eCQM Affinity GroupSession #2

Technical Discussion –State eCQM Models, Data Types and Formats, Data Intermediary Services, and Data Quality supporting priority uses of eCQM information

Agenda

• Introductions• Context• Technical models

– State eCQM Technical Models– Data types– Shared services through data intermediaries and governance – QRDA / C-CDA

• Next steps

ContextONC 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

Context: eCQM FrameworkBuild 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 InfrastructureKey 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 informationKey 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

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.

Context: eCQM Uses and BenefitsUses Benefits

• 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

State eCQM Technical ModelsClaims 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 NetworkTulsa, OK

The Health Collaborative Cincinnati, OH

Utah UHIN

Medicaid EHR Incentive Program attestation

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?

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

SystemIndividual

OrganizationIndividual Practice

Provider PatientPopulation

Clinical

Coordinated CentralDecentralized

Central/shared

1

3

Data Type

Identity Management

Unit of Measurement

Claims

Independent

2

4

eCQMs – Use Case #1 – Claims Only

Governance

Advantages Disadvantages

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 Value Clinical action and population health

measurement

Pt Cohort Decision support &

management

Program requirements and

evaluation

Cost and quality transparency public

reporting

SystemCross

OrganizationCross

PracticeProvider PatientPopulation

Clinical

Coordinated CentralDecentralized

Central/shared

1

3

Data Type

Identity Management

Unit of Measurement

Claims

Independent

2

4

eCQMs – Use Case #2 – Claims Only & Shared Identifier

Governance

Advantages Disadvantages

Data easy to access Measurement/

comparison across organizations and practices

- No use for clinical quality measurement

- Value of data for clinical action goes down

Uses

Clinical Quality Measurement

Pay for Value Clinical action and population health

measurement

Pt Cohort Decision support &

management

Program requirements and

evaluation

Cost and quality transparency public

reporting

SystemCross

OrganizationCross

PracticeProvider PatientPopulation

Clinical

Coordinated CentralDecentralized

Central/shared

1

3

Data Type

Identity Management

Unit of Measurement

Claims

Independent

2

4

eCQMs – Use Case #3 – Clinical Only & Shared Identifier

Governance

Advantages Considerations

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 Value Clinical action and population health

measurement

Pt Cohort Decision support &

management

Program requirements and

evaluation

Cost and quality transparency public

reporting

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

Notification Services

Consumer Tools

Analytic Services

Provider Portal

Data QualityPt.

Prov/Attribution

Data Transport and Load (Warehouse/Repository)

Data Extraction

Identity Management Provider Directory/Registry

Security Mechanisms Consent Management

Governance

Financing

Policy/LegalBusiness

Operations

Data quality

Patients with >1 clinical data sources

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?

QRDA Cat 1 and C-CDA for Quality ReportingQRDA Cat I C-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

PerspectiveAmbulatory/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 Data QRDA 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

Clinical Data Format Discussion1. 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?

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

• 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

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.

21https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/qrda_ep_hqr_guide_2015.pdf

• 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

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

Appendix: Regional case study – The Health Collaborative

Clinical data Claims data Central CQM Processing eCQM + Cost Combining Process

Source Health 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

Transport Daily CCD extract - DIRECT method utilizing existing MirthMail

sFTP collection