New Era of CQMs, Part I: Quality Measures in The Age of MIPS

The first performance year for the CMS Merit-based Incentive Payment System (MIPS) begins on January 1 of next year, yet much of the healthcare world is still in the dark about large portions of the program. Or even unaware of its existence entirely.

Perhaps one of the most misunderstood aspects of the program: MIPS does not apply to Medicaid Meaningful Use or eligible hospital Meaningful Use (MU) programs.

With MIPS beginning in earnest and ramping up over the next few years, we wanted to provide a series of plain-language posts and address how it will affect your use of clinical quality measures.

Via CMS

Our goal as the program unfolds is to grow our CQMsolution software to support as many measures as possible.

Background
MACRA sets up a new system of quality-based reimbursement for clinicians called the Quality Payment Program.  Within this new model, there are two pathways to select:

• The Merit-based Incentive Payment System (MIPS)
• Advanced Alternative Payment Models (APMs)

For this post, we will focus on quality assessment within the context of MIPS. Multiple quality reporting programs are folded into MIPS:

• Physician Quality Reporting System (PQRS)
• Value-Based Payment Modifier (VBM)
• Medicare Electronic Health Records (EHR) Incentive Program (ie, Meaningful Use)

As with the current PQRS program, multiple clinicians can participate in MIPS as an individual or a group.

Payment adjustment
In determining the payment adjustment based on MIPS, clinicians will received a composite score, weighting four different categories of performance:

• Quality
• Resource user
• Clinical practice improvement activities
• Advancing care information 

Quality Measures under MIPS

Quality receives the highest weight under MIPS and to determine quality score. The program has taken PQRS and the value-based modifier, mashed them up and provided a menu of quality measures that will determine reimbursement.

MIPS-eligible clinicians and groups can select their measures from either the list of all
MIPS measures or a subset of specialty-specific measure as identified by CMS. Unlike the current requirements under PQRS, clinicians will not be required to report a "cross-cutting measure." The program has been positioned to allow clinicians to select measures that are the most relevant to their practice.

In the transition from the current state of quality reporting (PQRS/VBM/MU) to MIPS, there are a few other key points to bear in mind:

• Registry, EHR and QCDR reporting measures currently require 9 measures across three quality domains, but thew new requirement is 6 measures
• Measures can now have any combination of NQF quality domains, though the 6 selected must include an outcome measure (as opposed to strictly process, for example)
• MAV process changed (more on this in future posts)
• PQRS registry measures group method is eliminated
• Registry and QCDR reporting requires meeting a "data completeness" standard: 50% of patients in the denominator

There are more complexities to explore - and changes and clarifications in the coming months, as always. We look forward to staying on top of these and simplifying the process for each of our clients.

FHIR works: Notes from Baltimore Plenary Meeting and Virginia CCDA 2.1 Implementationathon

We say this every time we attend a meetup, but it remains true: interest in HL7 interoperability standards continues to grow remarkably. As FHIR in particular matures, we see proliferation of attendees, ballot comments and general buzz. As Graham Grieve mentioned over on the FHIR Directors Blog, the most recent meetup was most likely HL7's largest meeting to date.

Baltimore at night.

Members of the DHIT team traversed the DMV (that's DC-Maryland-Virginia, in Beltway-speak) last month, heading to Baltimore for the annual plenary meeting and Arlington, VA, for the C-CDA Implementation-A-Thon.

News on FHIR
As the FHIR Chief himself, Grahame Grieve, mentions over at his blog, there were some major headlines at the very well-attended FHIR plenary event:

• FHIR release 3 is slated for release at the end of this year.
• New communities are cropping up, including from medical disciplines that hadn't previously shown up on the FHIR scene
• The FHIR Foundation will continue to be a key player, supporting the "implementation process of standard"
• The site fhir.registry.org will go live soon
• Discussion of whether to support logical reference; in short, a "URL-based view of the world," as Grahame puts it, may be incomplete.

As Grahame also mentioned, the "most significant single decision" made at the plenary was to take the specification known previously as “DAF-core” and rename it the US Realm Implementation guide. That may sound like inside baseball, but it's another symbolic leap in the maturity of the standard.

From the DHIT standpoint, we are well underway developing features in our flagship interoperability application, ConnectEHR, and across our product line to support EMR clients, including the development of testing and production FHIR servers. Our overriding goal is for our clients to move forward in interoperability as they meet the latest edition of ONC Certification Standards (2015 Edition).

We anticipate that FHIR may one day become an explicitly mandated standard and, as it stands, is a boon not only to interoperability but meeting meaningful use in Stage 3 and beyond.

We participated in the "CCDA on FHIR" track as document creator as well as document consumer, testing our implementation against multiple servers (including those of other participants as well as the reference servers from Grahame Grieve and Furore). Our coding was done in C# using the fhir-net-api provided by fellow FHIR Chief Ewout Kramer.

CCDAs in VA
HL7 hosted its third C-CDA Implementation-A-Thon last week in Arlington, VA. The DHIT team kept up its perfect attendance, convening with other CCDA developers and experts just outside DC.

In addition to the usual networking and educational opportunities afforded at HL7 Events, it's always interesting to chart the development progress of the industry as a whole. And the "real-world" scenarios provided at the event - creating and exchanging live data - are worth the trip alone.

As is typical of healthcare standards-based Connectathons, clinical scenarios are laid out for participants to navigate. In this case, the exercises were related to the exchange of v2.1 documents, discharge summaries and electronic referrals. We're proud to report that we all the CCDA Homework Scenarios were accomplished. 'A+' goes to the DHIT developers on hand.

Valueset OIDs
Valueset OIDs continue to be a point of some controversy. There was a presentation at the event providing background and information on the process of creating them. For the initiated, value sets for use in EMRs, CQMs, research and other contexts are created by professionals and organizations and submitted to be approved by the National Library of Medicine (NLM), under its Unified Medical Language System (UMLS) arm. The code sets are validated and checked for duplicates. However, our development has uncovered some of the codes may be subject to duplication and we've requested some further information from NLM.

Lessons learned

We left with some takeaways on the process of generating a v2.1 CCDA and we wanted to share with our audience:

• Often overlooked, developers should pay a little bit more attention to mood codes and their usage even though it may complicate the data that is requested from a client
• C-CDA Scorecard is a very useful checkpoint in development
• Having lower score in the scorecard doesn’t mean that the CCDA will fail the validation. Higher scores will determine that the CCDA is much closer to the expected standard
• Display name should come from the code system otherwise it will lower the score. 
• Narrative Text for all sections and textual clinical notes
• The task of categorizing results may tolerate multiple pathways. Example: CT scans go to Procedures or Results or both
• Allergies and problems should always have time recorded
• For effectiveTime of immunizations, do not use low+high when moodCode=EVN

NTT's Optimum and Dynamic Health IT Partner on Forward-Thinking Solution for CQMs

DHIT President Jeff Robbins addressing the
NTT Data Client Conference

After wrapping up our successful ONC certification testing for CQMsolution in early September, we headed to Newport Beach, CA, for the NTT Data Client Conference. Held annually, the conference offers clients of NTT Data products and services a wide range of educational sessions, networking opportunities and face-time with NTT DATA staff.

The event was a great opportunity to meet with implementers and users of CQMsolution. We were able to provide specific education on our application through the lens of the NTT's Optimum clinical ecosystem. CQMsolution is developed as universal quality measure solution, but context always matters, of course.

In keeping with the mission of the conference, we also spent time discussing some policy specifics to help NTT users prepare for changes in quality measurement. This included a glimpse into the future to MIPS/MACRA and Meaningful Use Stage 3.

We also expressed our confidence that our solution will continue to be among the first - if not the very first - to update with each successive release of CMS measures. Among other benefits, this allows maximal testing and educational opportunities in the lead-up to submission.

As with all DHIT clients, we seek to offer a full range of development, quality assurance, support and project management resources, tailored to the environmental needs of the specific implementation and user base. Our close collaboration with NTT has yielded a solution that allows their EMR team to focus on development and customer support, while we provide an effective and aggressively-supported tool to attack quality measures.

DHIT VP Raychelle Fernandez providing
clinical background for CQM calculation process.

By way of demonstration, DHIT gave a detailed presentation on CQMsolution and showed key elements of the software using a specific clinical use case: Ischemic/Hemorrhagic Stroke (via CMS measure 102v4). With our goal of guiding clients through CQMs from start to finish, we discussed not only the calculation and display of measures in CQMsolution, but the process of submission.

It's our hope that CQMsolution, like that Southern California weather, makes everything a little sunnier.

CQMsolution blazes trail as first 2015 Edition Certified CQM product

Dynamic Health IT is proud to announce that we're the first software developer to be certified for Clinical Quality Measures under the latest ONC Health IT Certification (2015 Edition).

But don't take our word for it: our listing on the ONC CHPL website is viewable here.

The process of certification testing gives our clients confidence that our product can support eligible clinicians and eligible hospitals in meeting CMS EHR Incentive Program objectives. We have developed the product with an eye on not only the current formulation of Meaningful Use, PQRS, IQR and other quality measurement programs, but the changes to come under MIPS/MACRA.

“Dynamic Health IT remains a trailblazer in clinical quality measures software development. We’re very proud to be the first vendor to certify for 2015 Edition Quality Measures Quality Measures for Cypress 3.0,” said Jeff Robbins, President of Dynamic Health IT.

Certification is proud achievement, but also a way station to further development. DHIT continues to enhance our software to include bulk, automated practice and user adds, API access and a number of other new features.  We hope to provide our client not only quality measure compliance, but a transparent user interface that enables easy analysis.

CQMsolution 3.0 certification meets the following certification CQM-related criteria:

• 170.315(c)(1) Clinical Quality Measures- Capture And Export
• 170.315(c)(2) Clinical Quality Measures- Incorporate And Calculate
• 170.315(c)(3) Clinical Quality Measures- Reporting
• 170.315(c)(4) Clinical Quality Measures- Filter

CQMsolution Version 3.0 also includes new interface enhancements driven by 170.315(C) (4) - a brand new module in 2015 Edition - allowing users to filter report data on a number of demographic categories. In addition, we also certified our solution on:

• 170.315(g)(4) Quality Management System
• 170.315(d)(1) Authentication, access control, authorization
• 170.315(d)(2) Auditable events and tamper-resistance
• 170.315(d)(3) Audit report(s)
• 170.315(d)(5) Automatic access time-out

The clinical quality measures to which CQMsolution has been certified include:

• All 29 updated measures for eligible hospitals
• All 64 updated measures for eligible professionals
• All 64 aligned PQRS measures for EPs (additional PQRS measures can be supported)

This marks the fourth ONC-certified version of CQMsolution, the previous certification coming in conjunction with the release of Cypress 3.0 validation software.

Photo credit: MJ Boswell

Version 3.0 was certified by ICSA Labs, an Office of the National Coordinator-Authorized Certification Body (ONC-ACB) and is compliant in accordance with applicable criteria adopted by the Secretary of Health and Human Services (HHS). 

Eliminating the Hurdles of Clinical Quality Measures for the 2016 Reporting Year

Dynamic Health IT is proud to announce we have successfully pilot-tested with ICSA Labs for 2015 Edition CQM-related measures (c)(2) and (c)(3).

That's a bit of a mouthful, but it means that our software, CQMsolution, remains at the forefront in providing meaningful, submission-ready clinical quality measure output. CQMsolution supports 93 CMS eCQMs and the 64 aligned PQRS measures.

Under 2015 Edition, Clinical Quality Measure reporting has been made more comprehensive. The three existing measures (c)(1), (c)(2) and (c)(3) have been revised:

• Cypress 3.0 validation software, which includes more robust testing relative to 2.6.1, must be supported
• The latest set of measure versions for the 2016 reporting year, validated by Cypress, must be supported
• Required data export capability is expanded
• Data import should be more accessible (“without developer assistance”)
• Exported data file must meet R2 implementation guide for QRDA

The three CQM measures are also joined by a new measure: measure(c)(4) - filtering. In meeting (c)(4), EHRs must be able to filter quality measure results at the patient and aggregate levels by a list of variables. The filtered results must be made available in a human-readable format and data file.

Not reinventing the wheel, replacing tires

Our developers put in rigorous work over the last quarter, incorporating feedback from clients, to dramatically enhance the software, making it easier-to-use, more robust and, of course, certification-ready for ONC 2015 Edition and Cypress 3.0.

We saw this development cycle as a great opportunity to take everything we have learned over the past few years - in the form of our feature enhancements and performance improvements - and integrate it fully with new development.

This meant taking the principles behind engine and UI that worked and preserving them, while using the regulatory changes in measure logic and output as a chance for a coordinated re-design. The CQMsolution calculation engine uses the eMeasure HQMF files, which are based on the Quality Data Model (QDM), as the basis for evaluation. We use these files to create the data structures through which we process patient data. 

In contrast to feature-specific roll-outs, this was a bottom-up version. It is not often you get a chance to re-write core parts of your application. This can be a perilous process, but there were two factors that made it successful:

• The ability to create a completely new calculation engine for 2016 reporting year without altering previous reporting year calculation engines meant we were not required to maintain backwards compatibility in the new code
• After identifying our time parameters and client needs, our development team realized complete development focus would be needed. The project was afforded development time in a distraction-free environment.

CQM data intake and calculation were worked all at once, allowing for a holistic approach. Combined with extensive testing, relying in part on a more exhaustive Cypress data set, the result was a robust upgrade, built on clean code.

-         Key changes

-        

The changes from the 2014 release measure to the 2015/2016 release measures were dramatic, requiring a rewrite of major portions of CQMsolution. Example of these changes can be seen in the text of the measures. New subset operators were added and new temporal operators that make the measures more clear. 

The changes in QRDA format also called for a rewrite to the parsing and generating pieces that enable our clients' certification and submission of CQMs.

On top of the CQM engine, we integrated user experience changes to make both certification testing and day-to-day use of the application easier and reflective of technical changes. These changes range from easier report tracking in the UI, to one-click certification testing through single-upload "compound" report and API to Cypress.

Improvements ahead

-         

CQMsolution 3.0 is now in beta testing with clients, pending final ONC certification. The development cycle is perpetual and we intend to stay at the forefront of CQM development. By year's end, 2017 reporting year support should be complete and a number of features are in the pipeline for the near term, including API-based data collection from client EMRs. 

We look forward to rolling those out and, of course, to our full certification on all four CQM measures. Stay tuned!

FHIR Applications Roundtable at Harvard Medical School

The DHIT Team has been an active participant in FHIRConnectathons during the past two years. Among the benefits of these events is the unique glimpse they provide into what the industry is delivering with FHIR and how the standard continues to evolve through active development.

Our team is also eager to find connections between out interoperability expertise and real-world healthcare problems. With those (and other) goals in mind, our President Jeff Robbins attended the 1^st annual FHIR Applications Roundtable at Harvard  Medical School in Boston to learn more.  

Although FHIR is a relatively new standard, it has great potential and forward-thinking healthcare IT organizations are already deploying FHIR solutions. 

Harvard Medical School

The Roundtable consisted of a series of 15 minute presentations by academics, software developers and consultants highlighting FHIR-related projects.

The projects on display included patient and provider-facing apps, Clinical Decision Support, clinical collaboration platforms, patient education, all the way up to a complete, native FHIR-based EHR. The expansiveness of the applications and implementations discussed demonstrates just how far the standard has come from its days in draft status.

On the policy front, Steve Posnack, Director of the Office of Standards and Technology at the Office of the National Coordinator for Health Information Technology spoke about efforts to encourage interoperability through FHIR developement and the  HL7 FHIR App Ecosystem. ONC is encouraging market-ready FHIR support through its "challenges."

DHIT plans to offer a CCDA-to-FHIR converter in the near future.  Stay tuned!

Solving 2015 Edition Certification: CCDA and Common Clinical Data Set

ONC's 2015 Edition Health IT Certification Criteria mark the latest chapter in the certification process for health information technology. The roster of measures was made effective on January 14, 2016, and the certification testing process has begun in earnest. 

Despite the flurry of activity around 2015 Edition, it should be noted that there is not yet an expiration date for 2014 Edition testing, which is expected to continue through the end of FY 2017. 

While vendors are not under immediate deadline, it is highly useful to adopt and certify, at minimum, the functionality that is relevant to your user base. There are a number of early adopter advantages, including the delivery of more interoperable software to users. Now that the all-or-nothing "Complete EHR" certification is gone, developers may choose to focus "Base EHR" measures and/or those needed for their uses to meet Meaningful Use and/or other user objectives.

The 2015 measures mark a significant overhaul to the previous 2014 Edition regulations. A look at some of the major changes in the 2015 measures gives us a signal of where the industry is headed (or at least where it thinks it's going).

General themes

As Keith Boone pointed out, 2015 Edition represents a pivot “from EHR focus to Health IT focus.” ONC intends to make its Certification accessible to a broader range of health IT applications than simply those directly in line with the CMS EHR Incentive Programs, while attempting to galvanize broader interoperability.

This rationale is behind retiring the “Complete EHR” certification in 2015 Edition. It’s also why ONC has swapped out the term “EMR” for “health IT,” renamed the Common MU Data set the “Common Clinical Data Set” and provided more incentives for vendors to give patients access to their data using methods outside the traditional medical record, such as APIs and non-encrypted email.

ONC is also attempting to address health disparities by capturing more categories of race and ethnicity in EMR systems and there has been reaffirmation of the importance of privacy and security in the updated measures.

CCDA

The Consolidated Clinical Document Architecture (C-CDA) format remains vital to ONC's efforts to foster interoperability and data integrity. 

To that end, C-CDA requirements have seen a major update in 2015 Edition. Vendors must support both v1.1 and v2.1 releases – and the latter must be backwards compatible. ONC is providing a “gold standard sample document” available to assist with adoption and has provided a "sandbox" of C-CDA resources, including a tool for vendors can test against the standard with a web-based scorecard. 

There are 3 C-CDA templates that must be supported for transition of care:

• CCD
• Referral Note
• Discharge Summary (Inpatient Only)

Health IT must also support the number of preferences for display and usage of CCDA, including:

• Display only a particular section (or sections) at a time
• Display order
• Number of initial sections to display

Common Clinical Data Set (CCDS)

Formerly known as the Common MU Data Set, the CCDS is a series of data stipulated for use across the 2015 Edition measures. ONC has provided a useful crosswalk, comparing the 2014 Common MU Data Set with its new incarnation.

Common Clinical Data Set is comprised of data from standards adopted by ONC, such as the CDC Race and Ethnicity Code Set Version. It is explicitly referenced in the following measures, often as a baseline that the certifying technology must receive, send out and/or make viewable:

• § 170.315(b)(1): Transitions of Care
• § 170.315(b)(4): Common Clinical Data Set summary record – create
• § 170.315(b)(5): Common Clinical Data Set summary record – receive
• § 170.315(b)(6): Data export
• § 170.315(e)(1): View, download, and transmit to 3rd party
• § 170.315(f)(5): Transmission to public health agencies – electronic case reporting
• § 170.315(g)(6): Consolidated CDA creation performance
• § 170.315(g)(8): Application access – data category request
• § 170.315(g)(9): Application access – all data request

Stay tuned for more information on new CQM requirements and their implications for population health monitoring!

Matthew Dugal celebrates five years with Dynamic Health IT

Dynamic Health IT congratulates Matthew Dugal on five years with the company!

Matthew has blazed new trails with our development team. He is a dedicated, caring employee, offering a wealth of expertise on any project to which he lends his talents. 

Matthew, congratulations on your 5 year anniversary with DHIT.  I feel very fortunate to have you on our team and have really come to appreciate your huge talent for software development through seeing the success of the products you’ve developed here, particularly CQMsolution.  You are also an amazing resource and trove of information for all things related to computer software and hardware, from setting up servers to finding the right piece of software to get a task done, to security and network troubleshooting.  Finally, you are reliable, dependable and ethical --- all great qualities for an employee.  Thanks for all you do!

-- Jeff Robbins

A big 5 year Congratulations to you Matthew! You are an integral part of Dynamic Health IT’s team. Your engagement in the ‘Magic’ that occurs here at DHIT encourages our clients to count on us. Your patience and perseverance on some of the most difficult projects has contributed to our products' success. Your honesty and dedication is admired. Thank you for all you do.
-- Raychelle Fernandez

Matthew is a great resource when it comes to programming. Not only does he know how to get the job done, but he can clearly explain and teach you how it was done so you feel confident to do it again in the future. Over the past 5 years he has taught me several valuable tricks of the trade that I’ve applied here at DHIT and at school. THANKS MATTHEW!!!
-- Maria Ruiz

Congratulations on your 5 years with Dynamic Health IT, Matthew. It is a pleasure working with you. Your programming and problem-solving skills are enormous and appreciated. Your knowledge of technology is very broad and invaluable. Beyond that, you are a very kind person to work with. We are so lucky to know you as a person and have you as a team member!
-- Ozlem Kurt

Matthew is a pleasure to work with - very knowledgeable and always willing to help. He’s not only very committed to the company, he also invests time and energy to his coworkers. DHIT would not be what it is without Matthew’s support and dedication. 

-- Maureen Bell

Matthew is a great coworker and a complete professional. He always shows good results in his projects and I always learn from him when we work together.
-- Erick Lanford

Matthew is a wizard coder whose technical expertise touches everything DHIT does - from our product line to our network infrastructure. Each time we attend a conference or interact with colleagues and clients in the industry, you can see the fruits of his labor. His hard work and deep dive into quality measures is evident when you realize the kinds of unparalleled things CQMsolution can do. I'm grateful for his guidance anytime I seek information across our projects. Matthew is thoughtful and thorough in everything he does. It's fun to hear his insights, whether work-related or not.
-- Joshua Shreve

CCDA Implementation-a-Thon II: Chicago

HL7 International, the standard bearer for healthcare information exchange, has kept up its hands-on approach with implementers and developers. One of their newest offerings is a series of Implementation-a-thons for C-CDA. As we did in Orlando, our team traveled to take part in the C-CDA Implementation-a-Thon this month in Chicago.

HL7.org

After the Orlando meetup, we were looking to take a deeper dive into the standard and share what we had been working on since January.

One of HL7's stated goals for the event was to "identify issues and potential trouble spots" in the CCDA. While some of us in the room are nominally competitors, we are all united around the common goal of making CCDA use and implementation as easy as possible, resolving ambiguities in the standard and working toward greater interoperability. EHR firms such as Epic and NextGen and a range of other developers, users and experts were all in the room, working toward this shared goal.

The collaborative spirit was encouraging, though some of the major industry players have been missing. This can make it difficult to coalesce around a decision on how to overcome major roadblocks to interoperability.

As is often the case at Connect-a-thons and other healthcare IT meetups, there were plenty of new faces, an indication of the growth in interest and a reminder that the standard requires ongoing outreach and education.

Here's a quick and dirty rundown of some key topics covered, followed by a few of our observations on specific discussion areas:

• Implantable devices
• Gender identity: administrative gender and birth gender
• "Assessment and Plan" vs. "Assessment" and "Plan of Care" 
• Approaches to "no known" value (allergies, medications, problems, etc.)
• Discharge Medications (v1.1 vs. v2.1)
• Care Plan: when to send, defining sections
• ONC C-CDA test data review and import
• Human readable vs. machine readable format and its effect on interoperability
• Medications: approaches to recording a "tapered dose"

Implantable devices

PHOTO: Boston Scientific

A key question around implantable devices - a class of equipment that includes artificial joints and pacemakers - is where the implant should be recorded in a C-CDA.

Does it go into "Procedures,""Medical Equipment" or some combination of the two?

For ONC Certification, it is expected to be in "Procedures" section, unless there is no implantable info, then it lives in the"Medical Equipment" section. At the Implementation-a-thon, HL7 further clarified that the implantable device information should always appear in the Medical Equipment section. When the specific procedure for the implant is known, it should also go into Procedures.



Gender identity

There is not yet an agreed-upon standard in healthcare data for distinguishing the sex of the patient as determined at birth from other notions of gender identification.

HL7 currently uses the concept of administrative gender, defined as "the gender of a person used for administrative purposes." FHIR, which built upon RIM, can incorporate XML resources to capture gender identity, but the best practice has not been decided.

In the case of a transgender male - whose birth sex was assigned female and whose current gender identification is male - SNOMED codes are capable of capturing this distinction. Common practice in C-CDA would most likely record the Administrative gender for this patient as female.

As HL7 explains in its current detailed descriptions:

(G)ender may not match the biological sex as determined by genetics, or the individual's preferred identification... Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosonal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. 

That last sentence gets at the fact that even the underlying process for recording gender identity and sex assignment is in need of clarity. There is no single approach, for instance, to mapping gender as recorded on an intake form with relevant C-CDA sections.

The Implementation-a-thon also explored the example of administrative gender as represented in 'UNK' nullFlavor, paired with an observation recorded in Social History. The general guidance from HL7 is that gender identity concepts should appear in"Social History,"while the "pending guidance" on birth sex is as follows:

C-CDA recordtarget/Administrative Gender is the field used to record the Birth Sex and must be coded as follows: M (male), F (female) or a nullFlavor of 'UNK'.

However, there will be further clarification coming from ONC and report back to the group.

Future considerations on this subject:

• Some Clinical Quality Measures require a reliable location for patient birth sex.
• Similarly, certain genetic predispositions and Clinical Decision Support in general also require birth sex, but not at the expense of multiple conceptions of gender identity.
• Which concept of sex or gender identity should be used in patient matching across data sets?

The discussion centering around this issue further underscored the need for all major players to take part in the shaping of the standard in order to avoid confusion and incoherence.

Lessons Learned

HL7 events never fail to be highly educational. Among the takeaways for us:

• As the C-CDA standard becomes increasingly flexible and interoperable, wide participation in dialogue and educational outreach are esssential
• Recording of gender identity and sex will likely be unresolved until an industry-wide consensus can be achieved across major providers, EHR developers, payers and policymakers
• As the standard and certification testing evolve, development practices must follow suit. The new testing tool is a great help in this process.
• Translation codes for alternate value sets should be used whenever possible, rather than rejecting a C-CDA outright.
• More focus is needed on reconciling discrete values in machine readable with the text description in the human readable portion.

HIMSS '16 Las Vegas: Key takeaways

As the HIMSS Conference continues its growth, there is risk that attendees will lose the signal in the noise. But the event continues to defy expectations by delivering both volume and value (to borrow a popular healthcare line).

Held this year in a city built on distraction, HIMSS '16 was rich in substance: educational opportunities, personal engagement and accessibility by even the largest organizations and agencies.

Dynamic Health IT once again hosted a booth with our partners at MaxMD, conveniently located near the Interoperability Showcase. We enjoyed seeing new faces, catching up with old friends and immersing ourselves in everything healthcare IT. We also ventured out from the booth to take advantage of the vast landscape of HIMSS programming.

What follows are key takeaways from the conference, with a focus on interoperability and clinical quality measures (CQMs):

CQMs: finding common ground

During the conference, we talked to a lot of attendees about their experience with CQMs - both in-person and through social media - listening to their needs and concerns on issues from data extraction to final submission. We came away optimistic about the flexibility of CQMsolution to meet client needs on this spectrum and the advantages of being a Data Submission Vendor (DSV) to assist customers through final submission.

There is a truly dizzying array of quality measurement programs (and measures), but there are also concerted efforts to get them on the same page. In particular, CMS' MIPS program seeks to align the Physician Quality Reporting System (PQRS), the Value Modifier and the the Electronic Health Record incentive program into one program. There is also increasing use of eCQMs by private insurers, as reflected by NCQA's eMeasure Certification.

Checking in with DeSalvo and Slavitt

There was great interest in the Wednesday afternoon talk featuring Karen DeSalvo, National Coordinator for Health Information Technology, and Andy Slavitt, Acting Administrator at CMS.

One of our most-liked HIMSS '16 app posts was a quote from Slavitt during the discussion: "Interoperability is a means to an end."  This point was at the crux of the Interoperability Showcase, which featured patient-based stories as a reminder that data flow should always be in service of patient care. On the physician side, Slavitt offered a reminder, through emphatic quotes by physicians in the field, that EHRs are failing doctors in some fundamentals ways.

Slavitt openly acknowledged that Karen DeSalvo was the more positive of the two and this was certainly in evidence when she reminded the audience of the immense progress that has been made since the inception of HITECH certification. She cited, as HHS Secretary Burwell did, the fact that 75% of physicians now use EHRs.

CMS and ONC: In Real Life

One reason why real life conferences still matter: the opportunity for face-to-face, personal interactions with people driving policy in large government agencies. Not all questions are easily resolved by a phone call or a quick scan of a webpage. And it's nice to have the human side of what can sometimes be perceived as faceless organizations.

We met with CMS and ONC officials to discuss specifics about quality measure reporting. This collaborative spirit, reflected in initiatives such as the recently-announced ONC Tech Lab, is encouraging to see.

Quality Measure Testing Tools

Anyone who missed the MITRE sessions at HIMSS '16 missed a lot. At DHIT, we have been closely-involved with MITRE's Cypress and BONNIE tools, which assists in our quality measure development, testing and validation. MITRE previewed some exciting new features in these tools (such as a BONNIE API).

Interoperability Testing gets FHIRed up

Dynamic Health IT's booth neighbored the Interoperability Showcase, so we're naturally a little biased here. MITRE spoke on their FHIR-testing tool called Crucible, which includes over 200 tests and a testing vertical just for API.

DHIT with FHIR Chief Grahame Grieve

Along with ConCert, HIMSS' own interoperability testing and certification process, it's clear that the industry is making very concrete commitments to defining what is and is not interoperability. ConCert includes a self-service Interoperability Testing Tool that will help developers incrementally test as they progress toward true interoperability.

As always, we enjoyed spending some time with FHIR architect Grahame Greive. There were, of course, plenty of #FHIR puns to go around:

One more before lunch: #HIT us with your best shot (immunization), #FHIR away. #FHIRpuns #HIMSS16

— Dynamic Health IT (@DynamicHealthIT) March 1, 2016

Direct Trust expands its reach

Our discussions at the booth (and beyond), brought home the point that Direct protocol can be used for much more than just Transition of Care (TOC). Attendees were pleasantly surprised to hear "Yep, Direct can do that" in response to a number of use cases, including secure messaging via mobile device.

APIs
This really deserves its own post, but you really couldn't go anywhere at HIMSS '16 and be out of earshot from someone discussing APIs. Part of the "Interoperability Pledge" fostered by ONC, involved a commitment to using APIs.

We can certainly attest to this growth through our own work with API development. And I don't think we're alone in eagerly awaiting an API for clinical quality measure submission.

Peyton under center (stage)

The recently-retired Broncos quarterback spun out some inspiring quotes for the crowd:

"Football is a game. Revolutionizing healthcare is a mighty endeavor." 

"Pressure is what you feel when you do not have a plan. Be prepared. "

As a reminder that health IT cuts across nearly every industry, Manning was joined after his speech by a physician who spoke about the NFL's EHR system. We swelled with pride to see two New Orleans Natives (DeSalvo and Manning) giving high-impact speeches at the conference.

HIMSS '16 New Y-- err, Las Vegas.

FHIR Orlando: Getting up to code

FHIR Connectathon 11 took place in January 9 and 10 in Orlando, FL. As with every stop on the FHIR circuit, evidence of steady growth in the standard was in abundance. Look no further than the furious coding that took place in a crowded hotel conference room.

Credit: Bill Dickinson

At Dynamic Health IT, the focus of our FHIR development has been on clinical quality measures and patient-accessible data. We continue to refine our approach in these areas to match changes both in the standard and how it is understood and implemented in practice. Seeing the diversity of application using the standard– owing largely to potential for resources to be self-defined – reminds us why FHIR has become an increasingly essential building block in our product development.

Appropriately enough, the Connectathon has now expanded to eleven tracks – ranging from basic patient management to financial services to genomics. As a form of introductory track, implementers perform the following tasks in the "Patient" track (Track 1), against their own or an available FHIR test server:

• Register a Patient
• Update a Patient
• Retrieve Patient History
• Search for a Patient (using name)

HL7 International also offers four tutorials earlier in the week for those looking for a primer on the standard.

There were plenty of new coders in attendance in Orlando, which speaks to current developmental climate for FHIR. Roughly half of the attendees raised their hand when asked if this was their first Connectathon, It's worth noting that while FHIR is growing up, it is still a relatively young standard. Let’s not forget that HTML, often used as an exemplar for FHIR, was proposed in 1989 and is still undergoing major adaptations reflecting the evolution of the Web.

As Grahaem Grieve announced in Amsterdam, FHIR will now be a "working standard," reflecting the fact that it is being implemented in production environments, but still has many core elements subject to change. The move from a draft standard toward a "balloted" standard is due to take place officially sometime this spring.

This new-found maturity was evidenced in the shift toward implementing servers. There is now a major emphasis being placed on rigorous testing against servers. Vendors are presenting production-level products for testing FHIR servers and robust patient test decks are being rolled out to meet the demand.

It was great to again see a capacity crowd for this event (hopefully not a "FHIR hazard"). The ability of FHIR to realize all of its potential has much to do with the strong community it has built.

Welcome to 2016: HIMSS '16 Las Vegas, FHIR and more

The New Year is a time for reflection. At the pace the health IT world is moving, reflections must be followed quickly by actions.

As the calendar turned over, Dynamic Health IT took a moment to look back on a successful 2015. It was a year that included ambitious upgrades to our products, a wide range of fulfilling client work, a website refresh and some exciting new directions for our company (expanding our involvement in FHIR and PQRS, to name a few).

But we don't like to rest on our laurels for long. So we're also looking ahead to just a few of the things 2016 holds in store...

Photo: chensiyuan

HIMSS 2016

What happens in Vegas stays in Vegas - unless of course you attending a massive health IT convention. In that case, you're going to hear about it all over social media for five solid days (you're probably hearing about it already).

From February 29 to March 4, our industry will converge on the Sands Expo and Convention Center. Dynamic Health IT will be exhibiting with MaxMD and you can find us both at Booth 12251. We're once again looking forward to spending some time with old friends and collaborators, as well as hearing some new stories.  

We'll be sharing the fruits of our labor in 2015 and previewing some new developments for 2016, particularly in our Patient Portal and CQMsolution product lines.

Clinical Quality Measure Development

Having wrapped up a rigorous CQM development cycle in 2015 -  which included user interface upgrades and support for Cypress 2.6.1 - we are looking ahead to supporting measures for the 2016 reporting year and bringing our CQMsolution software into line with v2.7 and subsequent v3.0 Cypress upgrades. In addition to wider support for PQRS measures and other enhancement, this will be another year of big developments in CQMs.

CCDA 2.1 

This new draft standard for trial release (DTSU) of the Consolidated Clinical Document Architecture standard was released for comment last July. Vendors who are certifying under 2015 Edition will need to support both v1.1 and v2.1 releases and produce three flavors of C-CDA: CCD (v3), Discharge Summary and, for inpatient providers,  Referral Notes.

Just last week, DHIT took part in a Implementation Connectathon, exploring best practices for parsing and displaying these CCDAs alongside HL7 International, ONC and leading EMR systems. As HL7 continues to update the CDA framework, we will remain on the leading edge, updating our software so that our clients are well-positioned for the latest edition of EHR certification and industry standard changes in general. 

FHIR

Over 2015, Dynamic Health IT was an avid participant in the FHIR community, attending Connectathons, releasing a new FHIR white paper and working toward FHIR development goals (including the testing of clinical quality measures with a FHIR server). In fact, as this post was being written, a contingent of our DHIT team was in Orlando for a FHIR Connectathon. 

This year promises another full slate of FHIR events, ongoing community dialogue and new steps toward wider implementation of the standard. FHIR is now considered a "working standard" and should continue to progress in the steps of maturity as outlined by architect of the standard, Grahame Grieve.

Please do not hesitate to share concerns or questions about the upcoming policy changes and requirements with DHIT. We can reach out to ONC and CMS on our bi-monthly calls and other contacts to ensure that you have the latest intel.

Look out for more updates from our shop in our February Newsletter.