Under ONC, the Meaningful Use Program tests and certifies EHR technologies as part of the Meaningful Use Program via Authorized Testing Laboratories (ATLs), who are the organizations that use the tools and policies identified by ONC. The Cypress project is the authoritative testing and certification tool used for the MU Stage 2 Clinical Quality Measures, and includes testing for the QRDA Category 1 XML specification.
Based on all the work our team has been supporting with the QRDA Category 1 XML, I thought it would be helpful to demonstrate how a CQM can define the data that would need to be expressed in a QRDA Category 1 XML file.
As an example, I am selecting NQF 0018 "Controlling High Blood Pressure", which measures the percentage of patients, aged 18-85 years old at the time of the CQM's measurement, and who had some sequence of encounters with a provider, and a diagnosis of hypertension, and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
If you wanted to see the full logic of this particular CQM, the visualization that is automatically generated from the open source popHealth project that I am leading is below:
Denominator Logic
birth date
>= 18 years starts before start of measure period
birth date
<= 85 years starts before start of measure period
essential hypertension
<= 6 months starts after start of measure period
essential hypertension
starts before start of measure period
office visit
during measure period
face-to-face interaction
during measure period
preventive care services - established office visit, 18 and up
during measure period
preventive care services-initial office visit, 18 and up
during measure period
home healthcare services
during measure period
annual wellness visit
during measure periodNumerator Logic
diastolic blood pressure < 90 mm Hg
duringrecent of
office visit
during measure period
outpatient consultation
during measure period
preventive care services-initial office visit, 18 and up
during measure period
preventive care services - established office visit, 18 and up
during measure period
face-to-face interaction
during measure period
home healthcare services
during measure period
annual wellness visit
during measure period
systolic blood pressure < 130 mm Hg
duringrecent of
office visit
during measure period
outpatient consultation
during measure period
preventive care services-initial office visit, 18 and up
during measure period
preventive care services - established office visit, 18 and up
during measure period
face-to-face interaction
during measure period
home healthcare services
during measure period
annual wellness visit
during measure periodConsider some realistic but minimal health data applied against that particular CQM and let's see what what a QRDA Category 1 XML file for me would look like. Assume I have the following notional clinical data assigned to me in an Electronic Health Record system:
First Name: John
Last Name: Doe
DoB: June 24, 1975
Address: 123 Main Street Gardner, MA 01440
Work phone: 781-271-7102
HL7 Gender: Male
Spoken Language: English
CDC Race: White
CDC Ethnicity: Not Hispanic or Latino
Conditions: Hypertension diagnosed on March 1st, 2012
Encounters: Office Visit on March 1st, 2012
Office Visit on July 1st, 2012
Blood Pressure Visit on November 1st, 2012
Systolic BP: 127 mmHg on March 1st, 2012
123 mmHg on November 1st, 2012
Diastolic BP: 79 mmHg on March 1st, 2012
81 mmHg on November 1st, 2012
Now, lets see how that clinical data for this patient should be expressed in the (very verbose) QRDA Category 1 XML format. As an FYI for how the QRDA Category 1 XML specification works, the data expressed in the QRDA Category 1 XML is in response to a CQM request.
Assume that the QRDA Category 1 XML below were generate for that particular CQM NQF 0018 "Controlling High Blood Pressure" for the Meaningful Use Stage 2 program. Also, assume a reporting period ending on December 31st, 2012 23:59. I am highlighting in yellow within the XML below where the clinical data that I enumerated for our notional patient is expressed in the QRDA Category 1 XML:
<?xml-stylesheet type="text/xsl" href="cda.xsl"?>
<ClinicalDocument xmlns="urn:hl7-org:v3"
xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns:voc="urn:hl7-org:v3/voc"
xmlns:sdtc="urn:hl7-org:sdtc">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.22.1.1"/><templateId root="2.16.840.1.113883.10.20.24.1.1"/>
<templateId root="2.16.840.1.113883.10.20.24.1.2"/>
<id root="5b010313-eff2-432c-9909-6193d8416fac"/>
<code code="55182-0"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="Quality Measure Report"/>
<title>QRDA Report for John Doe</title>
<effectiveTime value="20130427145038"/>
<confidentialityCode code="N"
codeSystem="2.16.840.1.113883.5.25"/>
<languageCode code="eng"/>
<recordTarget>
<patientRole>
<id extension="12345" root="2.16.840.1.113883.4.572"/>
<addr use="HP">
<streetAddressLine>123 Main Street</streetAddressLine>
<city>Gardner</city>
<state>MA</state>
<postalCode>01440</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:+1-781-271-7102"/>
<patient>
<name>
<given>John</given>
<family>Doe</family>
</name>
<administrativeGenderCode code="M"
codeSystem="2.16.840.1.113883.5.1"
codeSystemName="HL7 AdministrativeGender"/>
<birthTime value="19750624120000"/>
<raceCode code="2106-3"
displayName="White"
codeSystemName="CDC Race and Ethnicity"
codeSystem="2.16.840.1.113883.6.238"/>
<ethnicGroupCode code="2186-5"
displayName="Not Hispanic or Latino"
codeSystemName="CDC Race and Ethnicity"
codeSystem="2.16.840.1.113883.6.238"/>
<languageCommunication>
<templateId root="2.16.840.1.113883.3.88.11.83.2"
assigningAuthorityName="HITSP/C83"/>
<templateId root="1.3.6.1.4.1.19376.1.5.3.1.2.1"
assigningAuthorityName="IHE/PCC"/>
<languageCode code="eng"/>
</languageCommunication>
</patient>
</patientRole>
</recordTarget>
<author>
<time value="20130427145038"/>
<assignedAuthor>
<id extension="FakeNPI" root="2.16.840.1.113883.4.6"/>
<addr>
<streetAddressLine>234 Main Street</streetAddressLine>
<city>Gardner</city>
<state>MA</state>
<postalCode>01440</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(781)271-7102"/>
<assignedAuthoringDevice>
<manufacturerModelName>AcmeEHR</manufacturerModelName>
<softwareName>AcmeEHR</softwareName>
</assignedAuthoringDevice>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>Fake Custodian</name>
<telecom use="WP" value="tel:(781)555-5555"/>
<addr>
<streetAddressLine>345 Main Street</streetAddressLine>
<city>Gardner</city>
<state>MA</state>
<postalCode>01440</postalCode>
<country>US</country>
</addr>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20130427145038"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="bc01a5d1-3a34-4286-82cc-43eb04c972a7"/>
<addr>
<streetAddressLine>567 Main Street</streetAddressLine>
<city>Gardner</city>
<state>MA</state>
<postalCode>01440</postalCode>
<country>US</country>
</addr>
<telecom use="WP" value="tel:(781)271-3000"/>
<assignedPerson>
<name>
<given>Mike</given>
<family>Doe</family>
</name>
</assignedPerson>
<representedOrganization>
<id root="2.16.840.1.113883.19.5"/>
<name>AcmeEHR</name>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
<documentationOf typeCode="DOC">
<serviceEvent classCode="PCPR">
<effectiveTime>
<low value="20100601"/>
<high value="20100915"/>
</effectiveTime>
<performer typeCode="PRF">
<time>
<low value="20020716"/>
<high value="20070915"/>
</time>
<assignedEntity>
<id root="2.16.840.1.113883.4.6" extension="111111111"/>
<representedOrganization>
<id root="2.16.840.1.113883.4.2" extension="1234567"/>
<id root="2.16.840.1.113883.4.336" extension="54321"/>
</representedOrganization>
</assignedEntity>
</performer>
</serviceEvent>
</documentationOf>
<component>
<structuredBody>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.24.2.2"/>
<templateId root="2.16.840.1.113883.10.20.24.2.3"/>
<code code="55186-1" codeSystem="2.16.840.1.113883.6.1"/>
<title>Measure Section</title>
<text>
<table border="1" width="100%">
<thead>
<tr>
<th>eMeasure Title</th>
<th>Version neutral identifier</th>
<th>eMeasure Version Number</th>
<th>NQF eMeasure Number</th>
<th>Version specific identifier</th>
</tr>
</thead>
<tbody>
<tr>
<td>Controlling High Blood Pressure</td>
<td>ABDC37CC-BAC6-4156-9B91-D1BE2C8B7268</td>
<td>1</td>
<td>5177f5798538a2f952caf324</td>
<td>8A4D92B2-397A-48D2-0139-C6208B875109</td>
<td/>
</tr>
</tbody>
</table>
</text>
<entry>
<organizer classCode="CLUSTER" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.24.3.98"/>
<!-- This is the templateId for eMeasure Reference QDM -->
<templateId root="2.16.840.1.113883.10.20.24.3.97"/>
<statusCode code="completed"/>
<reference typeCode="REFR">
<externalDocument classCode="DOC" moodCode="EVN">
<id root="8A4D92B2-397A-48D2-0139-C6208B875109"/>
<text>Controlling High Blood Pressure</text>
<setId root="ABDC37CC-BAC6-4156-9B91-D1BE2C8B7268"/>
<versionNumber value="1"/>
</externalDocument>
</reference>
</organizer>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.17.2.1"/>
<code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
<title>Reporting Parameters</title>
<text>
<list>
<item>Reporting period: January 1st, 2012 -
December 31st, 2012</item>
</list>
</text>
<entry typeCode="DRIV">
<act classCode="ACT" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.17.3.8"/>
<code code="252116004"
codeSystem="2.16.840.1.113883.6.96"
displayName="Observation Parameters"/>
<effectiveTime>
<low value="20120101000000"/>
<high value="20121231235900"/>
</effectiveTime>
</act>
</entry>
</section>
</component>
<component>
<section>
<templateId root="2.16.840.1.113883.10.20.17.2.4"/>
<templateId root="2.16.840.1.113883.10.20.24.2.1"/>
<code code="55188-7" codeSystem="2.16.840.1.113883.6.1"/>
<title>Patient Data</title>
<text/>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<templateId root="2.16.840.1.113883.10.20.24.3.57"/>
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce61000287"/>
<code code="8462-4"
codeSystem="2.16.840.1.113883.6.1"
sdtc:valueSet="2.16.840.1.113883.3.526.3.1033">
<originalText>Physical Exam, Finding:
Diastolic BP</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20120301120000"/>
<high value="20120301120000"/>
</effectiveTime>
<value xsi:type="PQ" value="79" unit="mmHg"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2"/>
<templateId root="2.16.840.1.113883.10.20.24.3.57"/>
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce6100028d"/>
<code code="8462-4"
codeSystem="2.16.840.1.113883.6.1"
sdtc:valueSet="2.16.840.1.113883.3.526.3.1033">
<originalText>Physical Exam, Finding:
Diastolic BP</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20121101120000"/>
<high value="20121101120000"/>
</effectiveTime>
<value xsi:type="PQ" value="81" unit="mmHg"/>
</observation>
</entry>
<entry>
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<templateId root="2.16.840.1.113883.10.20.24.3.23"/>
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce6100027f"/>
<code code="99201"
codeSystem="2.16.840.1.113883.6.12"
sdtc:valueSet="2.16.840.1.113883.3.464.1003.101.12.1001">
<originalText>Encounter, Performed:
Office Visit</originalText>
</code>
<text>Encounter, Performed:
Office Visit</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20120301120000"/>
<high value="20120301130000"/>
</effectiveTime>
</encounter>
</entry>
<entry>
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49"/>
<templateId root="2.16.840.1.113883.10.20.24.3.23"/>
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce61000280"/>
<code code="99201"
codeSystem="2.16.840.1.113883.6.12"
sdtc:valueSet="2.16.840.1.113883.3.464.1003.101.12.1001">
<originalText>Encounter, Performed:
Office Visit</originalText>
</code>
<text>Encounter, Performed:
Office Visit</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20120701120000"/>
<high value="20120701130000"/>
</effectiveTime>
</encounter>
</entry>
<entry>
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49" />
<templateId root="2.16.840.1.113883.10.20.24.3.23" />
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce61000281"/>
<code code="185349003"
codeSystem="2.16.840.1.113883.6.96"
sdtc:valueSet="2.16.840.1.113883.3.464.1003.101.12.1001">
<originalText>Encounter, Performed:
Blood Pressure Visit</originalText>
<translation code="99202" codeSystem="2.16.840.1.113883.6.12"/>
</code>
<text>Encounter, Performed:
Blood Pressure Visit</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20121101120000"/>
<high value="20121101130000"/>
</effectiveTime>
</encounter>
</entry>
<entry>
<encounter classCode="ENC" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.49" />
<templateId root="2.16.840.1.113883.10.20.24.3.23" />
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce61000281" />
<code code="185349003"
codeSystem="2.16.840.1.113883.6.96"
sdtc:valueSet="2.16.840.1.113883.3.464.1003.101.12.1048">
<originalText>Encounter, Performed:
Blood Pressure Visit</originalText>
<translation code="99202"
codeSystem="2.16.840.1.113883.6.12"/>
</code>
<text>Encounter, Performed:
Blood Pressure Visit</text>
<statusCode code="completed" />
<effectiveTime>
<low value="20121101120000" />
<high value="20121101130000" />
</effectiveTime>
</encounter>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
<templateId root="2.16.840.1.113883.10.20.24.3.57" />
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce61000285" />
<code code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
sdtc:valueSet="2.16.840.1.113883.3.526.3.1032">
<originalText>Physical Exam, Finding:
Systolic Blood Pressure</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20120301120500"/>
<high value="20120301120500"/>
</effectiveTime>
<value xsi:type="PQ" value="127" unit="mmHg"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.2" />
<templateId root="2.16.840.1.113883.10.20.24.3.57" />
<id root="1.3.6.1.4.1.115" extension="5177f5807938a7ce6100028b" />
<code code="8480-6"
codeSystem="2.16.840.1.113883.6.1"
sdtc:valueSet="2.16.840.1.113883.3.526.3.1032">
<originalText>Physical Exam, Finding:
Systolic Blood Pressure</originalText>
</code>
<statusCode code="completed"/>
<effectiveTime>
<low value="20121101120000"/>
<high value="20121101120000"/>
</effectiveTime>
<value xsi:type="PQ" value="123" unit="mmHg"/>
</observation>
</entry>
<entry>
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.4" />
<templateId root="2.16.840.1.113883.10.20.24.3.11" />
<id root="1.3.6.1.4.1.115"
extension="5177f5807938a7ce6100027e"/>
<code code="282291009"
displayName="diagnosis"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED-CT"/>
<text>Diagnosis, Active: Hypertension</text>
<statusCode code="completed"/>
<effectiveTime>
<low value="20120301123000"/>
<high nullFlavor="UNK"/>
</effectiveTime>
<value code="10725009"
codeSystem="2.16.840.1.113883.6.96"
xsi:type="CD"
sdtc:valueSet="2.16.840.1.113883.3.464.1003.104.12.1011">
<originalText>Diagnosis, Active: Hypertension</originalText>
<translation code="401.1"
codeSystem="2.16.840.1.113883.6.103"/>
</value>
<entryRelationship typeCode="REFR">
<observation classCode="OBS" moodCode="EVN">
<templateId root="2.16.840.1.113883.10.20.22.4.6"/>
<templateId root="2.16.840.1.113883.10.20.24.3.94"/>
<id root="da6b50c0-9177-0130-01b7-12313d02bdec" />
<code code="33999-4"
codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC" displayName="status" />
<statusCode code="completed"/>
<value xsi:type="CD"
code="55561003"
displayName="active"
codeSystem="2.16.840.1.113883.6.96"
codeSystemName="SNOMED CT"/>
</observation>
</entryRelationship>
</observation>
</entry>
</section>
</component>
</structuredBody>
</component>
</ClinicalDocument>
If your first impression that this is bloated XML... you are not alone.
The primary cause of this "bloat" really traces its routes back to the HL7 Clinical Document Architecture and the HL7 RIM for expressing effectively anything (from individual patient records to Clinical Quality Measure procedural logic!) in XML. However, as much as I hate HL7 XML-based documents, there is a little bit of goodness with respect to the QRDA Category 1 XML for expressing patient-level data as inputs to Clinical Quality Measures.
Several HL7 standards have proven to demonstrate failures as inputs to Clinical Quality Measures; the HL7 Continuity of Care Document (CCD), the HITSP C32, or the Consolidated CDA. These are all general XML standards meant for expressing patient-level data for continuity of care from one provider to another via an XML format.
The silver lining on the QRDA Category 1 cloud is that once the clinical data that is needed for a particular CQM has been identified in an EHR system, the way to express that clinical data on a patient-by-patient basis is clear(er) and more tractable for systems that will need to parse and interoperate with the structured data.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. © Rob McCready, 2013.
