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QRPH Session:
White Paper:Performance Measurement Data Element Structured for EHR Extraction
IHE North America Webinar Series 2008IHE North America Webinar Series 2008
Floyd Eisenberg, MD MPH FACPFloyd Eisenberg, MD MPH FACP Siemens HealthcareSiemens Healthcare
Jason ColquittJason ColquittGreenway Medical SystemsGreenway Medical Systems
Learning Objectives
Your Product:• How does QRPH work relate to you?• Performance Measurement Data Element
Structured for EHR Extraction– Aligning the EHR / HIE with quality reporting
standardization initiatives
• Clinical Research Data Capture – Aligning the EHR / HIE with clinical research
and clinical trials management
IHE QRPH
Figure 1. Evidence-Based Guideline & Measurement Process
Performance Measurement Data Element Structured for EHR ExtractionGuideline & Measurement Flow
IHE QRPH
Analyzer / Aggregator
Form Manager
Form Receiver
Form Archiver
Form Filler
Form Filler
Patient Encounter Source
Patient Encounter Consumer
Data Repository
Clinical Data Consumer
Information Source
Display
Document Registry
Document Consumer
Document Repository
Document Source
Enterprise Report
Repository
Report Creator
Care Delivery
Information System Actors`
Actors Grouped
for Options
Document Source
Document Recipient
Monitoring Agent / Destination Agency
Submit Report [Reserved]
Provide and Register Document Set [ITI-14]
Retrieve Document [ITI-17]
Query Registry[ITI-16]
Retrieve Document for Display [ITI-12]
Retrieve Specific Info for Display [ITI-11]
Patient Encounter Management [ITI-31]
Query Data [PCC 1 - 6]
Retrieve Form [ITI-34]
Submit Form [ITI-35]
Archive Form [ITI-36]
Submit Aggregate Data [reserved]
Provide and Register Document Set [ITI-14]
Provide Notification of New Measure Definition [reserved]
Patient Admin Management
(PAM)
Query for Existing Data
(QED)
Retrieve Into for Display
(RID)
Cross-Enterprise Document Sharing
(XDS)
Cross-Enterprise Document Reliable Interchange (XDR)
Retrieve Form for Data Capture
(RFD)
Key Actors from Other
Profiles
Patient Level Export of Quality DataPatient Level Export of Quality Data(PEQD)(PEQD)
IHE QRPH
Measurement Specification
http://www.ama-assn.org/ama1/pub/upload/mm/472/referenceguide.pdf
Collaborative for Performance Measure Integration with EHRS
• Create a standard way to express and communicate measures
• Establish standards that permit structured, encoded performance measure information to be incorporated into EHRS, preserving the clinical intent of the performance measure
• Improve the process of performance measurement update and maintenance for EHR Vendors
IHE QRPH
Measurement Specification
http://www.ama-assn.org/ama1/pub/upload/mm/472/referenceguide.pdf
Collaborative for Performance Measure Integration with EHRS
• Performance Measure Description
• Performance Measure in Template
• Patient Population
• Denominator
• Numerator
• Exclusions
• Logical Expressions
• Performance Measure in XML
IHE QRPH
Measure Description
http://www.ama-assn.org/ama1/pub/upload/mm/472/referenceguide.pdf
<xs:element name="Measure"><xs:complexType>
<xs:sequence><xs:element name="TopicType" type="xs:string" /><xs:element name="MeasureDeveloper" type="xs:string" /><xs:element name="MeasureDeveloperID" type="xs:string" />
<xs:element minOccurs="0" name="DateSent" type="xs:date" /><xs:element minOccurs="0" name="ApprovedBy" type="xs:string" /><xs:element minOccurs="0" name="DateApproved" type="xs:date" /><xs:element minOccurs="0" name="EndorsedBy" type="xs:string" /><xs:element minOccurs="0" name="EndorsedDate" type="xs:date" /><xs:element minOccurs="0" name="Rationale" type="xs:string" /><xs:element minOccurs="0" name="ImprovementNotation" type="xs:string" /><xs:element name="MeasureStatement" type="xs:string" /><xs:element name="MeasurementUnit" type="xs:string" /><xs:element minOccurs="0 "name="MeasurementLength" type="xs:unsignedByte"/><xs:element name="Copyright" type="xs:string" /><xs:element minOccurs="0" name="Disclaimer" type="xs:string"/><xs:element minOccurs="0" name="NoticeOfUse" type="xs:string"/>
</xs:sequence><xs:attribute name="ID" type="xs:string" use="required" /><xs:attribute name="Name" type="xs:string" use="required" /><xs:attribute name="Version" type="xs:decimal" use="required" /><xs:attribute name="VersionDate" type="xs:date" use="required" />
</xs:complexType></xs:element>In the XML Schema optional elements have a minOccurs="
IHE QRPH
Measure Element (Age)
http://www.ama-assn.org/ama1/pub/upload/mm/472/referenceguide.pdf
<xs:element maxOccurs="unbounded" name="Information"><xs:complexType>
<xs:sequence><xs:element minOccurs="0" name="Statement" type="xs:string" /><xs:element minOccurs="0" name="MinAge" type="xs:unsignedByte" /><xs:element minOccurs="0" name="MaxAge" type="xs:unsignedByte" /><xs:element minOccurs="0" name="AgeUnit" type="xs:string" /><xs:element minOccurs="0" name="CalculationDescription" type="xs:string" /><xs:element minOccurs="0" name="MeasureCalculationDate" type="xs:string"/><xs:element name="NumberOfLogicalExpressions" type="xs:int" /><xs:element maxOccurs="unbounded" name="LogicalExpression">
</xs:element></xs:sequence>
<xs:attribute name="Type" type="xs:string" use="required" /></xs:complexType>
</xs:element>
IHE QRPH
Guideline & Measurement Flow: EHRS
The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures [Version 2.5, Discharges 10-01-08 (4Q08) through 03-31-09 (1Q09)]
Note: To calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.
Patient is in the HF Initial Patient Population
>= 18 years
Patient not in the HF Initial Patient
Population
Patient is not eligible to be sampled for the
HF measure setPatient is eligible to be
sampled* for the HF measure set
Variable Key:Patient Age
Initial Patient Population Reject Case FlagLength of Stay
Set Initial Patient Population Reject Case Flag = “No”
Set Initial Patient Population Reject Case Flag = “Yes”
Return to Data Processing Flow
(Data Transmission section)
ICDEnd
Length of Stay (in days) = Discharge Date minus
Admission Date
Length of Stay
<= 120 days
> 120 days
ICD-9-CMPrincipal Diagnosis
Code
ICD-9-CM Principal or
Other Procedure Codes
OnTable 2.1
At least one on Table 2.2
All Missing orNone on Table 2.2
Note: To calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.
Patient Age (in years) = Admission Date minus Birthdate
PatientAge
< 18years
HF Initial Patient Population Algorithm
Process all cases that have successfully reached the point in the Data Processing Flow which calls this Initial Patient Population Algorithm. Do not process cases that have been rejected before this point in the Data Processing Flow.
Start HF Initial Patient Populationlogic sub-routine
ICDStart
IHE QRPH
Guideline & Measurement Flow: EHRSHF-3: ACEI or ARB for LVSD Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital discharge.Denominator: Heart failure patients with LVSD and without both ACEI and ARB contraindications.
START
HF-3H
Clinical Trial = YMissing
HF-3X
= N
Comfort Measures
Only =1,2,3Missing
HF-3X
= 4
Run cases that are included in the HF Initial Patient Population and pass the edits defined in the Data Processing Flow through this measure.
Discharge Status
= 01, 03, 04, 05, 06, 61, 62, 63, 64, 65, 70
=02, 07, 20, 43, 50, 51, 66
HF-3B
HF-3B
HF-3B
The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures [Version 2.5, Discharges 10-01-08 (4Q08) through 03-31-09 (1Q09)]
IHE QRPH
Guideline & Measurement Flow: EHRS
The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures [Version 2.5, Discharges 10-01-08 (4Q08) through 03-31-09 (1Q09)]
BNot in
Measure Population
LVSD
= Y
Contraindication to Both ACEI and ARB at Discharge
=N
=YMissing
HF-3
HF-3
HF-3
Stop
= YMissing
HF-3
ARB Prescribed at Discharge
XCase Will
Be RejectedD
In Measure Population
EIn Numerator Population
ACEI Prescribed at Discharge
=N
=YMissing
=N
Missing = N
HF-3B
IHE QRPH
Measurement Description Requirements
Content for Sharing Value Sets Profile – 2008 (ITI)
• Value Set for Each Data Element
• Context for Each Value Set
http://static.ihe.net/Technical_Framework/upload/IHE_ITI_TF_Supplement_Sharing_Value_Sets_PC_2008-06-06.pdf
IHE QRPH
Measure AMI-3, HF-3
Measure Version Number 2.5
Measure Table Number 1.2
Table Name ACEIs
Last Measure Version Update 1.05
Code System RxNorm (OID: 2.16.840.1.113883.6.88)
Test OID (For Illustrative Purposes ONLY) 1.2.6.1.4.1.21367.2008.3.1.2008.1
Medication (as per measure description)
RxNorm Semantic Clinical Drug (SCD) Associated RxNorm Code
Accupril quinapril 5 MG Oral Tablet 312750
quinapril 10 MG Oral Tablet 312748
quinapril 20 MG Oral Tablet 312749
quinapril 40 MG Oral Tablet 314203
Accuretic Hydrochlorothiazide 12.5 MG / quinapril 10 MG Oral Tablet
310796
Hydrochlorothiazide 12.5 MG / quinapril 20 MG Oral Tablet
310797
Hydrochlorothiazide 25 MG / quinapril 20 MG Oral Tablet
310809
Aceon Perindopril 2 MG Oral Tablet 312311
Perindopril 4 MG Oral Tablet 312312
Perindopril 8 MG Oral Tablet 312313
Altace Ramipril 1.25 MG Extended Release Capsule
346568
Ramipril 1.25 MG Oral Tablet 401965
Ramipril 10 MG Extended Release Capsule
348000
Ramipril 10 MG Oral Capsule 261962
Ramipril 10 MG Oral Tablet 401968
Ramipril 2.5 MG Oral Capsule 198188
Ramipril 2.5 MG Oral Tablet 251856
Ramipril 5 MG Oral Capsule 198189
Ramipril 5 MG Oral Tablet 251857
Benazepril Amlodipine 10 MG / benazepril 20 MG Oral Capsule
349442
Amlodipine 10 MG / benazepril 40 MG Oral Capsule
629569
Amlodipine 2.5 MG / benazepril 10 MG Oral Capsule
308137
Amlodipine 5 MG / benazepril 10 MG Oral Capsule
308138
Amlodipine 5 MG / benazepril 20 MG Oral Capsule
308139
Amlodipine 5 MG / benazepril 40 MG Oral Capsule
629570
benazepril 10 MG / Hydrochlorothiazide 12.5 MG Oral Tablet
308608
benazepril 10 MG Oral Tablet 308607
benazepril 20 MG / Hydrochlorothiazide 12.5 MG Oral Tablet
308610
benazepril 20 MG / Hydrochlorothiazide 25 MG Oral Tablet
308611
benazepril 20 MG Oral Tablet 308609
benazepril 40 MG Oral Tablet 308612
Measurement Value Sets:
IHE QRPH
Measurement Value Sets:ACEI Value Set XML<?xml version="1.0" encoding="utf-8"?><CodeGroup ID="CG1" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xmlns:ihe="urn:ihe:iti:svs:2008" xsi:noNamespaceSchemaLocation="../schema/Collaborative/Measure.xsd"> <ihe:ValueSet id="1.2.6.1.4.1.21367.2008.3.1.2008.1" displayName="ACEIs - NHIQM - Appendix C, Table 1.2" version="2.5" /> <ihe:SourceCodeSystem id="2.16.840.1.113883.6.88"/> <ihe:ConceptList> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="349442" displayName="Amlodipine 10 MG / benazepril 20 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="629569" displayName="Amlodipine 10 MG / benazepril 40 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308137" displayName="Amlodipine 2.5 MG / benazepril 10 MG Oral Capsule" />` <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308138" displayName="Amlodipine 5 MG / benazepril 10 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308139" displayName="Amlodipine 5 MG / benazepril 20 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="629570" displayName="Amlodipine 5 MG / benazepril 40 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308608" displayName="benazepril 10 MG / Hydrochlorothiazide 12.5 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308607" displayName="benazepril 10 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308610" displayName="benazepril 20 MG / Hydrochlorothiazide 12.5 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308611" displayName="benazepril 20 MG / Hydrochlorothiazide 25 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308609" displayName="benazepril 20 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308612" displayName="benazepril 40 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="313866" displayName="benazepril 5 MG / Hydrochlorothiazide 6.25 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="308613" displayName="benazepril 5 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="310796" displayName="Hydrochlorothiazide 12.5 MG / quinapril 10 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="310797" displayName="Hydrochlorothiazide 12.5 MG / quinapril 20 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="310809" displayName="Hydrochlorothiazide 25 MG / quinapril 20 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312311" displayName="Perindopril 2 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312312" displayName="Perindopril 4 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312313" displayName="Perindopril 8 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312748" displayName="quinapril 10 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312749" displayName="quinapril 20 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="314203" displayName="quinapril 40 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="312750" displayName="quinapril 5 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="346568" displayName="Ramipril 1.25 MG Extended Release Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="401965" displayName="Ramipril 1.25 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="348000" displayName="Ramipril 10 MG Extended Release Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="261962" displayName="Ramipril 10 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="401968" displayName="Ramipril 10 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="198188" displayName="Ramipril 2.5 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="251856" displayName="Ramipril 2.5 MG Oral Tablet" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="198189" displayName="Ramipril 5 MG Oral Capsule" /> <ihe:Concept codeSystem="2.16.840.1.113883.6.88" code="251857" displayName="Ramipril 5 MG Oral Tablet" /> </ihe:ConceptList></CodeGroup
IHE QRPH
XDS-MS Section ACEI Ordered at Discharge:
clinicaldocument / component / structuredbody / component / section [code=LOINC 10183-2 (hospital discharge medications)] / entry / substanceadministration / consumable / manufacturedproduct / labeleddrug / code=[Valueset=ACEIlist]
Value Set Data Context
IHE QRPH
Measurement Reporting
Quality Reporting Document Architecture - QRDA
• HL7 Ballot – September 2008
• Individual Patient-Level Reporting
• Aggregation of Individual Patient-Level Information
• Schematron Rules
• Levels of Aggregate Reporting in Consideration
http://www.alschulerassociates.com/library/documents/QRDA_Phase_I_Public_Report.pdf