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Chair:  Floyd Eisenberg 

Scribe: @ 

NOTE: This attendance applies if you are present at the related meeting/call, regardless if you have signed a different attendance for your WG. 

Attendees

Present

Name

Affiliation

ESAC, iParsimony, LLC
ESAC

@Andriena JimenezYale


Lantana
Anne SmithNCQA

NCQA

ESAC

University of Utah

@Cynthia BartonCognitive Medicine

Health eData Inc
ESAC

@Jana MalinowskiCerner

ESAC
@Joe BormelCognitive Medicine

NACHC
Mathematica

Diameter Health

NCQA



The Joint Commission
@Marc HallezThe Joint Commission

@Marcela ReyesAltarum

Max.md
ESAC
@Mia NieveraThe Joint Commission
@Mitra BiglariThe Joint Commission

The Joint Commission

MITRE
ESAC
@Ping JiangThe Joint Commission
@Piper RanalloAmerican Academy of Neurology

@Renee Towne

MD Partners
ESAC

@Scott FradkinFlexion 
Telligen

@Tammy KuschelAcustaf

Tamara Rudish


@Wayne Kerr
ESAC
@Yanyan HuThe Joint Commission

@Zahid ButtMediSolv

Topics

TopicAgenda item descriptionDiscussion
Depicting measure components for FHIR Quality Measure IG and DEQM

Diagrams referenced by:

  • FHIR-26656Definitions for new measure components (mostly for proportion measures):
    • Proportion measures:
      • Initial Patient Population (perhaps Eligibility requirements)
      • Denominator inclusion
      • Denominator exclusion
      • Numerator inclusion
      • Numerator exclusion
      • Denominator exception
    • Continuous variable measures
      • Consider Eligibility requirements instead of Measure Population
  • 25501 In Figure 3-9, shouldn't the patient that gets into the Measure Population also get into the Initial Population?
  • 25551 Revise the Calculation flow for Proportion Measures
  • 25550 Remove Initial population from the Denominator Exclusion definition for proportion measures
  • 26342Harmonize population terminology

Three new diagrams for consideration based on CQI discussion April 17:



Definitions:

CMS Measure Management Blueprint: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Downloads/Blueprint.pdf 

eCQI Resource Center https://ecqi.healthit.gov/glossary

eCQM Logic and Guidance document (page 3) on the eCQI Resource Center https://ecqi.healthit.gov/system/files/eCQM_Logic_and_Guidance_v3.pdf

Initial Population:

Blueprint:

Refers to all events to be evaluated by a specific performance measure involving patients who share a common set of specified characteristics within a specific measurement set to which a given measure belongs. All patients counted (e.g., as numerator, as denominator) are drawn from the initial population.

eCQI Resource Center:

The initial population refers to all events to be evaluated by a specific performance measure involving patients who share a common set of specified characteristics within a specific measurement set to which a given measure belongs. All patients counted (for example, as numerator, as denominator) are drawn from the initial population.

eCQM Logic and Guidance:

The set of patients or episodes of care to be evaluated by the measure.

HQMF:

Identifies the eligible group of entities that the measure is designed to address. Details could include such information as specific age groups, diagnoses, diagnostic and procedure codes, enrollment periods, insurance and health plan groups, etc. For example, a patient aged 18 years and older with a diagnosis of CAD who has at least two visits during the Measurement Period. The Initial Population may be the same across all quality measures within a single quality measure set, but this is not required. All patients counted (e.g., as Numerator, as Denominator) are drawn from the Initial Population. The Initial Population can have inclusion and exclusion criteria.

Denominator

Blueprint:

The denominator is a statement that describes the population evaluated by the performance measure and is the lower part of a fraction used to calculate a rate, proportion, or ratio. It can be the same as the initial population or a subset of the initial population to further constrain the population for the purpose of the measure. CV measures do not have a denominator, but instead define a measure population.

eCQI Resource Center:

The denominator is the lower part of a fraction used to calculate a rate, proportion, or ratio. It can be the same as the initial population or a subset of the initial population to further constrain the population for the purpose of the measure. Continuous variable measures do not have a denominator, but instead define a measure population.

eCQM Logic and Guidance:

May be the same as, or contain a subset, of the IP.

HQMF:

The lower part of a fraction used to calculate a rate, proportion, or ratio. The Denominator for proportion and ratio measures is a subset of the Initial Population, grouped for inclusion in a specific performance measure based on specific criteria (e.g., patient's age, diagnosis, prior MI). Different measures within a measure set may have different Denominators (e.g., measure #1 Denominator = Initial Population AND Smoker; measure #2 Denominator = Initial Population AND Atrial Fibrillation). A Denominator can have inclusion and exclusion criteria. Continuous Variable measures do not have a Denominator, but instead define a Measure Population.

Denominator Exception

Blueprint:

Those conditions that should remove a patient, procedure, or unit of measurement from the denominator of the performance rate only if the numerator criteria are not met. A denominator exception allows for adjustment of the calculated score for those providers with higher risk populations. A denominator exception also provides for the exercise of clinical judgment and should be specifically defined where capturing the information in a structured manner fits the clinical workflow. A denominator exception is used only in proportion measures. These cases are removed from the denominator. However, the number of patients with valid exceptions may still be reported. Allowable reasons fall into three general categories: • Medical reasons • Patient reasons • System reasons.

eCQI Resource Center:

A denominator exception is any condition that should remove a patient, procedure, or unit of measurement from the denominator of the performance rate only if the numerator criteria are not met. A denominator exception allows for adjustment of the calculated score for those providers with higher risk populations. A denominator exception also provides for the exercise of clinical judgment and should be specifically defined where capturing the information in a structured manner fits the clinical workflow. A denominator exception is used only in proportion measures. Denominator exception cases are removed from the denominator. However, the number of patients with valid exceptions may still be reported. Allowable reasons fall into three general categories - medical reasons, patient reasons, or system reasons.

eCQM Logic and Guidance:

A subset of the denominator. Only those members of the denominator that are considered for numerator membership and do not meet numerator criteria are considered for membership in the denominator exceptions.

HQMF:

Those conditions that should remove a patient, procedure, or unit of measurement from the Denominator only if the Numerator criteria are not met. Denominator exceptions allow for adjustment of the calculated score for those providers with higher risk populations. Denominator exceptions are used only in proportion eMeasures. They are not appropriate for ratio or continuous variable eMeasures.

Denominator exceptions allow for the exercise of clinical judgment and should be specifically defined where capturing the information in a structured manner fits the clinical workflow. Generic denominator exception reasons used in proportion eMeasures fall into three general categories:

  • Medical reasons
  • Patient reasons
  • System reasons

Denominator Exclusion

Blueprint:

Patients who should be removed from the measure population and denominator before determining whether numerator criteria are met. Denominator exclusions are used in proportion and ratio measures to help narrow the denominator. For example, patients with bilateral lower extremity amputations would be listed as a denominator exclusion for a measure requiring foot exams.

eCQI Resource Center:

A denominator exclusion is a case that should be removed from the measure population and denominator before determining if numerator criteria are met. Denominator exclusions are used in proportion and ratio measures to help narrow the denominator. For example, patients with bilateral lower extremity amputations would be listed as a denominator exclusion for a measure requiring foot exams.

eCQM Logic and Guidance:

A subset of the denominator that should not be considered for inclusion in the numerator.

HQMF:

Those patients who should be removed from the Initial population and denominator before determining if numerator criteria are met. Denominator exclusions are used in proportion and ratio measures to help narrow the denominator.

Numerator

Blueprint:

The upper portion of a fraction used to calculate a rate, proportion, or ratio. Also called the measure focus, it is the target process, condition, event, or outcome. Numerator criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A numerator statement describes the clinical action that satisfies the conditions of the performance measure.

eCQI Resource Center:

The numerator is the upper portion of a fraction used to calculate a rate, proportion, or ratio. Also called the measure focus, it is the target process, condition, event, or outcome. Numerator criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A numerator statement describes the clinical action that satisfies the conditions of the performance measure.

eCQM Logic and Guidance:

A subset of the denominator. The numerator criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator.

HQMF:

The upper portion of a fraction used to calculate a rate, proportion, or ratio. For a Proportion Measure, the Numerator is a subset of the Denominator, which defines the group of patients in the denominator for whom a process or outcome of care occurs (e.g., flu vaccine received).

Numerator exclusion

Blueprint: 

Defines instances that should not be included in the numerator data. Numerator exclusions are used only in ratio and proportion measures.

eCQI Resource Center:

The numerator exclusion defines the instances that should not be included in the numerator data. Numerator exclusions are used in ratio and proportion measures.

eCQM Logic and Guidance:

A subset of the numerator that should not be considered for calculation.

HQMF:

Numerator Exclusions are used in Proportion and Ratio eMeasures to define instances that should not be included in the Numerator (e.g., infections with a specific bacterium for a measure considering the number of central line blood stream infections per 1000 catheter days).



Measure Population:

Blueprint:

Measure Population is used only in CV eCQMs. It is a narrative description of the eCQM population. For example, all patients seen in the ED during the measurement period.

eCQI Resource Center:

NA

eCQM Logic and Guidance:

May be the same as, or contain a subset of, the IP.

HQMF:

Continuous variable measures do not have a Denominator, but instead define a Measure Population. To be in the Measure Population, a patient must be in the larger Initial Population. Proportion and Ratio measures do not have a Measure Population, but instead define a Denominator.

Measure Population Exclusion:

Blueprint:

Measure Population Exclusions are those characteristics of patients who meet measure population criteria that should cause them to be removed from the measure calculation. For example, for all patients seen in the ED, exclude those transferred directly to another acute care facility for tertiary treatment.

eCQI Resource Center:

NA

eCQM Logic and Guidance:

A subset of the measure population that is not used in measure observation calculations

HQMF:

Measure Population Exclusions are used in Continuous Variable eMeasures to define instances that should not be included in the Measure Population.


Measure Observations:

Blueprint:

Measure Observations is used only in ratio and CV eCQMs. They provide the description of how to evaluate performance. For example, the mean time from arrival to departure for all ED visits during the measurement period.

eCQI Resource Center:

NA

eCQM Logic and Guidance:

This describes the computation to be performed on the members of the measure population after removing the measure population exclusions. For example, measure CMS111, Median Admit Decision Time to ED Departure Time for Admitted ED Patients, computes the median duration from the Decision to Admit to the departure from the Emergency Department (ED).

HQMF:

No clear definition, not in glossary


The CQI sub-group discussed the drawing suggested and recommended edits.  After considerable discussion, the group determined intent of the text-only diagram is about information processing. The diagram containing pictures provides a population management approach.  Therefore, the group settled on providing both the pictoral and that text diagrams each for a different purpose.  The process (text only) diagram is updated to the following:

The group determined that a comparable process diagram is required for continuous variable measures. The proposal for that diagram is:

AND - retain the population flow diagrams containing pictures for both proportion and continuous variable measures but change Initial Patient Population with Initial Population.

The group also agreed that harmonization of the definitions presented is valuable.  Floyd agreed to propose a harmonized definition for each of the components based on the options identified and also to consider the definitions in the HQMF glossary.

The proposed definitions are: 

First - note that the FHIR Quality Measure IG for FHIR R4 draft currently points to the eCQI Resource Center definitions if a link to the source is provided.

Initial population (IP) (to be considered - variation from eCQI Resource Center text provided in red text):

The initial population refers to all events to be evaluated by a specific performance measure involving patients who share a common set of specified characteristics within a specific measurement set to which a given measure belongs. All patients or episodes counted (for example, as numerator, as denominator in a proportion measure, or as measure population in a continuous variable measure) are drawn from the initial population.

Denominator (DEN) (to be considered - added text from Blueprint definition provided in red text and new suggested text in red italics - note this definition now has to represent the parent of all denominator inclusion, exclusion and exception criteria):

The denominator is a statement that describes the population evaluated by the performance measure and is the lower part of a fraction used to calculate a rate, proportion, or ratio. It can be the same as the initial population or a subset of the initial population to further constrain the population for the purpose of the measure. Continuous variable measures do not have a denominator, but instead define a measure population (MSRPOPL). The denominator is calculated by determining those individuals, organizations or episodes that meet Denominator Inclusions (DENIN) and subtracting patients or episodes that meet criteria for Denominator Exclusions (DENEX) and Denominator Exceptions (DENEXCEP).

Denominator Inclusion (DENIN) (to be considered - modified from the initial eCQI Resource Center definition of denominator to be specific about inclusions - all in red italics since it is new):

The denominator inclusion describes the events to be evaluated by a specific measure that may be the same as the initial population or a subset of the initial population to further constrain the population for the purpose of the measure. Continuous variable measures do not have denominator inclusions, but instead define a measure population (MSRPOPL).

Proposed in FHIR-26655 - Getting issue details... STATUS denominator-inclusion|Denominator Inclusion|Denominator inclusion criteria define patients or events to be included in the denominator. Denominator inclusions are used in proportion and ratio measures to define the criteria for inclusion in the denominator.

Denominator Exclusion (DENEX) (to be considered - variation from eCQI Resource Center text provided in red text):

A denominator exclusion is a patient, procedure, or unit of measurement case that should not be part of the denominator whether or not it meets denominator inclusion criteria removed from the measure population and denominator before determining if numerator criteria are met. Denominator exclusions are used in proportion and ratio measures to help narrow the denominator. For example, diabetic patients with bilateral lower extremity amputations would be listed as a denominator exclusion for a measure requiring foot exams for patients with diabetes.

Denominator Exception (DENEXCEP)(to be considered - variation from eCQI Resource Center text provided in red text):

A denominator exception is any condition that should remove a patient, procedure, or unit of measurement from the denominator of the performance rate only if the numerator inclusion criteria are not met. A denominator exception allows for adjustment of the calculated score for individual or organizations those providers with higher risk populations. A denominator exception also provides for the exercise of clinical judgment and should be specifically defined where capturing the information in a structured manner fits the clinical workflow. A denominator exception is used only in proportion measures. Denominator exception cases are not included in removed from the denominator. However, the number of patients meeting denominator exception criteria (i.e., those with valid exceptions) may still be reported. Allowable denominator exception reasons fall into three general categories - medical reasons, patient reasons, or system reasons.

Numerator (NUM) (to be considered - modified from eCQI Resource Center in red text):

The numerator is a statement that describes the target processes, conditions, events or outcomes expected for each individual organization, or episode represented in the denominator (numerator inclusions), minus any numerator exclusions. The numerator is calculated by subtracting those targeted items that meet numerator exclusion (NUMEX) criteria from the total meeting numerator inclusion (NUMIN) criteria. A numerator statement describes the clinical action that satisfies the conditions of the performance measure.

Numerator Inclusion (NUMIN) (to be considered - variation from eCQI Resource Center text provided in red text):

The nNumerator inclusions are those target processes, conditions, events or outcomes expected for each individual, organization, or episode represented in the denominator. is the upper portion of a fraction used to calculate a rate, proportion, or ratio. Also called the measure focus, it is the target process, condition, event, or outcome. Numerator criteria are the processes or outcomes expected for each patient, procedure, or other unit of measurement defined in the denominator. A numerator statement describes the clinical action that satisfies the conditions of the performance measure.

Proposed in FHIR-26655 - Getting issue details... STATUS numerator-inclusion|Numerator Inclusion|Numerator inclusion criteria define patients or events to be included in the numerator. Numerator inclusions are used in proportion and ratio measures to define the criteria for inclusion in the numerator.

Numerator Exclusion (NUMEX) (to be considered - variation from eCQI Resource Center text provided in red text):

The numerator exclusion defines specific criteria for instances that meet numerator inclusion (NUMIN) criteria but should not be included in the numerator data. Those individuals, organizations or episodes for which numerator exclusion criteria are met remain in the denominator but are subtracted from the total meeting numerator inclusion (NUMIN) criteria to calculate the numerator (NUM). Thus, numerator exclusions lower the total measure proportion result. Target processes, conditions, events or outcomes that meet Numerator exclusions are used in ratio and proportion measures.

Measure Population (MSRPOPL) (not included in the eCQM Resource Center - modification is a combination of Blueprint and HQMF): 

Measure Population is a statement that describes the population evaluated by the continuous variable measure. It can be the same as the initial population or a subset of the initial population to further constrain the population for the purpose of the measure. The measure population is calculated by determining those individuals, organizations or episodes that meet specified criteria but subtracting patients or episodes that meet criteria for Measure Population Exclusion (MSRPOPLEX). Proportion and Ratio measures do not have a Measure Population, but instead define a Denominator. Continuous variable measures do not have a Denominator, but instead define a Measure Population.

Measure Population Inclusion (NEW ?MSRPOPLIN):

FHIR-26655 - Getting issue details... STATUS measure-population-inclusion|Measure Population Inclusion|Measure population inclusion criteria define patients or events for which the individual observation for the measure should be taken. Measure population inclusion criteria are used for continuous variable measures rather than numerator and denominator criteria.

Measure Population Exclusion (MSRPOPLEX) (not included in the eCQM Resource Center - modification is a combination of Blueprint and HQMF with variation provided in red italics): 

Measure population exclusions are those characteristics of individuals, organizations or episodes that patients who meet measure population criteria that should cause them to be removed from the measure calculation. For example, for all patients seen in the emergency department (ED), exclude those transferred directly to another acute care facility for tertiary treatment.

Measure Observations:  (Not described in the eCQM Resource Center - this definition from the eCQM Logic and Guidance which is more descriptive than the eCQI Resource Center with variation provided in red italics):

Measure observations This describes the computation to be performed on the members of the measure population after removing the measure population exclusions. For example, measure CMS111, Median Admit Decision Time to ED Departure Time for Admitted ED Patients, computes the median duration from the Decision to Admit to the departure from the Emergency Department (ED).


Participants on the call agreed to review the diagrams and the proposed definitions for discussion and potential approval on the CQI WG call Friday, April 24, 2020.


Definitions for DEQM

Determine if further discussion for DEQM is required (Eric Haas)

No further content review required.
QI-Core Vs QUICK Logical ModelDeferred until after May 2020 Connectathon - evaluating authoring measures with QI-Core (logical view) and QUICK logical modelDeferred until Connectathon outcome.
Adjournment

The meeting was adjourned at 10:58 AM April 21, 2020.


Supporting Documents

Outline Reference

Supporting Document

Minute Approval


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