Our underlying vision for the ADE Warfarin measure has been 1) few, widely calculated data elements and 2) that the EHR system would export all required data to a quality module, so that the quality module – rather than the core EHR system – would be required to calculate the measure. For example, the ADE Warfarin TTR measure would be calculated by popHealth or a data warehouse, rather than the EHR system that is sending raw data to popHealth. We did not want to require that the upstream core EHR system be responsible for calculating each patient’s TTR or the Average TTR for the reporting provider. Under our shared vision, the EHR system would export all of a patient’s INR results during the measurement period and send them to the quality module for calculation of both the patient’s TTR and the provider’s Average TTR.

After discussion with Saul Kravitz, we understand that there is no HQMF or standards-based mechanism available to instruct an EHR system to generate a QRDA-1 that contains all of a patient’s INR results during the measurement period. This is the “smoking gun” only issue that we have heard Bob Dolin mention before.

Saul informed us (attached email) that, in order for the TTR for each patient to be included in the QRDA-1, we need to include the TTR data element in either the “Initial Patient Population” or the “Measure Population” of the HQMF for this measure. This is a relatively quick change to the specification, and we have the QDM expression ready to go. But, as a consequence, Saul indicates that the core EHR system would be required to calculate each patient’s TTR, in order for that EHR system to meet EHR certification requirements for that measure. This may be a heavy lift for some EHR systems, in contrast to quality modules and warehouses that are optimized for such processor-heavy calculations.

• Are you aware of any other precedents of bypassing the QRDA-1 requirement for an eCQM? I have not, and I imagine that this also has implications for the CMS reporting warehouse, if it is expected to receive QRDA-1 for each patient.
• Would it be acceptable to require a core EHR system to calculate patient level TTRs? This would make the specifications simpler, more straightforward to implement, and ensure that TTR is included in QRDA-1, but we know it increases the technical requirements of the core EHR system. This option is also not consistent with the vision of “few, widely calculated data elements”.