Data Exchange For Quality Measures Implementation Guide (Release 0.2.0 STU2 Ballot)

This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v0.2.0: STU 1 Ballot 2) based on FHIR R3. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

Venous Thromboembolism Prophylaxis Use Case

Introduction

The VTE measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

The example presented is based on the QDM version of CMS 108v7, which has been represented using profiles derived from QI Core. Additional information regarding the measure specification can be found in the [Quality Measure Implementation Guide]

FHIR Resource Overview

Resources supported for this use case:

Resource Type Profile Name Link to STU3 Profile Link to R4 Profile
Condition QI Core Condition Profile QI Core Condition (STU3) QI Core Condition (R4)
Coverage QI Core Coverage Profile QI Core Coverage (STU3) QI Core Coverage (R4)
DeviceRequest DEQM DeviceRequest Profile DEQM DeviceRequest (STU3) DEQM DeviceRequest (R4)
DeviceUseStatement DEQM DeviceUseStatement Profile DEQM DeviceUseStatement (STU3) DEQM DeviceUseStatement (R4)
DiagnosticReport QI Core DiagnosticReport Profile QI Core DiagnosticReport (STU3) QI Core DiagnosticReport (R4)
Encounter QI Core Encounter Profile QI Core Encounter (STU3) QI Core Encounter (R4)
Library CFQM Library Profile CFQM Library (STU3) CFQM Library (R4)
Location QI Core Location Profile QI Core Location (STU3) QI Core Location (R4)
Measure CFQM Measure Profile CFQM Measure (STU3) CFQM Measure (R4)
MeasureReport DEQM Individual MeasureReport Profile DEQM Individual MeasureReport Profile (STU3) DEQM Individual MeasureReport Profile (R4)
MeasureReport DEQM Summary MeasureReport Profile DEQM Summary MeasureReport Profile (STU3) DEQM Summary MeasureReport Profile (R4)
MedicationAdministration DEQM MedicationAdministration Profile DEQM MedicationAdministration (STU3) DEQM MedicationAdministration (R4)
MedicationRequest DEQM MedicationRequest Profile DEQM MedicationRequest (STU3) DEQM MedicationRequest (R4)
Observation QI Core Observation Profile QI Core Observation (STU3) QI Core Observation (R4)
Organization DEQM Organization Profile DEQM Organization (STU3) DEQM Organization (R4)
Patient QI Core Patient Profile QI Core Patient (STU3) QI Core Patient (R4)
Practitioner DEQM Practitioner Profile DEQM Practitioner (STU3) DEQM Practitioner (R4)
Procedure QI Core Procedure Profile QI Core Procedure (STU3) QI Core Procedure (R4)
ProcedureRequest QI Core ProcedureRequest Profile [QI Core ProcedureRequest (STU3)] [QI Core ProcedureRequest (R4)]

Graph of VTE Resources:

This measure assesses the number of patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given the day of or the day after hospital admission, or surgery end date for surgeries that start the day of or the day after hospital admission

Below is listed a resource diagram that meets a situation in the VTE measure.

Option 1: Measure Report Using MedicationAdministration

When a patient has an inpatient encounter, is not either pregnant or currently diagnosed with a Venous Thromboembolism, and is administered either Heparin, a Factor Xa Inhibitor, or Warfarin on the calendar day of admission or the day after, the process for VTE Prophylaxis has been met. The medications that qualify for the measure are listed in the value sets of codes in the measure documentation. Below is the data structure for what would be included with a DEQM Individual MeasureReport when the patient has been administered one of these medications to meet the measure.

Figure 3-14
DEQM Resource Diagram - VTE1.jpg

Option 2: Measure Report Using DeviceUseStatement/Encounter

When a patient has an inpatient encounter, is not either pregnant or currently diagnosed with a Venous Thromboembolism, and has a device to prevent VTE on the calendar day of admission or the day after, the process for VTE Prophylaxis has been met. The devices that qualify for the measure are listed in the value sets of codes in the measure documentation. Below is the data structure for what would be included with a DEQM Individual MeasureReport when the patient has had one of these Devices applied to meet the measure.

Figure 3-15
DEQM Resource Diagram - VTE2.jpg

Option 3: Measure Report Using Observation

When a patient has an inpatient encounter, is not either pregnant or currently diagnosed with a Venous Thromboembolism, and has been observed to have a low risk for VTE on the calendar day of admission or the day after, the process for VTE Prophylaxis has been met. The result codes that qualify as “low risk for VTE” are listed in the value sets of codes in the measure documentation. Below is the data structure for what would be included with a DEQM Individual MeasureReport when the patient has had this Observation made to meet the measure.

Figure 3-16
DEQM Resource Diagram - VTE3.jpg

Option 4: Measure Report Using Encounter

When a patient has an inpatient encounter where the encounter is <2 days long, or when the encounter is includes an ICU stay of 1 or more days, the patient can be excluded from the measure for the qualifying encounter. Codes for the ICU facility location will come from the HL7 ServiceDeliveryLocationRoleType valueset.

Figure 3-17
DEQM Resource Diagram - VTE4.jpg

Option 5: Measure Report Using Encounter

When a patient has an inpatient encounter and is principally diagnosed with either a mental health condition, or a stroke (either hemorrhagic or ischemic), they are excluded from the numerator of the measure. Codes for the diagnoses will come from the respective valuesets from the measure.

Figure 3-18
DEQM Resource Diagram - VTE5.jpg

Option 6: Measure Report Using Procedure/Request and Encounter

When a patient has an inpatient encounter, during which they are provided Comfort Measures within 1 day of being admitted or 1 day of a surgical procedure for which they were admitted, these Comfort Measures satisfy the numerator logic for the measure. The surgical procedure is defined by the presence of a code from the “general or neuraxial anesthesia” value set present in the measure. The Comfort measures are represented by either a Procedure or a ProcedureRequest with a code from the “Comfort Measures” value set present in the measure.

Figure 3-19
DEQM Resource Diagram - VTE6.jpg

Option 7: MeasureReport using MedicationRequest, DeviceRequest, MedicationStatement, or DeviceUseStatement

When a patient has an inpatient encounter, during which they should be given VTE prophylaxis, but they are not given said prophylaxis, the patient’s record must document a reason the medication/device was not provided. This reason must be coded, and must come from either the “medical reason” or “patient refusal” value sets, as stated in the measure logic. If these criteria are met, the patient will have been found to satisfy the requirements of the measure.

Figure 3-20
DEQM Resource Diagram - VTE7.jpg

VTE-1 Data Exchange Interactions

Note to Balloters: We are actively seeking feedback on whether VTE-1 Data Exchange interactions are appropriate or useful for hospital systems.

VTE-1 Measure Reporting Interactions:

Individual MeasureReport

Aggregator pushed the Bundle of supporting resource with VTE-1 Individual MeasureReport Bundle to the end user.

Note to Balloters: We are actively seeking input on whether a technical workflow diagram would be of value for this use case

Examples

Scenario:

Payer X who is acting in the role of a Reporter submits a VTE Individual Report for Patient P to Receiver Z. The body of the request is a transaction bundle including the Individual MeasureReport and all the related resources containing the relevant data used to compute the CQM criteria. An HTTP Status success code is returned on successful submission.

POST Summary Report

POST [base]

Request body

{
  "resourceType": "Bundle",
  "type": "transaction",
  "entry": [
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc4",
      "resource": {
        "resourceType": "MeasureReport",
        "status": "complete",
        "type": "individual",
        "measure": {
          "reference": "Measure/measure-vte"
        },
        "patient": {
          "reference": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc6"
        },
        "date": "2019-03-14",
        "reportingOrganization": {
          "reference": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc5"
        },
        "period": {
          "end": "2018-01-01",
          "start": "2018-12-31"
        },
        "group": [
          {
            "population": [
              {
                "code": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/measure-population",
                      "code": "initial-population",
                      "display": "Initial Population"
                    }
                  ]
                }
              },
              {
                "code": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/measure-population",
                      "code": "numerator",
                      "display": "Numerator"
                    }
                  ]
                }
              },
              {
                "code": {
                  "coding": [
                    {
                      "system": "http://hl7.org/fhir/measure-population",
                      "code": "denominator",
                      "display": "Denominator"
                    }
                  ]
                }
              } 
            ],
            "measureScore": 100
          } 
        ]
      },
      "request": {
        "method": "POST",
        "url": "MeasureReport"
      }
    },
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc5",
      "resource": {
        "resourceType": "Organization",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/davinci-deqm/STU3/StructureDefinition/organization-deqm"
          ]
        },
        "identifier": [
          {
            "use": "official",
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/v2/0203",
                  "code": "TAX",
                  "display": "Tax ID number"
                }
              ]
            },
            "system": "urn:oid:2.16.840.1.113883.4.4",
            "value": "123456789",
            "assigner": {
              "display": "www.irs.gov"
            }
          }
        ],
        "active": true,
        "type": [
          {
            "coding": [
              {
                "system": "http://hl7.org/fhir/organization-type",
                "code": "prov",
                "display": "Healthcare Provider"
              }
            ]
          }
        ],
        "name": "DaVinciHospital01",
        "telecom": [
          {
            "system": "phone",
            "value": "(+1) 401-555-1212"
          }
        ],
        "address": [
          {
            "line": [
              "73 Lakewood Street"
            ],
            "city": "Warwick",
            "state": "RI",
            "postalCode": "02886",
            "country": "USA"
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Organization"
      }
    },
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc6",
      "resource": {
        "resourceType": "Patient",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
          ]
        },
        "extension": [
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-birthsex",
            "valueCode": "F"
          },
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-race",
            "extension": [
              {
                "url": "ombCategory",
                "valueCoding": {
                  "system": "urn:oid:2.16.840.1.113883.6.238",
                  "code": "2106-3",
                  "display": "White"
                }
              },
              {
                "url": "text",
                "valueString": "White"
              }
            ]
          },
          {
            "url": "http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity",
            "extension": [
              {
                "url": "ombCategory",
                "valueCoding": {
                  "system": "urn:oid:2.16.840.1.113883.6.238",
                  "code": "2186-5",
                  "display": "Not Hispanic or Latino"
                }
              },
              {
                "url": "text",
                "valueString": "Not Hispanic or Latino"
              }
            ]
          }
        ],
        "identifier": [
          {
            "use": "usual",
            "type": {
              "coding": [
                {
                  "system": "http://hl7.org/fhir/v2/0203",
                  "code": "MR",
                  "display": "Medical record number"
                }
              ]
            },
            "system": "http://hospital.davinci.org",
            "value": "67890"
          }
        ],
        "active": true,
        "name": [
          {
            "use": "official",
            "family": "Webster",
            "given": [
              "Thelma"
            ]
          }
        ],
        "gender": "female",
        "birthDate": "1948-04-28",
        "deceasedBoolean": false,
        "address": [
          {
            "use": "home",
            "line": [
              "7496 Beaver Ridge Ave"
            ],
            "city": "Thornton",
            "state": "NJ",
            "postalCode": "07003",
            "country": "USA"
          }
        ],
        "maritalStatus": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/v3/MaritalStatus",
              "code": "M",
              "display": "Married"
            }
          ]
        },
        "communication": [
          {
            "language": {
              "coding": [
                {
                  "system": "urn:ietf:bcp:47",
                  "code": "en-US",
                  "display": "US English"
                }
              ]
            },
            "preferred": true
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Patient"
      }
    },
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc7",
      "resource": {
        "resourceType": "Encounter",
        "meta": {
          "profile": [
            "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
          ]
        },
        "status": "finished",
        "class": {
          "system": "http://hl7.org/fhir/encounter-class",
          "code": "inpatient",
          "display": "inpatient"
        },
        "type": [
          {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "32485007",
                "display": "Hospital admission"
              }
            ]
          }
        ],
        "subject": {
          "reference": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc6"
        },
        "period": {
          "start": "2018-07-19T11:00",
          "end": "2018-07-19T:14:30"
        },
        "location": [
          {
            "location": {
              "reference": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc8",
              "display": "Mother Charity Hospital"
            }
          }
        ],
      },
      "request": {
        "method": "POST",
        "url": "Encounter"
      }
    },
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc8",
      "resource": {
        "resourceType": "Location",
        "identifier": [
          {
            "use": "official",
            "system": "http://www.hl7.org/oid/",
            "value": "1.2.3.4.181"
          }
        ],
        "status": "active",
        "name": "Mother Charity Hospital",
        "mode": "instance",
        "telecom": [
          {
            "system": "phone",
            "value": "(313) 555-5671",
            "use": "work"
          }
        ],
        "address": {
          "use": "work",
          "type": "physical",
          "line": [
            "869 W Oak Street"
          ],
          "city": "Royal Oak",
          "district": "Oakland County",
          "state": "MI",
          "postalCode": "48073"
        },
        "physicalType": {
          "coding": [
            {
              "system": "http://hl7.org/fhir/location-physical-type",
              "code": "bu",
              "display": "Building"
            }
          ]
        }
      },
      "request": {
        "method": "POST",
        "url": "Location"
      }
    },
    {
      "fullUrl": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc9",
      "resource": {
        "resourceType": "MedicationAdministration",
        "status": "completed",
        "medicationCodeableConcept": {
          "coding": [
            {
              "system": "http://www.nlm.nih.gov/research/umls/rxnorm",
              "code": "1658634",
              "display": "0.5 ML heparin sodium, porcine 10000 UNT/ML Injection"
            }
          ]
        },
        "subject": {
          "reference": "urn:uuid:b5cf5a8c-63f0-437f-84fd-dc8a3cf43cc6"
        },
        "effectivePeriod": {
          "start": "2018-07-19T12:00",
          "end": "2018-07-19T12:00"
        },
        "dosage": {
          "route": {
            "coding": [
              {
                "system": "http://snomed.info/sct",
                "code": "34206005",
                "display": "Subcutaneous route"
              }
            ]
          }
        }
      }
    }
  ]
}

Response

HTTP/1.1 200 OK
[other headers]

Summary MeasureReport

Note to Balloters: The Summary MeasureReport is not currently used for program level reporting. We are actively seeking input on potential uses for the summary report for VTE or other measures.

Aggregator pushed the Bundle of supporting resource with VTE-1 Individual MeasureReport Bundle to the end user.

Note to Balloters: We are actively seeking input on whether a technical workflow diagram would be of value for this use case

Examples

Scenario:

Payer X who is acting in the role of a Reporter submits a VTE Summary Report for COL for period P to Receiver Z. The body of the request is MeasureReport resource containing the required summary data for VTE attestation for the period. An HTTP Status success code is returned on successful submission.

POST Summary Report

POST [base]/MeasureReport

Request body

{
  "resourceType": "MeasureReport",
  "meta": {
    "profile": [
      "http://hl7.org/fhir/ig/davinci/StructureDefinition/summary-measurereport-deqm"
    ]
  },
  "status": "complete",
  "type": "summary",
  "measure": {
    "reference": "Measure/measure-vte"
  },
  "date": "2019-03-14",
  "period": {
    "start": "2018-01-01",
    "end": "2018-12-31"
  },
  "reportingOrganization": {
    "reference": "Organization/organization01"
  },
  "group": [
    {
      "identifier": {
        "system": "http://www.acme.org/groups",
        "value": "123"
      },
      "population": [
        {
          "identifier": {
            "system": "http://www.acme.org/populations",
            "value": "456"
          },
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/measure-population",
                "code": "initial-population",
                "display": "Initial Population"
              }
            ]
          },
          "count": 100
        },
        {
          "identifier": {
            "system": "http://www.acme.org/populations",
            "value": "789"
          },
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/measure-population",
                "code": "numerator",
                "display": "Numerator"
              }
            ]
          },      
          "count": 50
        },
        {
          "identifier": {
            "system": "http://www.acme.org/populations",
            "value": "987"
          },
          "code": {
            "coding": [
              {
                "system": "http://hl7.org/fhir/measure-population",
                "code": "denominator",
                "display": "Denominator"
              }
            ]
          },
          "count": 100
        }
      ],
      "measureScore": 50
    }
  ]
}

Response

HTTP/1.1 200 OK
[other headers]