Da Vinci Connectathon and the Challenge of eCQM Data Capture

Dynamic Health IT (DHIT) was in attendance for the Da Vinci FHIR Connectathon hosted by GuideWell  (parent company of Florida Blue) in Jacksonville Florida.  For those of you not familiar, the Da Vinci Project is a collaboration of trail-blazers in the healthcare space who are looking to revolutionize information sharing.  It is a private sector initiative comprised of experts from some of the largest and most prestigious payer, provider and vendors in the healthcare marketplace.  Their goal is to accelerate the adoption of HL7® FHIR® as the standard to support and integrate data exchange for value-based care (VBC) with a focus on provider/payer data exchange.

The Connectathon featured three different tracks.  We participated in the Clinical Reasoning Track, which focuses on exploring the use of FHIR to calculate Clinical Quality Measures (CQMs). As we’ve contributed to this track, we’ve also increased our understanding of issues related to migrating to FHIR-based CQMs. For DHIT, this means the integration of separate products - Dynamic FHIR Server with CQMsolution.

As it stands today, FHIR data types are not used in the calculation of eCQMs. (eCQMs are the Clinical Quality Measures generated directly from EHR data with no intervening manual abstracting process). But Da Vinci members are looking to obsolete the Quality Data Model (QDM) data elements currently used for calculation and presentation in the QRDA Cat I files and replace them with FHIR.  A FHIR Measure Report could replace the QRDA Cat I and QRDA Cat III files. FHIR also offers new operations that instruct the FHIR server to perform measure calculation.  Tangentially, DHIT has explored the use of the 2.1 CCDA as a data source for calculating eCQMs (more on that later).

The Clinical Reasoning Track is evolving as well. Previous iterations used "normal" QDM-based eCQMs but relied on FHIR patient data that was converted using QDM to QI Core Mappings. Developers have been hard at work doing a trial run to populate existing eCQMs by using FHIR data types. This will make it possible to run FHIR-based eCQMs against FHIR data elements.

DaVinci has expanded this track include additional operations related to submitting and collecting data. These include the submission of data from the producer to the consumer.  In this scenario, an EHR might submit data directly to a Payer. Additionally, consumers can request data from the producer using a “Collect Data” operation or subscribe to the producer's Subscription Service to be notified when CQM data becomes available.  All of these operations limit the scope of data collected to what is required by the measures.

During this Connectathon we focused on one CQM - Venous Thromboembolism Prophylaxis (VTE-1). Some of the issues we faced were the sheer scope of changes required to begin this process.  For example, the version of the CQL language itself differs between the current CMS version of the measure and the newly released FHIR version of the measure.  In the end Dynamic Health IT was able to make considerable progress towards the goal of the track.

Back to the challenge of using the 2.1 CCDA as a data source for calculating eCQMs:  Based on our research to-date, many current eCQMs cannot be accurately calculated from standard 2.1 CCDA data elements. NCQA offers an eCQM certification process that involves calculating quality measures from CCDA documents but it only includes a subset of the MIPS/QPP eCQMs and some are older definitions.  Why is this?  We suspect it is because the remainder are problematic to calculate from a CCDA.

There are several reasons for this:

• Many measures include exceptions and exclusions and these are not captured in a standard CCDA.  For example, skipping a Breast Cancer screening for a woman with bi-lateral mastectomies would be an exclusion.  “Patient refused to get a flu shot” would be an exception.  Calculating eCQMs without exceptions and exclusions is possible but will result in an inaccurate and lower score. 
• A typical 2015 Edition Certified 2.1 CCDA (the kind produced by most EHRs) lacks a standard representation for the Adverse Event used by CMS347v2 (Statin Therapy).
• Some measures call for Assessments but there's no standard way to convey the result of the Assessment in the CCDA.

DHIT’s flagship product ConnectEHR is certified for CCDA creation. We are currently working with HL7 to expand the CCDA data elements to accommodate more of the eCQM measure requirements. Most current adjustment to CCDA is related to negation. There are also other issues relate to using a CCDA as a data source, such as values being provided as free-text, rather than being codified and different EHR systems capturing the same clinical values/events in different ways.   Despite these obstacles, we continue to pursue the eCQM data capture challenge and look forward to participating in the next Connectathon in Atlanta.  Hope to see you there!

2019 MIPS – What You Need to Know

You’ve completed 2018 MIPS – everything is submitted and filed away.  Time to relax? 

Well you certainly deserve some R&R but don’t lose sight of the upcoming MIPS challenges and opportunities for 2019 reporting year.  Increasingly, MIPS success will mean a year-round focus as CMS ratchets down on scoring thresholds and imposes greater penalties for weak and non-performers.  Here is our roundup of changes that will present challenges and opportunities in the upcoming year.

 

Opportunities

·      By June of 2019, CMS will have digested and posted MIPS scores in a patient-friendly format on the Medicare Physician Compare website.  The site will have a new hyperlink indicating “Performance information available”.   This “Performance information” is derived from MIPS scoring and may be used not just by patients and prospective patients but by any other interested parties.  So, even though your practice may provide excellent patient care, a sub-standard MIPS score could drag you down.

·        Strong performers can submit both as group and individual and then choose the highest score.  Eligible Clinicians now include Physical therapist, Occupational therapists, Qualified speech-language pathologists, Qualified audiologists, Clinical Psychologists, and Registered dieticians/nutrition professionals. 

·        eCQMs, Promoting Interoperability and Improvement Activities (details below) can now all be submitted via the new QPP API, eliminating the old manual upload process. 

Challenges

·        2015 Certified software must be in place during the entire reporting period, although it is permissible for the certification to happen after the start of the reporting period, as long as it is prior to the end of the reporting period. 2014 Certified software is no longer acceptable for 2019 reporting. 

·        To avoid a penalty, the minimum score is 30 points as opposed to 15 points in 2018. Likewise, the exceptional performance bonus threshold is up from 70 points to 75 points.

·        The 4 categories from 2018 remain but some percentages have been adjusted  for 2019:

1.      Quality 45% (decrease of 5%)

·        Minimum of 6 measures for 1 year

·        1 must be an outcome or High Priority Measures (awarded higher points)

·        Bonus points awarded if you choose the same measure and show improvement from 2018

·        Avoid topped out measures, since scoring is capped at a maximum of 7 points

·        On the overall list of Quality Measures, 26 were removed and 8 were added 8 (6 of which are high priority -- see chart below)

·        Of the 26 and 8, some eCQMs changed:

o   CMS 249 and CMS 349 have been added

o   CMS 65, CMS 123, CMS 158, CMS 164, CMS 167, CMS 169 were removed

o   CMS166 -previously for Medicaid-only submission – has been phased out.

·        New for 2019: CMS will aggregate eCQMs collected through multiple collection types; if the same measure is collected, the greatest number of measure achievement points will be awarded.

Measure ID	eCQM ID	New Measures for 2019: Name	Measure Type
468	None	Continuity of Pharmacotherapy for Opioid Use Disorder	High Priority
469	None	Average Change in Functional Status Following Lumbar Spine Fusion Surgery	High Priority
470	None	Average Change in Functional Status Following Total Knee Replacement Surgery	High Priority
471	None	Average Change in Functional Status Following Lumbar Discectomy Laminectomy Surgery	High Priority
472	CMS249v1	Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	High Priority
473	·        None	·        Average Change in Leg Pain Following Lumbar Spine Fusion Surgery	High Priority
474	None	Zoster (Shingles) Vaccination	Process
475	CMS349v1	HIV Screening	Process

2.      Promoting Interoperability 25%

·        Minimum of 90 days

·        Only one set of objectives & measures (reduced from 2 in 2018)

·        4 Objectives include: e-Prescribing, Health Info Exchange, Provider to Patient Exchange and Public Health & Clinical Data Exchange

·        50 point “base value”/bonus from 2018 has been removed

3.      Improvement Activities 15%

·        Minimum of 90 days

·        Added 6, Modified 5, removed 1 = 118 total Improvement Activities

·        Bonus removed

4.      Cost 15% (increase of 5%)

·        1 year

·        No actual submission

Deadlines

·        Groups must register by June 30.

·        Submission Deadline:  March 31, 2020

The bottom line (in our opinion):  Don’t wait until the year is over to take action to improve your MIPS score.  Remember, the bar is set higher for 2019 and the financial incentives and penalties are also greater. 

Prepping for 2019 Hospital Quality Reporting

Now that the 2018 reporting year has been wrapped up and submitted, this is a good opportunity to examine what worked and what areas need improvement to ensure a successful 2019 reporting year.

Rear-View Mirror

• On the Quality Net site, we experienced issues with generating reports and site speed.  Apparently, others had the same issues.  Fortunately, CMS extended the 2018 deadline from February 28 to April 14.
• To compound the frustration, Quality Net lacks an open forum for support tickets.  MIPS, Cypress, CDA 2.0 and C-CDA and FHIR all have open Jira or Google Groups for support, allowing developers, implementers, and users to comment and ask questions using a transparent process. CMS does not.
• The support process is tedious and time-consuming.  Undisclosed reporting tool issues created “false alarms” for our calculations and turnaround on support tickets moved slowly.   Nonetheless, we worked with the CMS help desk and technical support to ensure that our CQMsolution calculations matched Quality Net.
• In spite of these obstacles, our new ‘Submit to DHIT’ button made testing and submitting a much smoother process.   All clients submitted successfully prior to the deadline.

Challenges

• 2015 Certified EHR Technology (CEHRT) must be in place during the entire reporting period, although it is permissible for the certification to happen later, as long as it is posted on the ONC CHPL prior to the end of the reporting period. 
• In case you still have doubts, 2014 Certified software is not acceptable for 2019 reporting.
• 2019 Promoting Interoperability (formerly Meaningful Use) now has a MIPS-like scoring system, although unlike MIPS, Quality Measures are not part of the scoring.
• The big challenge for EHR vendors and other suppliers of eCQM software is the transition to Clinical Quality Language (CQL) but, if done correctly, this transition should be transparent to software users.
• Keep in mind that your CQM results are digested and posted to the Medicare Hospital Compare website.

Opportunities for Success

• By submitting eCQMs to the IQR program, you will meet PI (MU) requirements for EHR submission.
• Start running CQM reports early to identify problem areas and home in on CQMs that are best suited to your hospital.
• In spite of CMS’ new “Meaningful Measures” initiative, the actual eCQMs and reporting period requirements are not changing for 2019:  You still choose a minimum of 4 eCQMs for one self-selected calendar quarter.
• The overall list of hospital CMS eCQM measures in 2019 will stay the same, except for one adjustment:
• CMS 55 is discontinued in the IQR program, but will remain in TJC (see below).
•  For 2020, CMS is proposing to remove the 7 eCQMs (highlighted in blue, below) so you may want to take this into consideration when choosing your 2019 eCQMs:

• For 2021, CMS is proposing to adopt two new opioid-related eCQMs: 
• Safe Use of Opioids – Concurrent Prescribing eCQM, and
• Hospital Harm – Opioid-Related Adverse Events eCQM. 

TJC Submission

• The big news is that next year Joint Commission ORYX vendors will assist hospitals using their Direct Data Submission Platform (DDSP).  Additional communication regarding the transition is supposed to be released this Spring.
• 2019 Measure selection was due on 12/31/2018. Hospitals that still need to select can do so by contacting hcooryx@jointcommission.org .
• 2019 Measures: (no changes from 2018), hospitals choose a minimum of 4 measures for 1 quarter.
• We submitted to ORYX for a number of clients and found that the calculations from our CQMsolution software were consistent with TJC across the board.

We hope this helps with your 2019 reporting process and, as always, welcome your feedback.

 

FHIR Heats Up HIMSS

In the middle of eCQM submissions for our EH and EP clients, and Carnival season here in New Orleans, it seems impossible that something would be able to pull us away from our office in the Crescent City. However, HIMSS accomplishes this on an annual basis and we were eager to arrive in Orlando for the 2019 conference last week. ONC had just announced a new proposed rule, including the endorsement and mandatory incorporation of FHIR, and the news was traveling faster than the Boeing 737 we were on. This was quite the way to start off our eighth HIMSS conference. Fortunately, we also frequent FHIR Connectathons and have been, and continue to, prepare for the FHIR-based changes ahead.

The New Proposed Rule

“FHIR” and “API” were two of the hottest acronyms at this year’s HIMSS Conference. This is still a proposed rule that is open for comments but, if finalized, ONC would require EHR vendors to offer a well-documented API that:

•         Exposes US Core Data for Interoperability (USCDI v1) data elements
•         Uses FHIR to support USCDI data classes and data elements
•         Supports the SMART Application Launch Framework Implementation Guide

USDCI expands on the Common Clinical Dataset that was introduced with the 2015 Edition final rule and includes two additional data classes: Clinical Notes and Provenance. Clinical Notes is aptly named and may include notes detailing assessment, a plan of care, patient teaching, and other relevant data points. While defining Provenance is not as straightforward, the objective is using metadata that defines the creator and owner of an element to deepen trust in and alleviate audit pains with that dataset as it is passed between systems and APIs.

We were also gifted an abbreviated version of “API Resource Collection in Healthcare” as the proposed rule introduced us to the acronym ARCH. ARCH is aligned with the proposed USCDI and references 15 FHIR resources that certified vendors would be required to support. To help achieve this goal, ONC has created an open source (and still under development) tool for testing if patients can access their health data as expected. Fans of Dante, Dan Brown, and Tom Hanks are delighted with the naming of the new tool and “Inferno” is available at: https://inferno.healthit.gov/inferno/. 

More details on the testing suite can also be found here: https://www.healthit.gov/buzz-blog/interoperability/onc-is-fhird-up-unwrapping-the-new-inferno-testing-suite.  Additionally, the proposed rule would require adoption of SMART (Substitutable Medical Applications, Reusable Technologies) which uses OAuth2 to provide a layer of security for FHIR interfaces. OAuth2 is a widely used industry standard that, coupled with OpenID Connect, provides a level of authentication and authorization that is outside of FHIR’s scope. It also describes a process by which an EHR application can launch an external application while preserving the patient and user context, thus providing secure access to EHR data.

Information blocking (including seven exceptions) is also a large part of the proposed rule and attempts to codify the concept of patients, rather than their health systems, owning their data and being entitled to access that data free of charge. As CMS administrator Seema Verma noted, “The idea that patient data belongs to providers or vendors is an epic misunderstanding. Patient data belongs to patients.”

Final Thoughts

Of course, the highlight of our HIMSS experience is interacting with our peers who are equally passionate about healthcare IT. Throughout the event, current and prospective DHIT clients stopped by our booth to chat and the energetic environment of HIMSS left us with additional motivation and a renewed commitment to healthcare IT and providing our client base with outstanding customer service.

Our promise is continuing to strive towards an impactful footprint in the HIT industry by providing research, news, and innovative development. If you missed us at HIMSS, plan to meet us at the next FHIR Developer Days, FHIR Connectathon, or ONC Annual Meeting as we dive deep into ongoing development on FHIR Resources and C-CDA requirements. We have a blog on NPRM, comments to ONC, newsletters, and emails all coming soon and, in the meantime, you can join us on Twitter @DynamicHealthIT.

HL7 January 2019 Working Group Meeting, FHIR Connectathon and C-CDA IAT: A Recap (Part II)

For the week following January 12th, a delegation from the Dynamic Health IT development team was on hand in San Antonio for the HL7 Working Group Meeting and FHIR Connectathon. Our team shared technical approaches and a vision for the future of FHIR, C-CDA and our industry at large. This is Part II of our recap of the week’s events.

While the Working Group Meeting (WGM) covered the entire week’s festivities, FHIR and C-CDA got the intensive treatment over the weekend of January 12th. While FHIR had its own discussion track at the WGM, in-depth technical discussions of interoperability at the document and data levels reigned over the weekend.

As in any technological meeting of minds, some of the discussion can become obscure. But it is just this level of detail that is pushing the maturity of the standards and is proving crucial to adoption.

Among other efforts over a busy weekend, our team discussed important use cases for the standards, reviewed USCDI data elements, shared our methodology for C-CDA to FHIR (not to be confused with C-CDA on FHIR) and went deep into the details of Clinical Notes. There were also, as always, a range of tracks offered to put developers through their paces.

In Part II, we summarize few more of these important flash points.

Provenance comes of age

DHIT team in a rare moment of down time.

Provenance is “data and metadata for who and when information was/is created, for the purposes for trust, traceability and identification.” And it’s been hot topic of conversation in some recent C-CDA events and this time was no different. To show that it’s arrived (and needs to be taken seriously) it has been included in the expanded USCDI.
If document-level meta-data can be verified and included as a matter of course, it will go along way to breaking down barriers of distrust between providers and systems.

Patient Summary vs. Encounter Summary

We discussed Encounter Summary documents at length in our previous post in which we reviewed some of the Carequality/CommonWell recommendations. Whereas an encounter summary is meant to be limited to a specific episode of care, patient summary documents contain a record of care over a period of time, including multiple encounters. 

But as debated at the IAT, how do we represent a problem list – should it show a snapshot in time, a net problem list or be in some way shifted to another document type or section to avoid any confusion? Most clinicians, at any given time, want condensed data that provides direct insight to the patients’ current state of being – so what happens to the history when a document is compiled?

Meds and Labs

Shades of meaning become increasingly important as standards are defined down to the last character.  While a ‘Medication, Administered’ should indicate that a clinician confirmed that the patient took the med, medication “complete” is another story.

There was a consensus for putting all lab results in the results section, while some associated procedures may be essential dual-entered in the procedures section.

Close quarters at Connectathons, while at times chaotic, have the virtue of providing sustained and meaningful interaction. Many questions that may get overlooked during a normal workday back at each of our respective offices get answered.

If the spirit of the event is “share and share alike,” then San Antonio was another roaring success. When it comes to interoperability, the learning and collaboration never stops.

HL7 January 2019 Working Group Meeting, FHIR Connectathon and C-CDA IAT: A Recap (Part I)

Tower of the Americas, San Antonio, TX.

For the week following January 12th, a delegation from the Dynamic Health IT development team was on hand in San Antonio for the HL7 Working Group Meeting and FHIR Connectathon. Our team shared technical approaches and a vision for the future of FHIR, C-CDA and our industry at large. 

For the uninitiated, the event is an interoperability extravaganza, allowing implementers to dive deep and uncover best practices in health data sharing.  The Connectathon portion now also hosts the C-CDA Implementation-a-Thon (IAT), allowing in-depth collaboration with industry leading EHR developers.

Major policymakers, developers and stakeholders are in attendance for an ambitious look at interoperability from practical and conceptual standpoints. The free flow of information on display mirrors what interoperability itself aspires to be: open and unencumbered. Perhaps most importantly, it reminds us that our human connections are essential to our virtual ones.

FHIR: Is the future now?

The FHIR Connectathon added the C-CDA IAT track, which allowed for exploration of the connection between FHIR and C-CDA documents. We continued our active engagement in this collaboration as we hammered out the C-CDA to FHIR Mapping. A CDA to FHIR and FHIR to CDA roundtrip allows implementers who only do CDA (or who only do FHIR) to communicate with each other.

One of the greatest challenges in this effort is to decide on and maintain the conversion mechanism that translates a C-CDA document into a FHIR C-CDA document (and vice versa). C-CDAs rendered in XML do not always map neatly to FHIR resources and there are all sorts of judgment calls to be made; though it should be said: getting these two to play nicely is a key goal for HL7 policymakers and the next major release of FHIR (R5) will have more support for migrating data to and from v2.1 CDA documents.

FHIR Connectathon swag.

One conceptual hurdle, aside from mapping, is the fact that a C-CDA document tells a clinical story and is therefore more legible. FHIR’s resources are more abstract and, while highly flexible. Therefore, they’re better positioned to serve as the clearinghouse: to be “read” directly by EHRs and mobile applications. But clinicians and other human readers require the narrative quality that a discrete document format provides.

The Dynamic team shared its experience with implementing CCDA to FHIR in and our decision to emphasize the use of a document repository that creates FHIR resources on the fly. We have rolled this all the way up to a prototype mobile app for patient end-users, while our near terms goals include having Apple HealthKit talking directly to our Dynamic FHIR product.

Quality Measures – they’re everywhere

Clinical quality measures calculation from FHIR (or CCDA) remains a nascent field of inquiry. The data sources for CQMs currently in the field are overwhelmingly based on mapping measure logic to some existing relation data format used by the EHR. But as our team has shown in previous Connectathon events, CQM calculation can work hand-in-hand with FHIR.

With the advent of Clinical Quality Language (CQL) in 2019, there is further hope that this more interpretable logic will enable more interoperability in CQMs. In theory, CQL files should be easier to create, read and share across domains beyond CQM compliance (for instance, clinical decision support). And by extension, they should dovetail more easily with FHIR resources.

There is plenty of cause for optimism here, including the fact that the team beyond CQL offers a wealth of open source tooling and some emerging recommendations that CQM programs support more of the code systems under 2015 Edition.

Here is another example of the way in which clinical documents are colliding with CQMs:  The CPC+ program, which includes a subset of required CQMs, will also be requiring the output of a Care Plan document. Dynamic Health IT, along with a handful of other vendors, has previously implemented the Care Plan C-CDA in a production environment.

Connecting and collaborating.

C-CDA Scorecard rubric updates
Many EHRs have implemented some version of incoming C-CDA grading consistent with 2015 Edition. Use of the ONC-engineered Scorecard Tool is not required for certification, but some form validation similar to that made available by ONC via API is needed. The Scorecard, which provides the additional flourish of a letter grade, was ONC’s way of allowing users to check the quality of the C-CDA from a sending system and provide a channel for accountability.

However, there has been some pushback by EHRs that the analysis provided by the tool is too blunt and users of the tool are getting caught up in the grade, as opposed to what the grade represent (not unlike college). EMR vendors seem to prefer a Progress Bar allowing the end-user to understand where progress can be made to improve the provided data. 

ONC has some enhancements coming to provide more meaningful feedback to implementers by indicating the number of tests graded and number of tests passed, while indicating the number of unique issues.

There has also been a request from EHR vendors for more clarity in error messaging, which may be addressed in part by further education.

Stay tuned for our next post for more information on some of the lead-edge discussions around interoperability standards.