Agile Health Services - A resource for the intersection of healthcare, computer science, and design: qrda

I have been preparing to lead a summit in D.C. tomorrow to discuss versioning of the various Meaningful Use Clinical Quality Measure (CQM) standards. During final preparation for the summit, I have been digging into the QRDA Category 3 XML specification. As I detailed a few months ago, the QRDA Category 3 XML is used for reporting aggregate data for reporting CQMs. The more that I go spelunking into the QRDA Category 3 standard, the more I understand the complexities associated with it. I am hoping that providing an example QRDA Category 3 XML will be helpful to the broader community.

Detailed below is a (verbose) example QRDA Category 3 XML file for expressing the Meaningful Use Stage 2 Clinical Quality Measure for expressing the results for "NQF 0018 Controlling High Blood Pressure". Assume that this CQM is being considered against a population of patients that would generate aggregate section results that would look like this:

Initial Patient Population (IPP): 3
Denominator: 3
Numerator: 1
Exceptions: 1
Exclusions: 0

Additionally, Electronic Health Record (EHR) systems are required to report on the supplemental data for sex, ethnicity, race and payer. So for this data set, assume that there are two males that meet the IPP and only one female. Then, assume only one of the males meets the numerator requirement. For simplicity, assume that we do not have any information on race, ethnicity, or payers… so assume "unknown" for all the patients on those dimensions.

Scrolling below, I enumerate a valid example QRDA Category 3 XML file and the sections used to report the aggregate results via CQM QRDA Category 3. I highlighting the aggregate section results with a yellow background, and the supplemental data with a violet background.

Similar to the QRDA Category 1, it is really difficult to understand why there is so much XML bloat here. For expressing the CQM results I enumerated after the third paragraph of this blog entry, it takes 679 lines of XML to express these results in the QRDA Category 3! It is a real struggle to attempt to explain why so much verbose XML is needed to convey such little aggregate information.

With a more detailed understanding of the QRDA Category 3 specification, I think it is finally time to seriously question the ongoing use of the HL7 Clinical Document Architecture (CDA) and the HL7 Reference Implementation Model (RIM) for expressing any type of healthcare data in XML. While I appreciate what the leaders at HL7 are attempting to do, the QRDA Category 3 XML bloat is probably the best (worst?) example I have seen to support use of a simpler and less complex standard that deviates from the CDA and RIM.

Steve Jobs quote that needs to be considered here “Simple can be harder than complex. You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.” See the evidence of the need for this type of change below:

<?xml version="1.0" encoding="utf-8"?>
<ClinicalDocument xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"
xmlns="urn:hl7-org:v3" xmlns:cda="urn:hl7-org:v3">
<realmCode code="US"/>
<typeId root="2.16.840.1.113883.1.3" extension="POCD_HD000040"/>
<templateId root="2.16.840.1.113883.10.20.27.1.1"/>
<id root="9c9762c0-2ac3-0131-4e2f-0050560100a9"/>
<code code="55184-6" codeSystem="2.16.840.1.113883.6.1"
codeSystemName="LOINC"
displayName="QRDA Category 3 Summary Report"/>
<title>QRDA Category 3 Calculated Summary Report</title>
<effectiveTime value="20131108164909"/>
<confidentialityCode codeSystem="2.16.840.1.113883.5.25" code="N"/>
<languageCode code="en-US"/>
<versionNumber value="1"/>
<recordTarget>
<patientRole>
<id nullFlavor="NA"/>
</patientRole>
</recordTarget>
<author>
<time value="20131108164909"/>
<assignedAuthor>
<id extension="Foo" root="Bar"/>
<assignedAuthoringDevice>
<softwareName/>
</assignedAuthoringDevice>
<representedOrganization>
<id root="root" extension="ext"/>
<name/>
</representedOrganization>
</assignedAuthor>
</author>
<custodian>
<assignedCustodian>
<representedCustodianOrganization>
<id root="root"/>
<name>Some Custodian Name</name>
</representedCustodianOrganization>
</assignedCustodian>
</custodian>
<legalAuthenticator>
<time value="20131108164909"/>
<signatureCode code="S"/>
<assignedEntity>
<id root="root"/>
<representedOrganization>
<id root="root"/>
</representedOrganization>
</assignedEntity>
</legalAuthenticator>
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<section>
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<templateId root="2.16.840.1.113883.10.20.27.2.2"/>
<code code="55187-9" codeSystem="2.16.840.1.113883.6.1"/>
<title>Reporting Parameters</title>
<text>
<list>
<item>Reporting period Dec 31 2011 -
Dec 31 2012</item>
</list>
</text>
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<high value="20121231120000"/>
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<title>Measure Section</title>
<text></text>
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<id root="40280381-3D61-56A7-013E-66BC02DA4DEE"/>
<text>Controlling High Blood Pressure</text>
<setId
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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. © Rob McCready, 2013.

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