This page is part of the Da Vinci Data Exchange for Quality Measures (DEQM) FHIR IG (v2.1.0: STU 3) based on FHIR R4. The current version which supercedes this version is 3.1.0. For a full list of available versions, see the Directory of published versions

General Guidance

ONLY the new content for Gaps in Care is in the scope for ballot for the September, 2020 Ballot Cycle.

Introduction

Clinical Quality Measures are a common tool used throughout healthcare to help evaluate and understand the impact and quality of the care being provided to an individual or population.

The Data Exchange for Quality Measure (DEQM) Implementation Guide defines the interactions for two purposes in the Quality Measure Ecosystem. The first interaction is when a Producer, such as a practitioner, or owner of data needs to exchange that data with a Consumer of that data, such as a payer, a registry or public health. We call this the Data Exchange scenario. Examples of this interaction might be when a provider has patient information from a recent visit that he needs to share with a payer under a value based contract.

The second scenario defined in this guide is when a Reporter needs to exchange a measure report with a Receiver. This guide addresses the Individual Measure Reporting and the Summary Reporting. As an example, Individual Measure Reports may be used by hospitals acting as the Reporter to report a specific measure to a payer acting as a Receiver. Similarly, Summary Measure Reports may be used to report yearly eCQM results on a specific measure.

This version of the guide adds the Gaps in Care Reporting scenario. The Gaps in Care Reporting is used to report the open and/or closed gap(s) for quality measure(s) over a gaps through period specified by a Client. Optionally, it is also used to report details to the open gaps identified and mitigation steps taken for addressing them. It further provides capability of associating clinical data included in the report with the population criteria (i.e. denominator, numerator) of a measure that they apply to.

Patient List Reporting is a third reporting type which is similar to a QRDA Category 2 report. This Type is out of scope for this version of the Implementation Guide. In a future version this guide, Patient List Reporting will be addressed.

Preconditions and Assumptions

• Although the exact mechanisms for securing these exchanges are not specified as part of this implementation guide:

  • Exchanges are limited to mutually agreed upon (i.e., between the Producer and Consumer) patients list or population.

  • Systems should use standard authentication and authorization approaches. The SMART App Launch and SMART backend services authentication/authorization approach are recommended models.

• The Measure resource is used to provide both human- and machine-readable definitions of a quality measure

• The MeasureReport provides an association to a specific quality measure and links the submitted data together to simplify processing for the receiver.

• It is the responsibility of the Producer to ensure that measure data is present in a structured, retrievable form.

• The required data is represented in the referenced resources defined by the MeasureReport.

  • Multiple MeasureReport may reference the same instance of a resource.

• Both Consumers and Producers should use a common clinical quality language (CQL) that would allow the same measures to be applied in healthcare and at the aggregator. This would also enable the application of the same measures across populations that span multiple Consumers (such as payers). Using common measures across payers reduces development burden for FHIR implementers.

DEQM MeasureReport Profiles

The MeasureReport resource is used as an organizer for both the data exchange scenario and for measure reporting scenario. To meet the different needs in these scenarios, DEQM has created 3 MeasureReport profiles. Technically the type of profiles can be determined by inspecting the meta.profile element if present or the type element.

The MeasureReport resource is also used for the gaps in care reporting scenario. A new MeasureReport profile is defined in this guide to support the specific needs of gaps in care reporting.

Data Exchange

The DEQM Data Exchange MeasureReport Profile is used to get the data from the producer to a consumer of the data. The consumer might be a system that calculates the measure report but they could also be an aggregator who sends that data on to another system to do measure calculation and reporting. Along with Data-Exchange MeasureReport Profile, the data producer sends the Organization, Patient and any relevant resources for the measure they have produced data on. When a data producer, such as a practitioner, sends a MeasureReport bundle, they may not have all the data that is required to calculate the measure report. One example might be because the measure requires outcome data from at a later point in time during the measurement period. Another example where the data producer may not have all the data would be continuous coverage period as the producer of the data may not know the patient was covered on the day the patient was seen. The Consumer (in this case the payer as aggregator) is the owner of all coverage information. Therefore, only the consumer could determine if the continuous coverage period requirement is met.

Measure Reporting

Measure Reporting is done by a Reporter who has all of the data that is required to generate a report(s). Two profiles for measure reporting have been defined in this guide.

The DEQM Individual MeasureReport Profile is used when a measure is reported for a specific patient. It contains all of the data that is relevant to generate the report including the measure outcome and is similar to a QRDA Category 1 report. The MeasureReport(s) are packaged in a FHIR Bundle with Organization, Patient and any other resources that were used to calculate this measure.

The DEQM Summary MeasureReport Profile is used when a measure is reported for a group of patients at the conclusion of a measure measurement period. It includes the measure outcome data and is similar to a QRDA Category 3 report. Unlike the DEQM Individual MeasureReport Profile, the report is typically transacted as a single MeasureReport report. Although several Summary reports may be transacted together as Bundle.

Default Profiles Used in the Evaluation of a Measure

Depending on the specific Measure and Interaction, Default Profiles from DEQM, QI Core, and CQFM are used in the evaluation of a measure and referenced by a MeasureReport. These profiles apply to any resource that does not otherwise have an explicit profile assigned by the implementation guide. Note that several DEQM Profiles are derived from QI Core profiles and are used as the default instead of the corresponding QI Core profile. Refer to the QI Core implementation guide for examples of how to represent data involved in calculation of quality measures.

Negation Patterns for Quality Measures

​Refer to the Quality Measure Implementation Guide for guidance on negation patterns in quality measurements. Note that implementations processing negated data may not be returned with a single code, but rather a value set identifier represented by the Valueset Reference extension which are part of the QI Core profiles, and should consider data with the appropriate value set identifier as satisfying the criteria for value set membership. The negation pattern for the MedicationRequest resource is demonstrated in the Single Indv Vte Report Option 7 example.

The negation patterns described here are about approaches for identifying when events are not present or when events are documented as not occurring for a reason. These patterns may appear throughout a measure in any of the various population criteria, depending on measure intent. For example, the absence of a particular medication may be grounds for membership in the initial population, denominator, numerator, or an exclusion or exception criteria, depending on how the measure is constructed. An example of this is the VTE-1 USE Case Option 7.

Using Contained Resources in the Response Transaction

Contained resources SHOULD NOT be used when responding to the submit-data or collect-data operation or to the Individual reporting transactions. The data exchange transaction payloads are Parameters resources containing resource parameters. The response to the individual reporting transactions are Bundles. The only time contained resource can be used is when the source data exists only within the context of the transaction. For example, if the only information about the patient’s coverage is the payor name, the Coverage resource could be contained by the Patient resource:

{
  "resourceType": "Patient",
  "id": "patient01",
  "contained": [
    {
      "resourceType": "Coverage",
      "status": "active",
      "beneficiary": {
        "reference": "#"
      },
      "payor": [
        {
          "reference": "Organization/organization04"
        }
      ]
    }
  ]
  ...<rest of patient resource>
}

Contained resources SHOULD NOT be used when responding to the care-gaps operation.

Must Support

• This guide adopts the QI Core Must Support definition with the following additional expectation:

The receiver of data may not be able to complete processing and may report an error if a Must Support element is unavailable.