Data Exchange For Quality Measures Implementation Guide
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## Summary Reporting

### Introduction

A summary report contains calculated summary data for one or more Clinical Quality Measures (CQMs) for a specified population of patients within a particular health system over a specific period of time. For example, a colorectal cancer screening CQM has patient counts for the initial population, denominator, denominator exclusions, and numerator respectively for a specified population of patients. Summary reports may also contain summary data for stratifier criteria (such as gender or age) as defined in a CQM.

The Summary reporting scenario is supported by the DEQM Summary MeasureReport Profile. Transactions between Reporters (for example, organizations that deliver care to patients, such as a practice or hospital) and Receivers (organizations that want to evaluate CQMs, such as quality reporting programs) are triggered by specific administrative events such as the submission of summary level quality reports for CQMs to various quality reporting programs.

### Relationship of Measure and MeasureReport Resources

The Quality Reporting Page in the R4 Release of the FHIR Specification provides an overview of CQM structures, how CQMs are represented using the Measure resource, and how CQMs are reported using the MeasureReport resource. The Reporting Population Datasection describes how to use a MeasureReport resource to represent the results of a summary calculation, as well as how to use the $evaluate-measure operation to generate a summary MeasureReport from a Measure.

### Supplemental Data Resources in MeasureReport

The supplementalData extension allows supplementalData to be included in the MeasureReport. For supplementalData that is a calculation, this will be a reference to an Observation containing the result of the supplementalData calculation. For supplementalData that is a resource, this will be a reference to the supplementalData resource. For supplementalData that is calculated only for the measure being reported the resource may be in a contained resource.

### Relationship between QI-Core, DEQM, and CQMs

As described in the Quality Measurement Standards Landscape section of this implementation guide, the QI-Core IG defines a set of FHIR profiles with extensions and bindings needed to create interoperable, quality-focused applications. For implementers that are familiar with the previous generation of standards that supports summary reporting—Quality Data Model (QDM), Clinical Quality Language (CQL), and the Quality Reporting Document Architecture Category III (QRDA Category III), QI-Core profiles are equivalent to the Quality Data Model (QDM) and the DEQM Summary MeasureReport Profile is equivalent to the QRDA Category III in the QDM-CQL-QRDA paradigm.

### Default Profiles

The following resources are used in the summary reporting scenario:

Resource Type | Profile Name | Link to Profile
--- | --- | ---
Measure | CRMI Shareable Measure Profile | CRMI Shareable Measure
Summary MeasureReport | DEQM Summary MeasureReport Profile | DEQM Summary MeasureReport Profile
Organization | QI Core Organization Profile | QI Core Organization

### Summary Measure Reporting

When the results of a quality measure are completed for a population at the end of a measurement period, they are POSTed to the quality measure Receiver's FHIR Server. The report may only consist of the Summary MeasureReport in which case it is POSTed to the MeasureReport endpoint. If there are other referenced resources all the resources are bundled together as a set of `POST` interactions and sent as a single transaction interaction using the Standard FHIR API. Multiple summary results can be sent in a single FHIR Bundle as described here. (Note that if the Bundle consist of only Summary MeasureReports, then a collection bundle is used.)

In order to support real-world implementations (i.e. QPP) where:

- External producers submit summary MeasureReport resources for multiple providers (TINs/NPIs) in a single bundle.

- FHIR servers often act as facade layers over existing APIs (e.g., Measurement /api/submissions/measurements) that perform individual POST/PUT operations atomically.

- In scenarios where the FHIR layer interacts directly with the database, supporting true bundle-level atomicity (e.g., 500+ entries) often requires pessimistic locking of rows or tables, increasing the risk of contention and deadlocks.

All systems SHALL support one of "batch" or "transaction", and that the server SHALL declare its support in the capability statement for these Bundle transaction types.

Posting a Summary Measure Report is typically a one time event, although there may be a need to amend or update a report or to report periodically based on the reporting program. If the payload is a single Summary MeasureReport it is updated using the PUT or Delete transactions. Otherwise, the FHIR transaction bundle is used and SHALL contain only the new and updated DEQM and QI-Core Profiles since the last transaction or those that need to be deleted. (`Bundle.request.method` = POST, PUT, or DELETE).

Figure 2-11 POST Summary Report

#### Usage

for a single MeasureReport:

`POST|[base]/MeasureReport`

for a Bundle Transaction:

`POST|[base]`

Standard error responses to the Summary Reporting FHIR RESTful transactions including appropriate http response codes are documented in the FHIR specification for RESTful API.

#### Examples

Scenario:

Payer X who is acting in the role of a Reporter submits a MRP Summary Report for MRP for period P to Receiver Z. The body of the request is MeasureReport resource containing the required summary data for MRP attestation for the period. (Note that this a simplified example and just populates the count for initial population. However, counts for all populations specified in an eCQM should be reported in a summary report) An HTTP Status success code is returned on successful submission.

POST Summary Report

`POST [base]/MeasureReport`

Request body

    {
      "resourceType" : "MeasureReport",
      "id" : "summ-measurereport01",
      "meta" : {
        "source" : "http://example.org/fhir/server",
        "profile" : ["http://hl7.org/fhir/uv/deqm/StructureDefinition/deqm-summarymeasurereport"]
      },
      "language" : "en",
      "text" : {
        "status" : "extensions",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\" xml:lang=\"en\" lang=\"en\"><p class=\"res-header-id\"><b>Generated Narrative: MeasureReport summ-measurereport01</b></p><a name=\"summ-measurereport01\"> </a><a name=\"hcsumm-measurereport01\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\">Language: en; </p><p style=\"margin-bottom: 0px\">Information Source: <a href=\"http://example.org/fhir/server\">http://example.org/fhir/server</a></p><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-deqm-summarymeasurereport.html\">DEQM Summary MeasureReport Profile</a></p></div><p><b>DEQM Measure Scoring Extension</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-scoring proportion}\">Proportion</span></p><p><b>status</b>: Complete</p><p><b>type</b>: Summary</p><p><b>measure</b>: <a href=\"Measure-measure-mrp-example.html\">MRP Measure</a> version: 1.0.0-ballot</p><p><b>date</b>: 2018-09-05 16:59:52+0000</p><p><b>reporter</b>: <a href=\"Organization-organization01.html\">Organization DaVinciHospital01</a></p><p><b>period</b>: 2018-08-01 --&gt; 2018-09-01</p><p><b>improvementNotation</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-improvement-notation increase}\">Increased score indicates improvement</span></p><blockquote><p><b>group</b></p><p><b>Extension Definition for MeasureReport.group.linkId for Version 5.0</b>: mpr-group</p><p><b>code</b>: <span title=\"Codes:{http://example.org/fhir/ mrp-group}\">MRP Group</span></p><blockquote><p><b>population</b></p><blockquote><p><b>id</b></p>initial-population</blockquote><p><b>Extension Definition for MeasureReport.group.population.linkId for Version 5.0</b>: initial-population</p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-population initial-population}\">Initial Population</span></p><p><b>count</b>: 100</p></blockquote><blockquote><p><b>population</b></p><blockquote><p><b>id</b></p>numerator</blockquote><p><b>Extension Definition for MeasureReport.group.population.linkId for Version 5.0</b>: numerator</p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-population numerator}\">Numerator</span></p><p><b>count</b>: 80</p></blockquote><blockquote><p><b>population</b></p><blockquote><p><b>id</b></p>denominator</blockquote><p><b>Extension Definition for MeasureReport.group.population.linkId for Version 5.0</b>: denominator</p><p><b>code</b>: <span title=\"Codes:{http://terminology.hl7.org/CodeSystem/measure-population denominator}\">Denominator</span></p><p><b>count</b>: 100</p></blockquote><p><b>measureScore</b>: 0.8</p></blockquote></div>"
      },
      "extension" : [{
        "url" : "http://hl7.org/fhir/uv/deqm/StructureDefinition/deqm-measureScoring",
        "valueCodeableConcept" : {
          "coding" : [{
            "system" : "http://terminology.hl7.org/CodeSystem/measure-scoring",
            "code" : "proportion"
          }]
        }
      }],
      "status" : "complete",
      "type" : "summary",
      "measure" : "http://hl7.org/fhir/uv/deqm/Measure/measure-mrp-example|1.0.0-ballot",
      "date" : "2018-09-05T16:59:52.404Z",
      "reporter" : {
        "reference" : "Organization/organization01"
      },
      "period" : {
        "start" : "2018-08-01",
        "end" : "2018-09-01"
      },
      "improvementNotation" : {
        "coding" : [{
          "system" : "http://terminology.hl7.org/CodeSystem/measure-improvement-notation",
          "code" : "increase",
          "display" : "Increased score indicates improvement"
        }]
      },
      "group" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.group.linkId",
          "valueString" : "mpr-group"
        }],
        "code" : {
          "coding" : [{
            "system" : "http://example.org/fhir/",
            "code" : "mrp-group",
            "display" : "MRP Group"
          }],
          "text" : "MRP Group"
        },
        "population" : [{
          "id" : "initial-population",
          "extension" : [{
            "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.group.population.linkId",
            "valueString" : "initial-population"
          }],
          "code" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
              "code" : "initial-population",
              "display" : "Initial Population"
            }]
          },
          "count" : 100
        },
        {
          "id" : "numerator",
          "extension" : [{
            "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.group.population.linkId",
            "valueString" : "numerator"
          }],
          "code" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
              "code" : "numerator",
              "display" : "Numerator"
            }]
          },
          "count" : 80
        },
        {
          "id" : "denominator",
          "extension" : [{
            "url" : "http://hl7.org/fhir/5.0/StructureDefinition/extension-MeasureReport.group.population.linkId",
            "valueString" : "denominator"
          }],
          "code" : {
            "coding" : [{
              "system" : "http://terminology.hl7.org/CodeSystem/measure-population",
              "code" : "denominator",
              "display" : "Denominator"
            }]
          },
          "count" : 100
        }],
        "measureScore" : {
          "value" : 0.8
        }
      }]
    }

Response

    HTTP/1.1 200 OK
    [other headers]

for an example of a Summary MeasureReport with counts for multiple populations and stratifiers specified in an eCQM see the Medicare Stratification Example. For an example of a Bundle of multiple summary results see the Bundle Multiple Summ Report.