HealthQualityMeasuresFormat:eMeasures

HL7V3QM,R2

HL7Version3Standard:RepresentationoftheHealthQualityMeasuresFormat(eMeasure),Release2[DW1]

DraftStandardforTrialUse

V3_HQMF_DSTUR2_U1_2012SEP

July2012

Author/Co-Chair / RobertH.Dolin,MD, FACP

Lantana Consulting Group
Co-Chair/Co-Editor / Calvin Beebe

Mayo Clinic/Foundation
Co-Chair / Brett Marquard

Lantana Consulting Group
Co-Chair / Austin Kreisler

SAIC Consultant to CDC
Co-Chair / Grahame Grieve

Kestral Computing Pty Ltd
Co-Editor / LioraAlschuler

Lantana Consulting Group
Co-Editor / KeithBoone

GEHealthcareIntegratedITSolutions
Co-Editor / GuntherSchadow,MD

RegenstriefInstitute,Inc
Co-Chair/Co-Editor / RobertA.Jenders,MD,MS,FACP,FACMI

Professor,DepartmentofMedicineUniversityofCalifornia,LosAngeles
Co-Editor / DouglasS.Bell,MD,PhD

ResearchScientist,RANDHealthAssociateProfessorofMedicine,DavidGeffenSchoolofMedicineatUCLA
Co-Editor / FloydP.Eisenberg,MD,MPH

NationalQualityForum
Co-Editor / Christopher Millet

National Quality Forum
Co-Editor / Gaye Dolin, MSN, RN

Lantana Consulting Group
Co-Editor / Crystal Kallem, RHIA, CPHQ

Lantana Consulting Group
Co-Editor / Rick Geimer

Lantana Consulting Group
Co-Editor / Jingdong (JD) Li, MD

Lantana Consulting Group
Co-Editor / Chengjian Che, MD

Lantana Consulting Group
Co-Editor / Dale Nelson

Lantana Consulting Group
Co-Editor / Yan Heras, PhD

Lantana Consulting Group
Co-Editor / Stan Rankins

Telligen
Co-Editor / Marc Hadley

MITRE Corporation
Co-Editor / Nageshwara Bashyam (Dragon)

Harris Corporation
Co-Editor / Brian Fitzgerald

Lantana Consulting Group
Tehcnical-Editor / Diana Wright

Lantana Consulting Group
Publishing Facilitator / Andy Stechishin

Lantana Consulting Group

LastPublished:03/02/201011:08AM

ContentLastEdited:3/01/201010:56:20PM[DW2]

HL7(tm)Version3Standard,(c)2010 2012 HealthLevelSeven(tm),Inc.AllRightsReserved.

HL7andHealthLevelSevenareregisteredtrademarksofHealthLevelSeven,Inc.Reg.U.S.PatTMOff

Table of Contents[DW3]

Preface

Acknowledgements

Changes from Previous Release

1HQMF Overview

1.1What is the HQMF, and what is an eMeasure?

1.2Guidance for Measure Developers

1.3HQMF and the quality life cycle

1.4HQMF and Templated CDA

1.5Backwards Compatibility

1.6General HQMF Concepts

1.6.1Measure Period

1.6.2Data Criteria

1.6.2.1Filters and Data Criteria

1.6.2.2Time Relationships and Data Criteria

1.6.2.3Value Sets and Data Criteria

1.6.3Population Criteria

1.6.3.1Population Criteria and Data Criteria

1.6.4Stratifier Criteria

1.6.5Human Readability and Rendering HQMF Documents

1.6.6Encoding eMeasure quality statements

1.6.6.1General Approach

1.6.6.2Patient criteria vs. aggregate scores

1.6.6.3Measure definition vs. Reporting requirements

1.6.7Data collection and missing data

1.6.8Relationship of the HQMF to HL7 Messaging Standards

2Introduction to HQMF Technical Artifacts

2.1HL7 Reference Information Model

2.2V3 Data Types

2.3Concept Domains and Value Sets

2.4HL7 HQMF Model

2.5HL7 HQMF Constraints

2.6HL7 HQMF Hierarchical Description

2.7HL7 HQMF XML Implementation

3HQMF Model

3.1QualityMeasureDocument

3.1.1QualityMeasureDocument Attributes

3.1.1.1QualityMeasureDocument.typeId

3.1.1.2QualityMeasureDocument.classCode

3.1.1.3QualityMeasureDocument.moodCode

3.1.1.4QualityMeasureDocument.id

3.1.1.5QualityMeasureDocument.code

3.1.1.6QualityMeasureDocument.title

3.1.1.7QualityMeasureDocument.text

3.1.1.8QualityMeasureDocument.statusCode

3.1.1.9QualityMeasureDocument.effectiveTime

3.1.1.10QualityMeasureDocument.availabilityTime

3.1.1.11QualityMeasureDocument.languageCode

3.1.1.12QualityMeasureDocument.setId

3.1.1.13QualityMeasureDocument.versionNumber

3.1.2QualityMeasureDocument Participations

3.1.2.1QualityMeasureDocument.author

3.1.2.2author.typeCode

3.1.2.3author.contextControlCode

3.1.2.4author.functionCode

3.1.2.5author.time

3.1.2.6author.signatureCode

3.1.2.7author.responsibleParty

3.1.2.8responsibleParty.classCode

3.1.2.9responsibleParty.id

3.1.2.10responsibleParty.code

3.1.2.11responsibleParty.addr

3.1.2.12responsibleParty.telecom

3.1.2.13QualityMeasureDocument.custodian

3.1.2.14custodian.typeCode

3.1.2.15custodian.contextControlCode

3.1.2.16custodian.responsibleParty

3.1.2.17QualityMeasureDocument.participation

3.1.2.18participation.typeCode

3.1.2.19participation.contextControlCode

3.1.2.20participation.functionCode

3.1.2.21participation.time

3.1.2.22participation.signatureCode

3.1.2.23participation.responsibleParty

3.1.2.24QualityMeasureDocument.verifier

3.1.2.25verifier.typeCode

3.1.2.26verifier.contextControlCode

3.1.2.27verifier.functionCode

3.1.2.28verifier.time

3.1.2.29verifier.signatureCode

3.1.2.30verifier.responsibleParty

3.1.3QualityMeasureDocument Relationships

3.1.3.1QualityMeasureDocument.relatedDocument

3.1.3.2relatedDocument.typeCode

3.1.3.3relatedDocument.parentQualityMeasureDocument

3.1.3.4QualityMeasureDocument.componentOf

3.1.3.5componentOf.typeCode

3.1.3.6componentOf.qualityMeasureSet

3.1.3.7QualityMeasureDocument.controlVariable

3.1.3.8controlVariable.typeCode

3.1.3.9controlVariable.localVariableName

3.1.3.10controlVariable.measurePeriod

3.1.3.11QualityMeasureDocument.subjectOf

3.1.3.12subjectOf.typeCode

3.1.3.13subjectOf.measureAttribute

3.1.3.14QualityMeasureDocument.definition

3.1.3.15definition.typeCode

3.1.3.16definition.valueSet

3.1.3.17QualityMeasureDocument.component

3.1.3.18component.typeCode

3.1.3.19component.contextConductionInd

3.1.3.20component.section

3.1.3.21component.measureDescriptionSection

3.1.1.1component.dataCriteriaSection

3.1.3.22component.populationCriteriaSection

3.1.3.23component.measureObservationsSection

3.2ParentQualityMeasureDocument

3.2.1ParentQualityMeasureDocument Attributes

3.2.1.1ParentQualityMeasureDocument.classCode

3.2.1.2ParentQualityMeasureDocument.moodCode

3.2.1.3ParentQualityMeasureDocument.id

3.2.1.4ParentQualityMeasureDocument.code

3.2.1.5ParentQualityMeasureDocument.text

3.2.1.6ParentQualityMeasureDocument.setId

3.2.1.7ParentQualityMeasureDocument.versionNumber

3.3QualityMeasureSet

3.3.1QualityMeasureSet Attributes

3.3.1.1QualityMeasureSet.classCode

3.3.1.2QualityMeasureSet.moodCode

3.3.1.3QualityMeasureSet.id

3.3.1.4QualityMeasureSet.title

3.4MeasurePeriod

3.4.1MeasurePeriod Attributes

3.4.1.1MeasurePeriod.classCode

3.4.1.2MeasurePeriod.moodCode

3.4.1.3MeasurePeriod.code

3.4.1.4MeasurePeriod.value

3.5MeasureAttribute

3.5.1MeasureAttribute Attributes

3.5.1.1MeasureAttribute.classCode

3.5.1.2MeasureAttribute.moodCode

3.5.1.3MeasureAttribute.id

3.5.1.4MeasureAttribute.code

3.5.1.5MeasureAttribute.value

3.6ValueSet

3.1.2Value Set Identification, Versioning, and Stewardship

3.6.1ValueSet Attributes

3.6.1.1ValueSet.classCode

3.6.1.2ValueSet.moodCode

3.6.1.3ValueSet.id

3.6.1.4ValueSet.title

3.6.1.5ValueSet.text

3.6.1.6ValueSet.value

3.6.2ValueSet Relationships

3.6.2.1ValueSet.component

3.6.2.2component.typeCode

3.6.2.3component.valueSet

3.7Section

3.7.1Section Attributes

3.7.1.1Section.classCode

3.7.1.2Section.moodCode

3.7.1.3Section.id

3.7.1.4Section.code

3.7.1.5Section.title

3.7.1.6Section.text

3.7.1.7Section.languageCode

3.7.2Section Participations

3.7.2.1Section.author

3.7.3Section Relationships

3.7.3.1Section.component1

3.7.3.2component1.typeCode

3.7.3.3component1.contextConductionInd

3.7.3.4component1.section

3.7.4Section Narrative Block

3.7.4.1paragraph

3.7.4.2list

3.7.4.3table

3.7.4.4footnote, footNoteRef

3.7.4.5content

3.7.4.6styleCode

3.7.4.7sub and sup

3.7.4.8br

3.7.4.9caption

3.7.4.10linkHTML

3.7.4.11renderMultiMedia

3.8MeasureDescriptionSection

3.8.1MeasureDescriptionSection Attributes

3.8.1.1MeasureDescriptionSection.code

3.9DataCriteriaSection

3.9.1DataCriteriaSection Attributes

3.9.1.1DataCriteriaSection.code

3.9.2DataCriteriaSection Relationships

3.9.2.1DataCriteriaSection.definition

3.9.2.2definition.typeCode

3.9.2.3definition.actDefinition

3.9.2.4DataCriteriaSection.entry

3.9.2.5entry.typeCode

3.9.2.6entry.localVariableName

3.9.2.7entry.subsetCode

3.9.2.8entry.actCriteria1

3.9.2.9entry.actReference

3.10PopulationCriteriaSection

3.10.1PopulationCriteriaSection Attributes

3.10.1.1PopulationCriteriaSection.code

3.10.2PopulationCriteriaSection Relationships

3.10.2.1PopulationCriteriaSection.component

3.10.2.2component.typeCode

3.10.2.3component.localVariableName

3.10.2.4component.patientPopulationCriteria

3.10.2.5component.numeratorCriteria

3.10.2.6component.denominatorCriteria

3.10.2.7component.denominatorExceptionCriteria

3.10.2.8component.numeratorExclusionCriteria

3.10.2.9component. denominatorExclusionCriteria

3.10.2.10component.measurePopulationCriteria

3.10.2.11component.stratifierCriteria

3.11MeasureObservationsSection

3.11.1MeasureObservationsSection Attributes

3.11.1.1MeasureObservationsSection.code

3.11.2MeasureObservationsSection Relationships

3.11.2.1MeasureObservationsSection.definition

3.11.2.2definition.typeCode

3.11.2.3definition.measureObservationDefinition

3.12Model Definitions

3.12.1Definition Attributes

3.12.1.1ActDefinition.classCode

3.12.1.2ActDefinition.moodCode

3.12.1.3ActDefinition.id

3.13Criteria

3.1.3Processing Order for Entries in the Data Criteria section

3.13.1ActCriteria Attributes

3.13.1.1ActCriteria.classCode

3.13.1.2ActCriteria.moodCode

3.13.1.3ActCriteria.actionNegationInd

3.13.1.4ActCriteria.id

3.13.1.5ActCriteria.code

3.13.1.6ActCriteria.derivationExpr

3.13.1.7ActCriteria.title

3.13.1.8ActCriteria.text

3.13.1.9ActCriteria.statusCode

3.13.1.10ActCriteria.effectiveTime

3.13.1.11ActCriteria.activityTime

3.13.1.12ActCriteria.availabilityTime

3.13.1.13ActCriteria.priorityCode

3.13.1.14ActCriteria.confidentialityCode

3.13.1.15ActCriteria.repeatNumber

3.13.1.16ActCriteria.uncertaintyCode

3.13.1.17ActCriteria.reasonCode

3.13.1.18ActCriteria.languageCode

3.13.1.19ActCriteria.isCriterionInd

3.13.2ActCriteria Participations

3.13.2.1ActCriteria.participation

3.13.2.2participation.patient

3.13.2.3participation.role

3.13.3ActCriteria Relationships

3.13.3.1ActCriteria.definition

3.13.3.2definition.typeCode

3.13.3.3definition.actReference

3.13.3.4ActCriteria.excerpt

3.13.3.5excerpt.typeCode

3.13.3.6excerpt.inversionInd

3.13.3.7excerpt.sequenceNumber

3.13.3.8excerpt.subsetCode

3.13.3.9excerpt.actCriteria1

3.13.3.10excerpt.actReference

3.13.3.11ActCriteria.temporallyRelatedInformation

3.13.3.12temporallyRelatedInformation.typeCode

3.13.3.13temporallyRelatedInformation.sequenceNumber

3.13.3.14temporallyRelatedInformation.pauseQuantity

3.13.3.15temporallyRelatedInformation.localVariableName

3.13.3.16temporallyRelatedInformation.subsetCode

3.13.3.17temporallyRelatedInformation.actCriteria1

3.13.3.18temporallyRelatedInformation.actReference

3.13.3.19ActCriteria.sourceOf

3.14EncounterCriteria

3.14.1EncounterCriteria Attributes

3.14.1.1EncounterCriteria.admissionReferralSourceCode

3.14.1.2EncounterCriteria.lengthOfStayQuantity

3.14.1.3EncounterCriteria.dischargeDispositionCode

3.15ObservationCriteria

3.15.1ObservationCriteria Attributes

3.15.1.1ObservationCriteria.value

3.15.1.2ObservationCriteria.valueNegationInd

3.15.1.3ObservationCriteria.interpretationCode

3.15.1.4ObservationCriteria.methodCode

3.15.1.5ObservationCriteria.targetSiteCode

3.16ProcedureCriteria

3.16.1ProcedureCriteria Attributes

3.16.1.1ProcedureCriteria.methodCode

3.16.1.2ProcedureCriteria.approachSiteCode

3.16.1.3ProcedureCriteria.targetSiteCode

3.17SubstanceAdministrationCriteria

3.17.1SubstanceAdministrationCriteria Attributes

3.17.1.1SubstanceAdministrationCriteria.methodCode

3.17.1.2SubstanceAdministrationCriteria.approachSiteCode

3.17.1.3SubstanceAdministrationCriteria.targetSiteCode

3.17.1.4SubstanceAdministrationCriteria.routeCode

3.17.1.5SubstanceAdministrationCriteria.doseQuantity

3.17.1.6SubstanceAdministrationCriteria.rateQuantity

3.17.1.7SubstanceAdministrationCriteria.doseCheckQuantity

3.17.1.8SubstanceAdministrationCriteria.maxDoseQuantity

3.17.1.9SubstanceAdministrationCriteria.administrationUnitCode

3.18SupplyCriteria

3.18.1SupplyCriteria Attributes

3.18.1.1SupplyCriteria.quantity

3.18.1.2SupplyCriteria.expectedUseTime

3.19References

3.19.1ActReference Attributes

3.19.1.1ActReference.classCode

3.19.1.2ActReference.moodCode

3.19.1.3ActReference.id

3.20PatientPopulationCriteria

3.20.1PatientPopulationCriteria Attributes

3.20.1.1PatientPopulationCriteria.classCode

3.20.1.2PatientPopulationCriteria.moodCode

3.20.1.3PatientPopulationCriteria.id

3.20.1.4PatientPopulationCriteria.code

3.20.1.5PatientPopulationCriteria.isCriterionInd

3.20.2PatientPopulationCriteria Relationships

3.20.2.1PatientPopulationCriteria.precondition

3.20.2.2precondition.conjunctionCode

3.20.2.3precondition.Grouper

3.20.2.4precondition.actReference

3.21NumeratorCriteria

3.21.1NumeratorCriteria Attributes

3.21.1.1NumeratorCriteria.code

3.22DenominatorCriteria

3.22.1DenominatorCriteria Attributes

3.22.1.1DenominatorCriteria.code

3.23DenominatorExceptionCriteria

3.23.1DenominatorExceptionCriteria Attributes

3.23.1.1DenominatorExceptionCriteria.code

3.23.2DenominatorExceptionCriteria Relationships

3.23.2.1DenominatorExceptionCriteria.precondition

3.23.2.2precondition.conjunctionCode

3.23.2.3NumeratorExclusionCriteria

3.23.2.4DenominatorExclusionCriteria

3.24StratifierCriteria

3.24.1StratifierCriteria Attributes

3.24.1.1StratifierCriteria.code

3.24.2StratifierCriteria Relationships

3.24.2.1StratifierCriteria.precondition

3.24.2.2precondition.conjunctionCode

3.25measurePopulationCriteria

3.25.1measurePopulationCriteria Attributes

3.25.1.1measurePopulationCriteria.code

3.26Logical Groupers

3.26.1Grouper Attributes

3.26.1.1Grouper.classCode

3.26.1.2Grouper.moodCode

3.26.1.3Grouper.id

3.26.2Grouper Relationships

3.26.2.1Grouper.precondition

3.26.2.2precondition.typeCode

3.26.2.3precondition.conjunctionCode

3.26.2.4Precondition.negationInd

3.26.2.5precondition.Grouper

3.26.2.6precondition.actReference

3.27measureObservationDefinition

3.27.1measureObservationDefinition Attributes

3.27.1.1measureObservationDefinition.classCode

3.27.1.2measureObservationDefinition.moodCode

3.27.1.3measureObservationDefinition.id

3.27.1.4measureObservationDefinition.code

3.27.1.5measureObservationDefinition.derivationExpr

3.27.1.6measureObservationDefinition.methodCode

4Definitions

4.1General Definitions

4.2Measure Parameter Definitions

4.3Reporting Parameter Definitions

4.4Quality Measure Scoring

4.5Quality Measure Types

5Examples

5.1eMeasure Example Files

5.2Sample HQMF Rendering Style Sheet

5.1Using Occurrences of QDM in HQMF

6HQMF Schema

Table of Figures[DW4]

Table of Tables[DW5]

Preface

Acknowledgements

Thisprojectwasoriginally supportedbyvolunteereffortsandthroughtheNationalQualityForum’s(NQF,

In addition, tThetheCollaborativeforPerformanceMeasureIntegrationwithEHRSystems("Collaborative"),co-sponsoredbytheAmericanMedicalAssociation(AMA), and theNationalCommitteeforQualityAssurance(NCQA),andthe ElectronicHeathRecordAssociation(EHRA),developedthe an HQMFreferenceguide,aprototypetoaddressperformancemeasurefunctionalityandintegrationwithEHRsystems.TheHQMFprototypedefinedastandardizedwayofexpressingperformancemeasureswhilepreservingtheclinicalintentofthemeasureitself.Inspring2009,NQFsponsoredeffortstoalign take theprototypeHQMFandalign it withHL7constructs.

ThisdraftHL7standardwasoriginally producedthroughvolunteereffortsandtheHealthQualityMeasureFormat(HQMF)projectsponsoredbytheNQF.Release 2 updates were sponsored by the Office of Clinical Standards and Quality of the Centers for Medicare and Medicaid Services (CMS) in partnership with Health Level Seven (HL7) and the Office of the National Coordinator (ONC). The project was carried out within the framework of ONC’s Standards and Interoperability (S&I) Framework Query Health Technical Workgroup.

Thedesignofthisspecificationwasproducedoverthecourseof22 multiple interdisciplinary stakeholder sessionsusinganopenandtransparentprocesstoensurebroadstakeholderinput.Thefollowingindividualswereinstrumentalinguidingtheproject so that alignment occurred between interested organizations:

  • ChadBennett,Iowa Foundation for Medical CareTelligen
  • KevinCoonan,Dana-FarberCancerInstitute
  • PattyCraig,TheJointCommission
  • AaronCutshall,IndianaHealthInformationExchange
  • LoriFourquet,eHealthSign
  • PaulFu,Illumisys
  • WilliamGoossen,Results4Care
  • KendraHanley,AmericanMedicalAssociation
  • DelaneHeldt,AmericanMedicalAssociation
  • JoyKuhl,ChildHealthCorporationofAmerica
  • ThomKuhn,AmericanCollegeofPhysicians
  • CecilLynch,OntoReason,LLC
  • SusanMatney,UniversityofUtahHealthCare
  • LloydMcKenzie,LM&AConsulting/HL7Canada
  • GregPawlson,NationalCommitteeforQualityAssurance
  • JacobReider,Allscripts
  • PhilRenner,NationalCommitteeforQualityAssurance
  • DanRussler,OracleCorporation
  • HarrySolomon,GEHealthcare
  • DavidStumpf,UnitedHealth
  • JulieThompson,NationwideITServices,Inc.
  • JimUnander,AmericanMedicalAssociation[ck6]

Theco-editorsalsoexpresstheirappreciationforthesupportandsponsorshipoftheHL7StructuredDocumentsWorkingGroup.WeacknowledgetheworkonHL7Version3andtheReferenceInformationModel(RIM),andthecontributionsfromHL7domaincommittees,especiallythe ClinicalDecisionSupport,PatientCare,andModelingandMethodologyWorkingGroups.

Finally,weacknowledgethefoundationalworkontheHQMF, initially a prototype of bytheCollaborativeforPerformanceMeasureIntegrationwithEHRSystems(a collaborative of the American Medical Association, the National Committee for Quality Assurance, and the Electronic Health Records Association); andtheRAND'sworkonaPerformanceMeasureReportingLanguage(PMRL)forrepresentingperformancemeasuresinacomputer-interpretableandsharableformat.

This material contains content from SNOMED CT® ( SNOMED CT is a registered trademark of the International Health Terminology Standard Development Organisation (IHTSDO).

This material contains content from LOINC® ( The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2010, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. All are available at no cost under the license at

Changes from Previous Release [ck7]

1HQMFOverview

"If you cannot measure it, you cannot improve it." — Lord Kelvin (1824-1907)

1.1What is the HQMF, and what is an eMeasure?

The Health Quality Measures Format (HQMF) is a standard for representing a health quality measure as an electronic document. A quality measure is a quantitative tool that provides an indication of an individual or organization’s performance in relation to a specified process or outcome via the measurement of an action, process, or outcome of clinical care. Quality measures are often derived from clinical guidelines and are designed to determine whether the appropriate care has been provided given a set of clinical criteria and an evidence base. Quality measures are also often referred to as performance measures or quality indicators.

Through standardization of a measure's structure, metadata, definitions, and logic, the HQMF provides for quality measure consistency and unambiguous interpretation. A health quality measure encoded in the HQMF format is referred to as an "eMeasure".

Standardization of document structure (e.g. sections), metadata (e.g. author, verifier), and definitions (e.g. "numerator", "initial patient population") enables a wide range of measures, currently existing in a variety of formats, to achieve at least a minimal level of consistency and readability, even if not fully machine processable.

From there, a formal representation of the clinical, financial, and/or administrative concepts and logic within an eMeasure support unambiguous interpretation and consistent reporting. Examples of statements that can be formally represented by the HQMF include:

To be included in a measure's Denominator. , a patient will have had at least two face face-to to-face visits; AND will have a confirmed diagnosis of coronary artery disease (based on diagnostic or procedure criteria).;

To be included in a measure's Initial Patient Population, a patient will have had a principal inpatient discharge diagnosis of stroke; AND a hospital length of stay less than or equal to 120 days.

1.2Guidance for Measure Developers

Creating eMeasures in HQMF format requires measure developers to adopt a programmer’s mind set. Measure developers must consider how a measure will be executed by a processing engine. This process is similar to constructing an SQL query. HQMF is effectively a declarative programming language, and like any such language it is possible to create code that is syntactically correct but contains unanticipated bugs or side effects, or simply does not make logical sense. As HQMF processing engines become more available, we envision that measure developers will need to adopt many of the practices common to software development, such as integrating testing with the development process.

1.3HQMF and the quality Quality life Life cycleCycle

HQMF is one component of a larger quality measure framework, as shown in the following figure.

Figure 11: Quality Measure measure Frameworkframework

Measure developers, often drawing upon available evidence, devise measureable parameters to gauge the quality of care in a particular area. These measureable parameters are assembled into quality measures, which are then expressible expressed as eMeasures in HQMF format. eMeasures may be understood by providersused to guide optimal care, and as well as to guide collection of data for Electronic Health Record (EHR) and other datasystems. The data, which is are then assembled into quality reports (e.g., HL7 CDA R2 Quality Reporting Document Architecture) and submitted to quality reporting or other organizations.

Unambiguous expression of concepts and logic within an eMeasure is a necessary step towards the larger objective of automatically enabling a direct query against an EHR or other operational data store. While HQMF is not an EHR query language, through the provision of unambiguous and formal definitions, it is an EHR query enabler. Additionally, an unambiguous representation of the clinical concepts in an eMeasure allows EHR vendors and healthcare providers to be proactive in capturing such information at the point of care. If, for instance, a quality measure reports on the provision of educational material to stroke patients, the corresponding eMeasure will make it clear exactly what type of educational care provisionmaterial would be considered appropriate care. If the eMeasure calls for the collection of a certain data element not normally captured by the EHR, the EHR might now prompt the user in some way to provide collect this information, thereby enhancing not only the quality of data reporting, but also the quality of care.

HQMF, like the HL7 Clinical Document Architecture (CDA) standard, is derived from an overarching Structured Document Architecture. HQMF is not a CDA standard, but rather, has a peer-to-peer relationship with CDA.

1.4HQMF and Templated CDA

HQMF criteria can have an association to a CDA template. For example, the National Quality Forum maintains a set of Quality Data Element (QDE) patterns that can be used in HQMF criteria. The HL7 Quality Reporting Document Architecture CDA Implementation Guide Release 2 [DW8][YH9]maintains a mapping of QDE pattern identifiers to QRDA templates that supply the data for the corresponding pattern. An HQMF instance will not directly reference a CDA template, but can contain the criteria id[DW10], and the relationship between the two can be asserted outside the HQMF document itself. See the QRDA Implementation Guide [DW11]Release 2 for a complete description of this approach.

1.5Backwards Compatibility

The use of HL7 R2 datatypes R2 and user friendly “business names” prevent HQMF R2 from being directly backwards compatible with HQMF R1. We envision that backwards and forwards compatibility will be handled via transforms. Prototype transforms have already been developed and tested with significant success, but complex HQMF R1 measures may still require some manual work for a successful migration to HQMF R2.

1.6General HQMF Concepts

This section serves as a high-level introduction to the concepts used within an eMeasure document, all of which are described in greater detail again and in greater detail later onin later sections. The intent here is to familiarize the reader with the high-level concepts to facilitate an understanding of the sections that follow.

1.6.1Measure Period[YH12]

Every quality measure has a Measure Period. The Measure Period for a quality measure designates the reference time frame based on which data is are identified, filtered and analyzed. Data that is are collected before or after the Measure Period can also be identified with a time relationship which will be explained in the next section.

1.6.2Data Criteria

The Data Criteria of a quality measure identify the various constraints and filters that can be applied on the data to identify populations.

For example:

  • “Identify the number of people between the ages of 20 – 30 years” narrows the universe of population down to just those who are between 20 and 30 years.
  • “Identify people who had a hbA1C test as part of last visit”
  • “Identify people with Diabetes type II condition”

Data Criteria can be defined on the following clinical data elements.

  • Patient Demographics
  • Encounters
  • Medications
  • Lab Results
  • Vital Signs
  • Problems
  • Procedures
  • Allergies
  • Immunizations
1.6.2.1Filters and Data Criteria

Filters can be applied on Data Criteria to further refine the data criteria to identify populations.

For example:

  • Identify people who have a hHbA1C value > 9% in the most “RECENT” lab test
  • Identify the “FIRST” encounter where the patient was diagnosed with Diabetes Type II.

In the above examples “RECENT” and “FIRST” are examples of filters that can be applied to initial data criteria to refine and extract the population of interest.

1.6.2.2Time Relationships and Data Criteria

Data Criteria can be related to other Data Criteria or Measure Period via time relationships.

For example: The following examples show how an encounter can have a temporal relationship with other Data Criteria or a Measure Period.

  • Identify the lab test which occurs occurred one year before the most recent encounter

The example relates the encounter with the lab test temporally

  • Identify encounters encounters where a particular medication was requested during the Measure Period

The example relates encounters where medications was requested to the Measure Period temporally

1.6.2.3Value Sets and Data Criteria

Quality Measures often need to select patients based on enumerated features of demographics, encounters, medications or other criterion criteria that span a range of coded values. These ranges of coded values are represented as Value Sets and are used to filter out populations.

A Value Set has a unique identifier that is assigned by the owner of the Value Set. These identifiers are referenced within the Data Criteria and included within the eMeasure. The exact representation will be described later in the this document.

An example of a Value Set is:

  • A Value Set for Diabetes Type II from National Quality Forum (NQF) is identified by 2.16.840.1.113883.3.464.1.37 and contains codes from SNOMED-CT, ICD-9-CM and ICD-10-CM vocabularies defining the various types of conditions that get designated as Diabetes.

This Value Set includes codes for conditions such as Diabetes Mellitus, Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled etc.

1.6.2.4Processing Order and Data Criteria[DW13]

The Data Criteria section specifies a set of filters on the events it identifies. The order that those filters are processed in determines the end result for any specific criteria. The following order should be used when processing these filters:

  1. Initial set of events - code value set and category of events
  1. Attributes (e.g., status, value)
  2. Temporal relationships
  3. Subsets - always processed last since some operators (COUNT, MIN, MAX, etc.) reduce the event list to a simple Boolean value preventing further processing.

Within each of the above classifications, filters are applied in document order. For example, if there are two excerpt elements, they are processed in the order they appear within the criteria.

Consider the following example.

<entry>

<localVariableName>HbA1C</localVariableName>

<observationCriteria>

<id

<item root="2.16.840.1.113883.190" extension="HbA1C"/>

</id>

<code valueSet="2.16.840.1.113883.3.464.1.72"/>

<statusCode code="completed"/>

<value xsi:type="IVL_PQ">

<low value="9" unit="%"/>

</value>

<definition>

<observationReference moodCode="DEF">

<id root="2.16.840.1.113883.190" extension="LabResults"/>

</observationReference>

</definition>

<excerpt>

<subsetCode code="RECENT"/>

<observationCriteria>

<id root="2.16.840.1.113883.190" extension="HbA1CMeasured"/>

</observationCriteria>

</excerpt>

<temporallyRelatedInformation typeCode="DURING">

<observationReference moodCode="EVN">

<id root="2.16.840.1.113883.190" extension="MeasurePeriod"/>

</observationReference>

</temporallyRelatedInformation>

</observationCriteria>

</entry>

What does this mean? This asserts criteria that the most recent HbA1C result is 9% or greater during the measurement period. This assertion is determined based on following the processing steps previously mentioned,

  1. Initial set of events
  1. Find all result events whose code matches one in the 2.16.840.1.113883.3.464.1.72 value set
  2. Attributes
  3. Remove any events for which the value is < 9%
  4. Remove any for which the status is not "completed"
  5. Temporal relationships
  6. Remove any events that are outside the measurement period
  7. Subsets
  8. Remove all but the most recent event

1.6.3Population Criteria

The Population Criteria identifies a population using one or more data Data criteria Criteria elements. Populations can be of multiple types and are used differently in the context of a query. The population types are “Initial Patient Population”, “Denominators”, “Numerators”, “Exceptions”, and “Exclusions”. These different population types provide the ability to group populations within a particular context. The following diagram shows the relationships between the populations pictorially and the table below provides their definitions.