Data Exchange For Quality Measures STU3 for FHIR R4
3.0.0 - CI Build

Data Exchange For Quality Measures STU3 for FHIR R4, published by HL7 International - Clinical Quality Information Work Group. This is not an authorized publication; it is the continuous build for version 3.0.0). This version is based on the current content of https://github.com/HL7/davinci-deqm/ and changes regularly. See the Directory of published versions

Data Exchange

Introduction

Clinical Quality Measures (CQMs) are a common tool used throughout healthcare to help evaluate and understand the impact and quality of the care being provided to an individual or population. The intent of data of interest is the source data needed to calculate a quality measure, as specified by the data requirements of the measure. For example, for a colorectal cancer screening measure, the data of interest is the set of conditions, procedures, and observations related to determining whether a patient is in the initial population, denominator, and numerator of the quality measure. To effectively evaluate quality measures in such an environment requires timely exchange of the relevant data.

Transactions between Consumers (organizations that want to evaluate quality measures) and Producers (organizations that deliver care to patients) are triggered by use case specific clinical or administrative events such as the completion of a Medication Reconciliation or a request from a Payer for the attestation information. Note that although triggering is implementation specific and out of scope for this IG, there are a variety of potential triggering points for reporting events within clinical systems. These include:

and there will be a need to convey triggering information in a computable way to EHRs and other clinical systems.

This Implementation Guide (IG) describes three methods of exchanging data quality information using a set of FHIR operations that provide the framework to exchange CQM data:

  1. CQM data may be submitted to the Consumer by the Producer using the Submit Data scenario
  2. CQM data may be requested from the Producer by the Consumer using the Collect Data scenario

Note that FHIR operations allow the implementation to be viewed as a ‘black box’ free to decide how to satisfy the query - “give me the data of interest for a measure” - without requiring generic FHIR search functionality.

This project recognizes the impact of the Argonaut Clinical Data Subscriptions project which is working on event based subscriptions and major revisions to the Subscription resource for FHIR R5. In a future version this guide, a subscription based exchange is planned and will align with the outcomes of the Argonaut project.

Default Profiles

The following resources are used in all data exchange transactions:

Resource Type Profile Name Link to Profile
Library CQFM Library Profile CQFM Library
Measure CQFM Measure Profile CQFM Measure
MeasureReport DEQM Data Exchange MeasureReport Profile DEQM Data Exchange MeasureReport Profile
Organization DEQM Organization Profile DEQM Organization
Patient QI Core Patient Profile QI Core Patient

Depending on the specific Measure, various DEQM and QI Core Profiles are also used in addition to the profiles listed above

Graph of DEQM Resources

The DEQM resources form a network through their relationships with each other - either through a direct reference to another resource or through a chain of intermediate references. These groups of resources are referred to as resources graphs. The DEQM data exchange resource graph is shown in Figure 2-1:

Figure 2-1 DEQM Resource Graph
measure-resource-graph.jpg

Submit Data

The $submit-data operation allows a Producer to submit data of interest for a particular quality measure within the specified submission period. The operation MAY be repeated during the submission period as additional data relevant to the quality measure becomes available. The Producer submits the data either as incremental or snapshot updates. These update methods are described in detail below.

Figure 2-2 Submit Data Steps
submit-data-step.jpg

Gather Data Requirements from Consumer

To support the Submit Data operation, an implementation needs to know specifically what data are required to provide as the payload for the operation. As described in the Background section of this guide, the profiles used in measuring and reporting CQMs are developed through a multi-stakeholder consensus-based process and are made available to the Producer. The Producer is able to query for profiles needed for reporting a given measure and the criteria for the sending of the data. This can be done manually by reviewing the measure definition or computationally by invoking the Data Requirements operation on a Consumer’s measure instance endpoint as described below. These profiles are subsequently referenced in the MeasureReport.evaluatedResources element when submitting the measure data to the Consumer.

Note that because the data exchange scenarios described are intended to support exchange throughout a measurement period, the versions of measure specifications may change during the measurement period. Care should be taken to ensure the appropriate versioning of measure specifications and the impact of those changes on data exchanged using these methods

Figure 2-3 Data Requirements Operation
data-requirement.jpg

APIs

In addition to the resources listed above, the following artifacts are used in this transaction:

  1. Data Requirements: $data-requirements operation
Usage

The required data for each Measure is discovered by invoking the Data Requirements operation on the Consumer’s Measure/[measure-id] endpoint. Using either the GET or POST Syntax, the operation can be invoked as follows:

GET|[base]/Measure/[measure-id]/$data-requirements?periodStart={periodStart}&periodEnd={periodEnd}

POST|[base]/Measure/[measure-id]/$data-requirements

Note the use of the periodStart and periodEnd parameters supports description of data requirements that filter based on the measurement period. For example, a measure may require data for a certain procedure within the last three years, and the data requirements returned will reflect that period.

Standard error responses to the Data Collection operation transactions including appropriate http response codes are documented in the FHIR specification for operation behavior.

Example

Scenario

Provider X acting in the role of the Producer requests data requirements for the MRP measure from Payer Z which is acting in the role of Consumer. A Library resource containing the required resources for MRP attestation returned on successful evaluation.

Request using GET

GET [base]/Measure/measure-mrp/$data-requirements?periodStart=2018&periodEnd=2018

Request using POST

POST [base]/Measure/measure-mrp/$data-requirements

Request body

{
   "resourceType":"Parameters",
   "parameter":[
      {
         "name":"periodStart",
         "valueDate":"2018"
      },
      {
         "name":"periodEnd",
         "valueDate":"2018"
      }
    ]
 }

Response

HTTP/1.1 200 OK
[other headers]

Response body

{
  "resourceType": "Library",
  "id": "library-mrp-example",
  "meta": {
    "source": "http://example.org/fhir/server"
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><h2>Data Requirements</h2><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/measurereport.html\">MeasureReport</a> (<a href=\"StructureDefinition-datax-measurereport-deqm.html\">DEQM Data Exchange MeasureReport Profile</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/patient.html\">Patient</a> (<a href=\"http://hl7.org/fhir/us/qicore/STU4/StructureDefinition-qicore-patient.html\">QICorePatient</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/encounter.html\">Encounter</a> (<a href=\"http://hl7.org/fhir/us/qicore/STU4/StructureDefinition-qicore-encounter.html\">QICoreEncounter</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/location.html\">Location</a> (<a href=\"http://hl7.org/fhir/us/qicore/STU4/StructureDefinition-qicore-location.html\">QICoreLocation</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/task.html\">Task</a> (<a href=\"http://hl7.org/fhir/us/qicore/STU4/StructureDefinition-qicore-task.html\">QICoreTask</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/organization.html\">Organization</a> (<a href=\"StructureDefinition-organization-deqm.html\">DEQM Organization Profile</a>)</td></tr></table><table class=\"grid\"><tr><td colspan=\"2\"><b>Type</b>: <a href=\"http://hl7.org/fhir/R4/practitioner.html\">Practitioner</a> (<a href=\"StructureDefinition-practitioner-deqm.html\">DEQM Practitioner Profile</a>)</td></tr></table><h2>Contents</h2></div>"
  },
  "url": "http://hl7.org/fhir/us/davinci-deqm/Library/library-mrp-example",
  "version": "3.0.0",
  "name": "DEQMLibraryMRPExample",
  "title": "DEQM Library MRP Example",
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/library-type",
        "code": "module-definition"
      }
    ]
  },
  "date": "2021-10-12T21:43:31+00:00",
  "publisher": "HL7 International - Clinical Quality Information Work Group",
  "contact": [
    {
      "telecom": [
        {
          "system": "url",
          "value": "http://www.hl7.org/Special/committees/cqi/index.cfm"
        }
      ]
    }
  ],
  "description": "Example Library resource to demonstrate the framework for MRP",
  "jurisdiction": [
    {
      "coding": [
        {
          "system": "urn:iso:std:iso:3166",
          "code": "US"
        }
      ]
    }
  ],
  "dataRequirement": [
    {
      "type": "MeasureReport",
      "profile": [
        "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/datax-measurereport-deqm"
      ]
    },
    {
      "type": "Patient",
      "profile": [
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"
      ]
    },
    {
      "type": "Encounter",
      "profile": [
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"
      ]
    },
    {
      "type": "Location",
      "profile": [
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location"
      ]
    },
    {
      "type": "Task",
      "profile": [
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-task"
      ]
    },
    {
      "type": "Organization",
      "profile": [
        "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/organization-deqm"
      ]
    },
    {
      "type": "Practitioner",
      "profile": [
        "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/practitioner-deqm"
      ]
    }
  ]
}

For another example see the COL Data Requirements Operation example.

Submit Data Operation

Once the Producer understands the data requirements, they will use the Submit Data operation to submit a MeasureReport and the referenced resources as discovered by the Data Requirements operation to the Consumer. There is no expectation that the submitted data represents all the data of interest, only that all the data submitted is relevant to the calculation of the measure for a particular subject or population. The Consumer simply accepts the submitted data and there is no expectation that the Consumer will actually evaluate the quality measure in response to every Submit Data. In addition, the Submit Data operation does not provide for analytics or feedback on the submitted data.

Figure 2-4 Submit data Operation
submit-data.jpg

Incremental and Snapshot Updates

When the Producer submits updates to the measure data within the data submission period, the Producer can use snapshot or incremental updates for submitting data based on Producer and Consumer agreement. Note that neither method is preferred or a default and has to be agreed upon out of band.

Examples of patient ‘events’ that could trigger the submission of an update:

  • A visit, including telemedicine, to a physician’s office.
  • Being discharged from a hospital.

Discovery:

  • The Consumer SHALL advertise whether it supports snapshot or incremental data exchange via its CapabilityStatement using the DEQM Submit Data Update Type Extension. The extension is added to the CapabilityStatement.rest.resource.operation element for the Submit Data operation and the code is valued incremental or snapshot as shown below:

    {
      "resource": [
    {
      "type": "Measure",
      "supportedProfile": [
        "http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/measure-cqfm"
      ],
      "interaction": [
        {
          "code": "read"
        }
      ],
      "operation": [
        {
          "name": "submit-data",
          "definition": "http://hl7.org/fhir/OperationDefinition/Measure-submit-data"
        },
        {
          "extension": [
            {
              "url": "http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-updateType",
              "valueCode": "incremental"
            }
          ]
        }
      ]
    }
    ...snipped content...
      ]
    }
    

(For a complete example, see the Consumer Server CapabilityStatement )

  • It is the responsibility of the Producer to discover whether snapshot or incremental data exchange is supported by the inspection of the Consumer’s CapabilityStatement.

  • The Producer SHALL populate the required DEQM Submit Data Update Type Extension on the DEQM Data Exchange MeasureReport Profile to indicate whether the payload is a snapshot or incremental update for both the initial transaction and subsequent updates.

  • The Consumer SHALL reject the submit data payload if there is mismatch between the Consumer’s stated capabilities and the required modifier extension by returning a 400 Bad Request http error code. An OperationOutcome SHOULD be returned stating that the [snapshot/incremental] update is not supported as shown in the following example:

    HTTP/1.1 400 Not Found
    [other headers]
    {
      "resourceType": "OperationOutcome",
      "id": "no-status",
      "issue": [
    {
      "severity": "error",
      "code": "business-rule",
      "details": {
        "text": "Snapshot/Incremental update is not supported."
      },
      "diagnostics": "Resubmit the payload as a snapshot/incremental update and populate the extension http://hl7.org/fhir/us/davinci-deqm/StructureDefinition/extension-dataa-updateType" with the code 'snapshot'/'incremental'"
    }
      ]
    }
    

Incremental Update Requirements and Expectations:

  • For incremental data exchange, stable logical (resource) ids and meta.source elements are required for ALL transacted resources across ALL transactions.

    • For example MeasureReport.id + MeasureReport.meta.source, Patient.id + Patient.meta.souce, etc … must be the same for all data exchange interactions for a patient and measure during the submission period.
  • Note that resource versions can be accessed using the FHIR RESTful history transaction

Snapshot Update Requirements and Expectations:

  • Snapshot data exchange overwrites previous data ( in other words, the Producer resubmit all data for multiple patients even for a single error).

  • Snapshot data exchange is appropriate when the Consumer system is stateless (doesn’t persist data)

    • Otherwise the Consumer may have to save previous snapshots
  • Snapshot data exchange is appropriate when the Producer can’t support stable logical (resource) ids

APIs

In addition to the resources listed above, the following artifacts are used in this transaction:

  1. Submit Data operation: $submit-data
  2. Various DEQM and QI Core Profiles depending on the specific Measure
Usage

Using the POST Syntax, the operation can be invoked by the Producer:

POST|[base]/Measure/[measure-id]/$submit-data

Standard error responses to the Submit Data operation transactions including appropriate http response codes are documented in the FHIR specification for operation behavior.

Examples

Scenario:

Provider X acting in the role of Producer submits MRP data for Patient Y to Payer Z who is acting in the role of Consumer. The body of the request is a Parameters resource containing the required profiles for MRP attestation using Task as the resource used to evaluate the measure. An HTTP Status success code is returned on successful submission.

Request using POST

POST [base]/Measure/measure-mrp/$submit-data

Request body

{
   "resourceType":"Parameters",
   "parameter":[
      {
         "name":"measurereport",
         "resource":"{"resourceType": "MeasureReport",
         ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Task",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Patient",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Location",
          ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Practitioner",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Organization",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Coverage",
        ...}
      },

    ]
 }

Response

HTTP/1.1 200 OK
[other headers]

For a complete un-edited example see the MRP Submit Data Operation and COL Submit Data Operation examples.

Collect Data

In this scenario, the Consumer initiates a $collect-data operation to gather any available CQM data for a particular measure from the Producer. In response to the operation, the Producer returns a MeasureReport containing data relevant to the Measure. The Producer gathers the data requirements as described above in the Submit Data scenario. Like the Submit Data scenario, there is no expectation that the data returned represents all the data required to evaluate the quality measure only that all the data submitted is relevant to the calculation of the measure for a particular subject or population. Unlike the Submit Data interaction, the exchange is typically incremental as detailed below.

Figure 2-5 Collect Data Steps
collect-data-steps.jpg

Collect Data Operation

The Consumer uses a Collect Data operation to request any available relevant data for the evaluation of a particular measure from a Producer. Unlike the Submit Data interaction, the collect data exchange is typically incremental. This would typically be done on a periodic basis to support incremental collection of quality data. The lastReceivedOn parameter can be used to indicate when the last Collect Data operation was performed, allowing the Producer to limit the response to only data that has been entered or changed since the last received on date.

Figure 2-6 Collect data Operation
collect-data.jpg

Incremental and Snapshot Updates
  • Unlike the Submit Data interaction, there is no need for out of band discovery.
  • The Consumer uses the Collect Data operation’s lastReceivedOn parameter for incremental data exchange - if the parameter present, it is an incremental update and snapshot if not.
  • The same Snapshot and Incremental Requirements and Expectations described above for the Submit Data transaction apply for Collect Data.
  • If the Producer cannot support the lastReceivedOn parameter then it SHALL return a 400 Bad Request http error code. An OperationOutcome SHOULD be returned stating that the lastReceivedOn parameter is not supported as shown in the following example:

    HTTP/1.1 400 Not Found
    [other headers]
    {
    "resourceType": "OperationOutcome",
    "id": "no-status",
    "issue": [
      {
        "severity": "error",
        "code": "business-rule",
        "details": {
          "text": "The `lastReceivedOn` parameter is not supported "
        },
        "diagnostics": "Resubmit all the information in the payload as a snapshot update"
      }
    ]
    }
    
APIs

In addition to the resources listed above, the following artifacts are used in this transaction:

  1. Collect Data operation:$collect-data
  2. Various DEQM and QI Core Profiles depending on the specific Measure
Usage

Collect Data:

Using either the GET or POST Syntax, the operation can be invoked by the Consumer:

GET|[base]/Measure/[measure-id]/$collect-data&[parameters]

POST|[base]/Measure/[measure-id]/$collect-data

Standard error responses to the Collect Data operation transactions including appropriate http response codes are documented in the FHIR specification for operation behavior.

Examples

Scenario:

Payer Z acting in the role of the Consumer collect Patient Z’s MRP data from Provider X which is acting in role of the Producer

Request using GET Syntax

GET [base]/MeasureReport/measure-mrp/$collect-data?subject=Patient/patient-z&provider=Practitioner/provider-x&periodStart=2018-06-19

Request using POST Syntax

POST [base]/MeasureReport/measure-mrp/$collect-data

Request body

{
   "resourceType":"Parameters",
   "parameter":[
      {
         "name":"subject",
         "valueUri":"Patient/patient-z"
      },
      {
         "name":"practitioner",
         "valueUri":"Practitioner/provider-x"
      },
      {
         "name":"periodStart",
         "valueDate":"Practitioner/2018-06-19"
       }
    ]
 }

Response

HTTP/1.1 200 OK
[other headers]

Response body

{
   "resourceType":"Parameters",
   "parameter":[
      {
         "name":"measurereport",
         "resource":"{"resourceType": "MeasureReport",
         ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Task",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Patient",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Location",
          ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Practitioner",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Organization",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Encounter",
        ...}
      },
      {
        "name":"resource",
        "resource":"{"resourceType": "Coverage",
        ...}
      },

    ]
 }

For a complete un-edited example see the COL Collect Data Operation example.

Submit Data and Collect Data for Multiple Patients

Submit Data Operation Request for Multiple Patients

The transaction bundle processing as defined by FHIR specification is used for transacting the body of Submit Data operation request for multiple patients in a single interaction.

  • The transaction bundle contains an entry for each patient as illustrated in the examples below:
    • The fullUrl is a UUID (urn:uuid:...).
    • The resource is a Parameters resource as defined in the operation.
    • The request method is POST
    • The request url is the operation endpoint Measure/$submit-data or Measure/[measure-id]/$submit-data.
  • When resolving references, references are never resolved outside the Parameters resource. Specifically, resolution stops at the elements Parameters.parameter.resource.”
  • The matching transaction response is returned by the operation endpoint server.
POST|[base]

{
  "resourceType": "Bundle",
  "type": "transaction",
  "entry": [
    {
      "fullUrl": "urn:uuid:79378cb8-8f58-48e8-a5e8-60ac2755b674",
      "resource": {
        "resourceType": "Parameters",
        "parameter": [
          {
            "name": "measurereport",
            "resource": {
              "resourceType": "MeasureReport",
              ...,
            "name": "resource",
            "resource": {
              "resourceType": "Patient",
              ...,
            [other "resource" parameters]
          ]
        },
        "request": {
          "method": "POST",
          "url": "Measure/[measure-id]/$submit-data"
            }
            ....
Collect Data Operation Response for Multiple Patients

Because operations are typically executed synchronously, a collect data request to a server returns a Parameter resource for a single patient as defined by the $collect-data operation. Execution of this operation and returning multiple patients in a single asynchronous transaction is outside the scope of this guide.

Provenance

Note that the use of the X-Provenance header data with provenance data that establishes provenance of the data being submitted/collected SHOULD be supported. This provides the capability for associating the provider with the data submitted through the $submit-data and $collect-data transactions described above. If the X-Provenance header is used it should be consistent with the reporter element in the DEQM Data Exchange MeasureReport Profile.