1. Clinical Quality Framework cqframework.info All Hands Meeting February 11, 2016 11am-12:30pm ET

2. 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).

3. Agenda TopicPresenter WelcomeSwapna Bhatia, Project Administrative Support DIGITizE/IOM Pilot on Genomics-Based CDS Sandy Aronson, DIGITizE Co-chair Sarah Beachy, DIGITiZE Director FHIR-Based CQF HarmonizationBryn Rhodes, CQF Subject Matter Expert FHIR-Based CQF Connect-a-Thon – May 2016 Bryn Rhodes, CQF Subject Matter Expert CQL-based HQMF Readability PilotBryn Rhodes, CQF Subject Matter Expert Managing Episode of Care for eCQM and CDS – Seeking Input and Experience Floyd Eisenberg, CQF Co-Coordinator Next StepsKen Kawamoto, CQF Co-Coordinator Questions and DiscussionKen Kawamoto, CQF Co-Coordinator CQF Wiki: cqframework.info 3

4. Welcome Announcements, Meeting Schedules, Agendas, Minutes, Reference Materials, Use Cases, Project Charter, and General Information are posted on cqframework.info cqframework.info Clinical Quality Framework (CQF) All Hands meetings are held bi-weekly on Thursdays from 11am to 12:30pm ET https://siframework1.webex.com/siframework1/onstage/g.php?t=a&d=666535029 Dial In: +1-650-479-3208 Access code: 666 535 029 CQF Data Model meetings are held weekly on Wednesdays from 1 to 2pm ET https://meetings.webex.com/collabs/#/meetings/detail?uuid=M8UL81KQZZKHCW46R28OYGI NQM-8ENJ&rnd=47738.082690 https://meetings.webex.com/collabs/#/meetings/detail?uuid=M8UL81KQZZKHCW46R28OYGI NQM-8ENJ&rnd=47738.082690 Dial In: +1-770-657-9270 Participant passcode: 217663 CDS-on-FHIR/CQF Office Hours meetings are held weekly on Wednesdays from 11am to 12pm ET https://global.gotomeeting.com/meeting/join/554237525 Dial In: +1-770-657-9270 Participant passcode: 6870541 CQF Wiki: cqframework.info 4

5. FHIR-Based CQF Harmonization First-class resources have been defined – Still have some polishing/documentation to do FHIR-Infrastructure Alignment is complete – ModuleMetadata type is committed – FHIR-I is submitting proposals for alignment of conformance resources Incorporating CDS/eCQM Ballot Comments is in progress – Reconciled spreadsheets are on Google docs – Anyone that can/wants to help is welcome to join the CQF calls where we will be coordinating the effort and reviewing progress

6. FHIR-Based CQF Connect-a-Thon May 2016 Proposal has been submitted Scenarios from the January Connect-a-Thon were brought forward Additional Scenarios: – Knowledge Management Repository service and client – Measure Evaluation results – SOA Integration Scenario Intended to model a complete clinical quality spike – Includes artifact distribution, ingestion, and evaluation for decision support and quality measurement Event Publish/Subscribe Service (EPS) Unified Communication Service (UCS)

7. CQL-Based HQMF Readability Pilot Objective – Supplement the CQL-Based HQMF IG with additional material to inform knowledge artifact development with CQL Areas of Focus – Display of CQL Population Criteria within the HQMF – Usability/Readability of the resulting HQMF – Consistent authoring of CQL – Accessible Documentation for CQL-Based Artifacts 7

8. Areas of Active Discussion Reordering criteria expressions – top-down vs bottom up Utilizing HTML Functionality – Linking, expand/collapse, fly-out options UX Review/508 Review Criteria Sections CQL Style Guide CQL Documentation Availability Common Library Usage 8

9. Reordering and Indenting of Criteria CQL expressions have been typically developed “bottom-up” – Starting from the data elements and value sets – Construct intermediate expressions to represent conceptual components of the criteria – Combine these intermediates to produce the overall criteria This approach makes sense from an authoring perspective, but can be confusing to someone coming at the measure from the criteria sections Reorder the expressions “top-down” – Starting from the top-level population criteria expressions – Display the component expressions involved as they are encountered, and indented below the referencing expression 9

10. Utilization of HTML UX/Usability Review/508 Review Several options here – Add hyper-links to the expressions to allow to be easily navigated Doesn’t work very well with native HTML functionality, the navigation is abrupt and often unclear what’s happening – Add expand/collapse functionality to help organize the criteria expressions The solution is functional, but it doesn’t really add much because it just hides the criteria. For very large measures, this may be useful, but in general, probably not – Add fly-outs to enable discovery without having to navigate This could be done in pure HTML with the “alt-text”, but it would rely on browser- specific behavior, and could potentially introduce some 508 compliance issues Adding java-script would enable some much more sophisticated functionality Specific coloring for valueset references Hyperlinks for valueset references to the data elements section 10

11. Criteria Sections Follow HQMF Guidance in ensuring all relevant criteria are displayed for a measure, even if the criteria is empty 11 Measure Score Initial Population DenominatorDenominator Exclusion Denominator Exception NumeratorNumerator Exclusion Measure Population Measure Population Exclusion ProportionRequired Optional RequiredOptionalN/A RatioRequired OptionalN/ARequiredOptionalN/A Continuous Variable RequiredN/A RequiredOptional CohortRequiredN/A

12. CQL Style Guide Work with Measure Authors to define a CQL Style Guide Specify conventions for – White-space usage – Naming – Casing of identifiers – Indenting style – Expression organization (e.g. when is a block “too big”) Identify and establish guidance for common patterns Potentially develop tooling to support automatic formatting (a la GoFormat) 12

13. CQL Documentation Availability Increase accessibility of relevant CQL documentation from the measure itself – Could use hyper-links to an online CQL Reference – Could embed documentation for CQL operations used within the measure As flyouts or a “documentation” section at the end of the measure 13

14. Common Library Usage/Documentation Work with artifact developers to establish common libraries As with any knowledge asset reuse effort, this would require – Governance How are the assets developed, tested, approved, published, and maintained? – Visibility How do artifact developers find relevant assets? – Guidance How do artifact developers know how to use the assets? Documentation accessibility from the resulting artifacts 14

15. Next Steps Develop more complex/representative measures – Complex Logic – Multiple Populations – Composite Measures – Stratification – Risk Adjustment Gather feedback from different venues 15

16. Defining Episode of Care Definition: A series of temporally contiguous healthcare services related to the treatment of a given spell of illness or provided in response to a specific request by the patient or other relevant entity. 1 16 1 National Quality Forum (NQF). Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. Washington, DC: NQF; 2009.

17. Defining Episode of Care 2 17 2 National Quality Forum (NQF). Evaluating Episode Groupers: A Report from the National Quality Forum. Washington, DC: NQF; 2014. (p. 8)

18. Episode of Care – Claims-based 3 18 3 National Quality Forum (NQF). Evaluating Episode Groupers: A Report from the National Quality Forum. Washington, DC: NQF; 2014. (p. 10)

19. Seeking Field Experience with Clinical Data Determining the “start” and “end” of clinical encounters within an episode – Examples: – Within a hospital facility: ED —› Observation Status —› Inpatient Outpatient Surgery —› Observation —› Admission Admission —› ICU —› Step-down Unit —› MedSurg – Cross settings of care – Examples: Ambulatory office —› Physical Therapy —› ED —› Ambulatory office Tracking care for a specific health concern over time and location – Admission – Discharge times – Arrival – Departure times 19

20. Episode of Care: Observation Use Case Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. 20 Medicare Benefit Policy Manual. (Chapter 6, Section 20.6) https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c06.pdf

21. Episode of Care: Observation Use Case Seeking input on how EHRs handle transition from Emergency Department to Observation Status to Admission within a single episode of care Purpose – to evaluate the single episode from facility arrival time to treatment to facility departure time 21 Single Episode of Care – 1 Facility Emergency Department Observation Status Hospital Admission

22. Episode of Care: Observation Use Case Method to Determine the Following Times 22 ED Arrival Time Departure Time Observation Arrival Time Departure Time Hospital Admission Arrival Time Departure Time Admission Time Discharge Time Admission Time Discharge Time Admission Time Discharge Time

23. Next Steps Engage in workgroups (www.cqframework.info)www.cqframework.info Pilots –Co-Coordinator, Ken KawamotoCo-Coordinator, Ken Kawamoto Standards Development –Subject Matter Expert, Bryn RhodesSubject Matter Expert, Bryn Rhodes Join us for the upcoming Clinical Quality Framework All Hands meeting: 2/25 CQF Wiki: cqframework.info 23

24. Questions and Discussion NameE-Mail Ken Kawamoto, Co-Coordinatorkensaku.kawamoto@utah.edu Floyd Eisenberg, Co-Coordinatorfloyd.eisenberg@esacinc.com Swapna Bhatia, Initiative Supportswapna.bhatia@esacinc.com cqframework.info CQF Wiki: cqframework.info 24