Clinical decision support (CDS) and electronic clinical quality measurement (eCQM) are closely related, share many common requirements, and are both in support of improving health care quality. However, the standards used for the electronic representation of CDS and eCQM have not been developed in consideration of each other, and use different approaches to patient data and computable expression logic.
Quality Information | Computable Expression Logic | Metadata | |
Clinical Decision Support | · Virtual Medical Record (for both physical and logical models) | · CDS Knowledge Artifact Implementation Guide | · CDS Knowledge Artifact Implementation Guide · Decision Support Service |
Electronic Clinical Quality Measurement (eCQM) | · Quality Reporting Data Architecture (for physical model) · Quality Data Model (for logical model) | · Health Quality Measure Format (for physical model) · Quality Data Model (for logical model) | · Health Quality Measure Format |
It is currently difficult to share logic between eCQMs and CDS interventions. Adhering to different standards places an additional implementation burden on vendors and providers with homegrown systems. Burdens on vendors and providers include the following:
Harmonization of the CDS and eCQM standards is required to reduce implementation burdens, promote integration between these two domains, and facilitate care quality improvement.
The scope of this initiative includes the following:
1) To identify, define, and harmonize electronic standards that promote integration between CDS and eCQM in the areas of:
2) To refactor existing CDS and eCQM standards to utilize the harmonized standards and, where possible, resolve current known limitations in these standards.
3) To the extent possible, to pilot the standards and refine them accordingly.
4) To engage the clinical quality community to optimize the rigor and usability of harmonized CDS and eCQM specifications, with the ultimate goal of improved patient outcomes.
5) To support the balloting and publication of the harmonized standards with the Health Level Seven International (HL7) standards development organization.
6) To discuss implications for current implementers.
7) To support emerging/leading edge approaches to eCQM and CDS, to the extent possible given available resources and priorities.
8) To support adoption of eCQMs across regulatory agencies.
All artifacts in the original scope of the base standards are in scope. For quality measures, this includes intermediate and clinical outcome measures as well as trending. Patient reported outcomes are also potentially included within scope.
Out-of-scope items will be identified by the Clinical Quality Framework initiative team during the discovery phase.
Much of the standards harmonization work is already underway in HL7 work groups. The Clinical Quality Framework ONC initiative will promote wider visibility into the standards under development and provide additional implementation-based feedback, leading to more robust specifications.
CDS and eCQM are complementary and essential components of clinical quality improvement (CQI). Harmonizing the electronic standards used for these two domains and developing a common Clinical Quality Framework will have a number of important benefits, including the following:
Community involvement in the harmonization of the eCQM and CDS standards gives participants the following:
Furthermore, implementation-based feedback will enhance the quality of the standards that are developed. Ultimately, the work of the CQF initiative will facilitate the achievement of improved clinical quality and outcomes.
– C-CDA (Consolidated Clinical Documentation Architecture)
– CIMI (Clinical Information Modeling Initiative)
– FHIM (Federal Health Information Model)
– ebRIM/ebRS
– HL7 Care Record
– HL7 FHIR
– HL7 HQMF
– HL7 RIM
– HL7 v2.5.1
– QDM (Quality Data Model)
– QRDA (Quality Reporting Documentation Architecture) I, II, III
– vMR (Virtual Medical Record)
– TLS+SAML
– TLS+OAuth2
– S/MIME
– MU2 ModSpec RTM
– SOAP (IHE SOAP)
– RESTful (IHE mHealth)
– Direct
– HTTP
– SMTP
– ArdenML
– Arden Syntax
– AHRQ eRecommendations Format
– CDSC L3
– CREF
– HQMF (Health Quality Measure Format)
– HL7 CDS Knowledge Artifact Specification
– GELLO
– GEM (Guideline Elements Model)
– IHE Sharing Value Sets
– SNOMED CT, LOINC, ICD, CPT, RxNorm, NDC, etc.
– Value Sets Used in eCQMs
– HL7 Decision Support Service (DSS) Specifications
– HL7 Context Aware Information Retrieval (InfoButton)
– HL7 Model Interchange Format
– IHE Care Management Profile
– IHE Retrieve Clinical Knowledge Profile (Profile for InfoButton)
– IHE RFD (Retrieve Clinical Format for Data Capture)
– IHE RPE (Request for Procedure Execution)
– IHE Request for Clinical Guidance Profile (an implementation of HL7 DSS)
– Academic and Community Provider Organizations
– Content Publishers
– HIT Vendors
– Medical Research Organizations
– Medical Societies
– Patients (PGHD – Patient Generated Health Data)
– Pharmaceutical and Medical Device Companies
– Public Health Agencies and other Government Agencies (CDC, NIH, NLM, FDA, etc.)
– Standard Terminology Suppliers
– Clinical Decision Support Consortium
– Content Publishers who offer CDS services
– Content Implementers (i.e. consulting firms)
– HIT Vendors
– HIEs
– HISPs (Health Information Service Providers)
– OpenCDS
– Providers implementing clinical content in an HIT system
– Registries (e.g., professional association registries)
– Case Managers
– Compliance, regulatory, and legal entities
– Home Health Agencies
– Patients
– Payers and their agents involved in revenue cycle
– Practitioners
– Provider Organizations (including VA and DoD)
– Public Health Agencies
– Pharmacies and MTM Services
– Social Security Administration (SSA)
– ASTM (American Society for Testing and Materials)
– CDSC (Clinical Decision Support Consortium)
– GLIDES (GuideLines Into DEcision Support)
– HITSP (Health Information Technology Standards Panel)
– HL7 (Health Level Seven International)
– IHE (Integrating the Healthcare Enterprise)
– NQF (National Quality Forum)
– OMG (Object Management Group)
– AHRQ USHIK (Agency for Healthcare Research and Quality United States Health Information Knowledgebase)
– AMA-convened Physician Consortium for Performance Improvement® (PCPI®)
– ANA (American Nursing Association) NDNQI (Nursing Database Nursing Quality Indicators)
– BTE (Bridges to Excellence)
– CDC (Centers for Disease Control and Prevention)
– CMS Hospital Inpatient Quality Reporting System
– CMS Hospital Outpatient Quality Reporting System
– CMS/PQRS (Center for Medicare and Medicaid Services, Physician Quality Reporting System)
– NCQA (National Committee for Quality Assurance)
– NQF (National Quality Forum)
– OFMQ (Oklahoma Foundation for Medical Quality)
– QOPI (Quality Oncology Practice Initiative)
– The Joint Commission
1.Given the aggressive timeline, a schedule delay in one item may have significant downstream scope and schedule impact.
2.Additional review and implementation-based feedback may introduce delays into the development of harmonized standards.
3.Implementation and piloting of non-final standards may result in “throwaway” work.
4.Vendors’ focus on Meaningful Use activities may impact their ability to participate in pilots.
Additional risks and mitigations may be identified during discovery phase.
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