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Interoperability Workshop

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					                  IHE Quality Domain

Presenter:
Floyd P. Eisenberg, MD MPH
Quality Domain Technical Committee Co-chair
Siemens Medical Solutions Health Services
September, 2005                1              What IHE Delivers
      Quality Domain
American Heart Association
Radiological Society of North America
HIMSS




                                 2
Quality Domain Planning Roadmap
 Peer Review and feedback
   ACR RadPeer program
   Decision support for ordering and procedure approvals (Massachusetts program)
     • Based on ACR appropriateness criteria

     • Generate justification data when needed

     • AQA appropriateness metrics

         – Imaging efficiency
         – Cost effectiveness
 Retrospective review of outcomes based on utilization of evolving technologies
   Radiation dose
 Real-time documentation of continuing education and accreditation (point-of-care
 CME)
 Adverse event reporting
 Measure Reporting
   Core Measure Reporting
   Patient assessment to prevent adverse events
 Data registries
   Procedure-specific datasets
   Gather quality data (peer review, patient safety, etc.) from various care settings
   Protocol utilization
                                                                                  3
                   Planning Roadmap
Standardized reporting format: (eg, Echo, Cath Lab, Nuclear Med) to ensure report
has elements needed to collect quality data
Harmonization with other initiatives
  Uniformity of measure import and export formats
  Measuring health delivery disparities across demographic segments (eg, race, gender,
    socioeconomic status) - AHA Health Research and Educational Trust, HRSA
  Care coordination efforts across disciplines - NQF, CMS
  Structural measures - different groups, data measures (eg, infection control)
  NCVHS hearings in July
  State/provincial/regional quality measures
  AHIC/ONC/HITSP Use Case on Quality
  Patient identity management / tracking of patients across settings
  Expected AHIC/ONC/HITSP Use Case on Adverse Events
Consumer aspects of quality reporting
  PHR as record of repeat procedures
  Consumer view of provider quality information
  Patient self management
  Home health monitoring
  Informed patient consent

                                                                                4
        To Everything There is a Purpose,
                and then some….
Landscape – Repurposing Clinical Data
                        Health data
                  for financial analysis
                                                  Health data shared
                                                  for bio-surveillance



                                                               Health data shared for
                                                                infectious disease
   Health data                                                     management
    for other                Health data shared
 secondary uses               for continuity of
                                care delivery                   Health data shared for
                                                                 quality improvement



                                                           Health data
                                                       shared for research
                 Health data
              pharmacovigilence

                                                                             5
        To Everything There is a Purpose,
                and then some….
Landscape – Repurposing Clinical Data
                             Health data
                       for financial analysis
                                                Health data shared
                                                for bio-surveillance



                                                                 Health data shared for
                                                                  infectious disease
    Health data                                                      management
     for other
  secondary uses                                                Health data shared
                                                                    for quality
                                                                  improvement


              Health data                               Health data
           pharmacovigilence                        shared for research




                                                                               6
        To Everything There is a Purpose,
                and then some….
Repurposing Clinical Data
                          Quality                                 Pub iHeal h
                                                                      c c lth
                                                              PuibliHleaHetalth
                            Quality
                         Strategiesy
                             Qualit                         Pu cl c tr l th
                                                         Pu clibSHeaatgi gies
                                                                   tSl e
                                                       PublibSHeaatgieses
                          Strategiesy
                               Qualit
                            Strategiesy
                                Qualit                           ragi th
                                                                ttetrhee
                                                      Public Ha al te s
                                                                e
                             Strategies                    ra r
                                                         StSttegies
   Reaserch                    Strategies              Strategies
     R t as es
   Straeegierch
       R t as es
     Straeegierch
          R t as es
       Straeegierch
            R t as es
          Straeegierch                                                             XYZ
            Strategies                                                            Strategy


 Workflow
 Classes                                    Simple Case
               Rule-driven                                        Decision
                Reporting                    Reporting            Guidance




                                Care Delivery Process

                                                                                      7
       To Everything There is a Purpose,
               and then some….
Repurposing Clinical Data
    Rule-driven             Simple Case                Decision
     Reporting               Reporting                 Guidance

Subscribe    Publish      Case           Case     Guideline
                          Definition     Report

          Rule                                         Guideline
                              Simple Case
      Computation                                     Computation
                              Management
       (Patient or
       aggregate)


              Publish      Form        Filled                 Guidance
    Input                                           Input     Alert
                                       Form


                     Care Delivery Process

                                                                    8
Patient-Level Export of Quality Data
   Data Elements
   • Measure definition and method of expression
   • Demographics (sources: ADT, Financial systems)
   • Results (Laboratory, Imaging)
   • Substance Administration
   • Procedures
   • Location
   • Events
   • Clinical Observations / Findings
   • Problems (Conditions, including but not limited to Allergies)
   • Diagnoses
   • History (patient or provider generated)



                                                             9
Patient-Level Export of Quality Data
  Measurement
  1. Denominator Inclusions
     • The population to be measured
  2. Denominator Exclusions
     • Exclusions from population measured
  3. Numerator Inclusions
     • Procedures performed
     • Medications ordered / administered
     • Etc.
  4. Numerator Exclusions (removes from population measured)
     • Allergies
     • Contraindications
     • Medical reasons
     • Patient reasons
                                                         10
                  ACEI / ARB Measure
                                            Description
 ICD-9 Code   AMI ICD-9 Diagnosis Codes
410.01      Anterolateral wall, acute myocardial infarction-initial episode
410.11        Other anterior wall, acute myocardial infarction-initial episode
410.21        Inferolateral wall, acute myocardial infarction-initial episode
410.31        Inferoposterior wall, acute myocardial infarction-initial episode
410.41        Other inferior wall, acute myocardial infarction-initial episode
410.51        Other lateral wall, acute myocardial infarction-initial episode
410.61        True posterior wall, acute myocardial infarction-initial episode
410.71        Subendocardial, acute myocardial infarction initial episode
410.81        Other specified sites, acute myocardial infarction-initial episode
410.91        Unspecified site, acute myocardial infarction-initial episode

                    Cardiac Catheterization (cath)               Left Ventricular
  Echocardiogram        with Left Ventriculogram Other                 Systolic
       (echo)                                      Tests
                              (LV gram)                           Function 11
                                                                            (LVSF)
    ACEI / ARB Measure
ACEI / ARB
Moderate / Severe Systolic Dysfunction
Allergies (Exclusion)
Medical Reasons (Exclusion)




                                         12
                                                                     PEQD
       Measure Definition [reserved]                                                                                    Monitoring Agent /             Document
                                                                                                                         Destination Agency             Recipient

                                                                                                                                                              
 Form           Form                         Form                                                                                                            Provide and
Manager        Receiver                     Archiver                                                                               Submit                     Register
                                                                                                                                   Aggregate                  Document Set
                                                                                                                                  Data                       [ITI-14]
                  Submit Form                   
                                                                                                                                   [reserved]
    Retrieve       [ITI-35]                      Archive Form
    Form                                         [ITI-36]                                                                                               Document
    [ITI-34]                                                                                                                                             Source


                                                                 Form Filler                                                        Analyzer / Aggregator


                           Patient Encounter         Clinical Data                                       Document                Document                                       Actors
                                                                                Display                                                                Report Creator         Grouped
                               Consumer               Consumer                                           Consumer                 Source
                                                                                                                                                                           for Options
                                                                                      Retrieve                   Retrieve            
                                                                                    Specific Info for                                 Provide and            
                                     Patient                                                                    Document
                                                                                                                                       Register
                                                            Query Data               Display [ITI-11]            [ITI-17]                                     Submit
                                     Encounter                                                                                         Document Set           Report
                                     Management             [reserved]                                                                 [ITI-14]               [reserved]
                                     [ITI-31]                                         Retrieve                Query
                                                                                     Document for             Registry
                                                                                     Display [ITI-12]         [ITI-16]

                                                                                                                                                                                  Care
                            Patient Encounter                                                                                                            Enterprise
                                                                               Information               Document                Document                                      Delivery
    Form Filler                  Source          Data Repository                                                                                          Report
                                                 X Data Repository               Source                   Registry               Repository                                Information
                                                  X Data Repository                                                                                      Repository
                                                                                                                                                                                System
                                                                                                                                                                                Actors




           Key to Actors
                                 Retrieve Form for         Patient Admin            Query for               Retrieve Info           Cross-Enterprise          Cross-Enterprise
           from other              Data Capture             Management             Existing Data             for Display           Document Sharing          Document Reliable
           Profiles                    (RFD)                   (PAM)                  (QED)                     (RID)                   (XDS)                Interchange (XDR)


                                                                                                                                                                                    13
Concurrent Efforts for Quality Reporting

   Landscape – Re-purposing of clinical data
   US Efforts: ONC – AHIC – HITSP – CCHIT
   The Collaborative
   IHE Quality Domain
   New Standards Development – HL7
   New Directions




                                            14
                       Harmony from Discord
American Health Information Community, Health Information Technology
 Standards Panel, Certification Commission for Health Information Technology
- Quality Use Case – Promoting automation of quality data reporting
-   HITEP NQF Expert Panel – Analyzing data element classes, types, pre-conditions
-   Possible vendor certification of identified standards

Collaborative for Performance Measure Integration with EHR Systems
(The Collaborative)
-   American Medical Association, National Committee on Quality Assurance
-   Workgroup A: Performance measure functionality and integration with EHRs
-   Workgroup B: Import criteria (measures), Export criteria (patient-level data)
-   Facilitating integration, calculation and reporting of measures within vendor products
    for reporting

Integrating the Healthcare Enterprise
- Building Technical Framework for coordination of quality data import, submission,
  aggregation and feedback
-   Driving vendor adoption of standards

                                                                                    15
                      Harmony from Discord
Standardization to fill the Gaps
 Health Level Seven
 - Vehicle to publish the Quality Reporting Document Architecture (QRDA) standard
 -   Working with Clinical Interoperability Council, Electronic Health Record Technical
     Committee, Government SIG, Pediatric Data Standards SIG, Structured Documents
     Technical Committee, and more
 -   Healthcare Associated Infection Reporting Document - CDC




                                                                                   16
ONC – AHIC Quality Use Case 2007




    http://www.hhs.gov/healthit/usecases/quality.html
                                                        17
ONC – AHIC Quality Use Case 2007




    http://www.hhs.gov/healthit/usecases/quality.html
                                                        18
  Quality Use Case: HITSP 2007 – Scoping

                                    Quality Interoperability Specification
                                                                                             <transaction>
                              • Document Name: String                                        Pseudonymize
     <component>
                                                                                           docid: = IST-24: Int
      Anonymize

   docid: = ISC-25: Int                                                                   <transaction> Patient
                                                                                          ID Cross-Referencing

 <transaction package>                                                                     docid: = IST-22: Int
Manage Document Sharing
                                                                                     <component> patient level
    docid: = IST-13: Int
                                   <transaction package>                               quality data message
                                   query for existing data
      <transaction> Patient                                                        <component> patient level
      Demographic Query                                                              quality data document
                                                      <transaction package>
       docid: = IST-23: Int                       Retrieve Form for Data Capture

                                                         docid: = IST-50: Int


<component> Measurement <component> Quality Measurement <component> Derived          <component> Case Review
Criteria Document (Phase II) Document (Phase III)       Information (Phase II)          Message (Phase II)

<component> Measurement <component> Quality Measurement <transaction package>        <component> Case Review
Criteria Message (Phase II)   Message (Phase III)           XCA (Phase II)                         19
                                                                                        Document (Phase II)
Quality Use Case: HITSP 2007 Public Comment




                                                                            20
  http://ansi.org/standards_activities/standards_boards_panels/hisb/hitsp.aspx
                         HITSP
Healthcare Information Technology Standards Panel
          Ongoing work on data taxonomy
  1. Comment Resolution and Completion IS-06
  2. Coordination, Referral of Gaps / Overlaps for 2008
     • Recommendations regarding Measure Development
       Organization activities – to NQF
     • Import and Export – to HL7, the Collaborative, IHE
     • IHTSDO Terminology Issues
     • Order model - to HL7 Orders Implementation Guide




                                                          21
                           The Collaborative:
Collaborative for Performance Measure Integration into EHRs
   Performance Measure Template
   •   Standard non-technical representation of performance measures
   •   Flexible – simple or complex measures, nested logic
   •   Shared model among for use by performance measure developers
   Section I
   •   Measure General Information - the data and calculation information
   Section II
   •   Measure Information - the algorithms and details about information types:
        •  Patient Population
        •  Denominator
        •  Numerator
        •  Exclusions
        •  Logical expressions and logical elements – pertinent code data for
           the calculation. Sequential logical expression operators ( “AND” / “OR”)
           – number unbounded
   Section III
   •   Code Information


                                                                                      22
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy
     1. logic of 84 IOM-related measures
     2. identify common data classes and types
     3. reduce logic to required data types
     4. algorithm to maximize data type order
     5. Pareto analysis all logic
     6. Pareto analysis excluding exclusions

     DRAFT Output of HITEP, National Quality Forum

                                                     23
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy




     DRAFT Output of HITEP, National Quality Forum

                                                     24
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy




     DRAFT Output of HITEP, National Quality Forum

                                                     25
    Healthcare Information Technology Expert Panel
            Ongoing work on data taxonomy




DRAFT
Output of
HITEP,
National
Quality Forum                                 26
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy
    Pareto Analysis (numerator and denominator only)




       DRAFT Output of HITEP, National Quality Forum
                                                       27
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy
 Pareto Analysis (numerator, denominator, and exclusion)




       DRAFT Output of HITEP, National Quality Forum
                                                       28
Healthcare Information Technology Expert Panel
     Ongoing work on data taxonomy
            Pareto Analysis (exclusion only)




      DRAFT Output of HITEP, National Quality Forum
                                                      29
HL7 – The Alliance for Pediatric Quality

 Asthma
 Quality               Data Elements in
Measures                                               Quality Reporting
                       Common Format                   Document Architecture
                       Measure Name                    Measure Name
                       Measure Set                     Measure Set
  CHF                  Submitting Entity
 Quality                                               Submitting Entity
                       Receiving Entity                Receiving Entity
Measures               Procedure Code                  Procedure Code
                       Diagnosis Code                  Diagnosis Code
                       Lab Results                     Lab Results
                       Criteria                        Criteria
   MI                  Patient/Provider data
 Quality                                               Patient/Provider data
                       etc.                            Etc…
Measures




    Quality Measures contain common elements that can be formatted and
                    communicated in a standard manner

     With Permission: Alliance for Pediatric Quality (www.kidsquality.org)
                                                                               30
         HL7 – The Alliance for Pediatric Quality
current work
                                     HL7 Structured Docs             DMIM


             CDA-report             CDA-R2         SPL               2 RMIMs          MR


           Q report     HAI     CCD          H&P


diabetic   asthma     BSI     SSI       AdmitH&P     PedH&P
Rules:
1. Relationship between DMIM/RMIMs:            1. R2-body based CDA-reporting
    1. blown out                               2. DMIM for SD/R2
    2. constrained                             3. CDA-R3
2. where can XML change?
3. what can extend/constrain a model?

           With Permission : Alliance for Pediatric Quality (www.kidsquality.org)31
         HL7 – The Alliance for Pediatric Quality
future work
                                     HL7 Structured Docs             DMIM


             CDA-report             CDA-R3         SPL               RMIMs         MR


           Q report     HAI     CCD          H&P

diabetic   asthma     BSI     SSI       AdmitH&P     PedH&P

Rules:                                              1. R2-body based CDA-reporting
                                                    2. DMIM for SD/R2
1. Relationship between DMIM/RMIMs                  3. CDA-R3
2. where can XML change?                               or
3. what can extend/constrain a model?               1. DMIM
                                                    2. CDA-R3
                                                    3. CDA-report

            With Permission : Alliance for Pediatric Quality (www.kidsquality.org)32
         IHE Quality Domain – Plan for 2008

•   Development Schedule:
    •   Planning Committee decision:                  November 5-6, 2007
    •   Technical Committee decisions:                January 8-10, 2008
    •   Issue Public Comment version:                 June 2008
    •   Public Comment Due:                           July 2008
    •   Issue Trial Implementation version:           August 2008
    •   IHE Connectathon:                             January 2009
    •   HIMSS Demo:                                   February 2009

•   Pending 2007 Quality Domain Profile
    •   Patient-Level Export of Quality Data (PEQD)

•   New Profiles For 2008
    •   Content Profiles TBD Pending November 5-6 Planning
        Committee Meeting



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           Questions
Floyd.Eisenberg@siemens.com
610 219-8547




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