electronic clinical quality measure (eCQM) data. QRDA reports contain data extracted from electronic health records (EHRs) and other information technology systems. The reports are used for the exchange of eCQM data between systems for quality measurement and reporting initiatives – QRDA Category I report contains raw applicable patient data. When pooled and analyzed, each report contributes the quality data necessary to calculate population measure metrics. – QRDA-III report is an aggregate quality report using data collected in patient-level QRDA-I reports. Each QRDA-III report contains calculated summary data for one or more measures for a specified population of patients within a particular health system over a specific period of time. 21 https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/qrda_ep_hqr_guide_2015.pdf

22. Clinical Decision Support (CDS) - A key functionality of health IT and certified EHRs that provides health care providers and patients with general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care. Common Data Element (CDE) - Clinical concepts that contain standardized and structured metadata, have unambiguous intent, and a clearly delineated value domain. These CDEs, such as “systolic blood pressure,” would define a curated, universal specification for each clinical or administrative concept, optimizing the data to be reused across the QI ecosystem. Common Definitions Sources: 1 http://www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment-Instruments/QualityMeasures/ index.html 2. Office of the National Coordinator, “ Health IT Enabled Quality: A Vision to Achieve Better Health and Health Care”, * http://www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment-Instruments/QualityMeasures/index.html

23. Additional Resources NRHI - Center for Healthcare Transparency Innovation Pilots – Integrating claims and clinical information Health Collaborative White Paper Pilot Summary: The Health Collaborative – Document Pilot Summary: The Health Collaborative – Presentation Pilot Summary: Utah Health Information Network (UHIN) – Document Pilot Summary: UHIN – Presentation Webinar Recording: Overview of Both Pilots – Patient experience survey pilots Pilot Summary: Patient Experience – Presentation Pilot Summary: Patient Experience – Document Pilot Research Findings Report Fielding Guide Literature Review Webinar Recording: Overview of Patient Experience Pilot

24. Appendix: Regional case study – The Health Collaborative Clinical dataClaims dataCentral CQM Processing eCQM + Cost Combining Process SourceHealth System utilizing Epic Self-insured health system Open Source / Freely Available Tools Measure Authoring Tool – author eCQM to produce HQMF Value Set Authority Center – official vocabulary sets BONNIE – eCQM testing tool Cypress – MU testing tool popHealth – eCQM engine 1.Generate the measure 2.Locate the Enterprise Patient ID in numerator and denominator 3.Locate EID from Cost data set 4.Include cost in measure Data Format Approximately 6,000 CCD’s Custom flat files for Member file Claims files Shared Services CCDs processed against MPI and stored for later use Files processed against MPI and stored for later use TransportDaily CCD extract - DIRECT method utilizing existing MirthMail sFTP collection