CQF on FHIR
This track defines several scenarios related to clinical quality that exercise the resources defined by the Clinical Decision Support and Clinical Quality Information Work Groups, as well as profiles and usage guidance defined in the Clinical Quality Framework Implementation Guide.
Submitting WG/Project/Implementer Group
- Clinical Decision Support Work Group
- Clinical Quality Information Work Group
- Clinical Quality Framework Initiative
The CDS and CQI Work Groups are incorporating feedback from previous ballots, prior connect-a-thons, as well as other work groups to refine and improve the structures used to enable the representation and evaluation of quality artifacts using FHIR. These efforts have resulted in several resources and related implementation guides that will be balloted both as part of the FHIR STU 3 ballot and as separate implementation guides in the upcoming September 2016 ballot cycle. The scenarios in this connect-a-thon track proposal are intended to support that ballot by exercising key resources and use cases in the implementation guides.
Proposed Track Lead
- Bryn Rhodes
- Email: bryn at databaseconsultinggroup dot com
- Skype: bryn.rhodes
- Partners Healthcare [Immunization Guidance Scenario]
- Cognitive Medical Systems
- University of Utah Healthcare
- ESAC, Inc
- HarmonIQ Health Systems Corporation
- Motive Medical Intelligence
The Guidance Service role provides real-time clinical decision support services. This component enables a consumer to request clinical decision support based on the current context. The consumer provides relevant contextual information as part of the request, and receives clinically relevant guidance as a set of resources describing potential actions to be taken.
The Guidance Client role consumes real-time clinical decision support services. The client integrates decision support at appropriate points in clinical workflow, allowing users of the system to respond to the guidance presented by the decision support system.
Knowledge Management Repository
A FHIR Server that implements search and retrieval functionality for the various quality artifact resources.
Knowledge Artifact Consumer
A system that consumes knowledge artifacts from a knowledge management repository
Measure Reporting Service
A system that provides measure evaluation results
An agent that subscribes to events published by an Event Publish Subscribe (EPS) system
A client to a Unified Communication System (UCS)
Order Set Service
A service capable of evaluating order set definitions to produce order sets applicable to a specific patient and/or context.
Order Set Client
A client capable of requesting the evaluation of an order set definition for a specific patient and/or context, and consuming the resulting order set instance.
A service that exposes an InfoButton decision support service module and implements the $evaluate operation to return InfoButton guidance.
A client that consumes InfoButton documentation via the $evaluate operation and a GuidanceResponse.
The Clinical Quality Framework Implementation Guide provides documentation for the resources that will be exercised by the above roles. Specifically, the following resources are utilized as part of those scenarios:
- $evaluate operation
IHE Radiology Guidance Request Scenario
- Action: A Guidance Client issues an $evaluate operation to a Guidance Service against the IHE Radiology Appropriateness Decision Support Service Module
- Precondition: The GuidanceService must have the $evaluate operation implemented and be able to process requests for the IHE Radiology Appropriateness Knowledge Module
- Success Criteria: The Guidance Client receives an appropriately filled GuidanceResponse and the appropriate resources for the radiology request as described in the IHE Radiology Appropriateness IG.
- Bonus point: Demonstrate the ability to request additional information through the questionnaire/questionnaire response functionality described in the IG
CDC Immunization Guidance Scenario
- Action: A Guidance Client issues an $evaluate operation to a Guidance Service against the CDC Immunization Decision Support Service Module. The parameters to the module are:
- patient - The patient for which immunization guidance will be returned. The birthDate and gender should be provided.
- organizationId - The Id of the requesting organization. For the purposes of this connect-a-thon, use the hardcoded value 'FHIR_CONNECT_A_THON'
- Precondition: The GuidanceService must have the $evaluate operation implemented and be able to process requests for the CDC Immunization Decision Support Service Module.
- Success Criteria: The Guidance Client receives appropriate immunization guidance based on the patient information provided in the request. The service provides guidance using the current CDC Immunization Guidelines. The test script is written with a male infant and receives an appropriate immunization schedule as ImmunizationRecommendation resources.
- Bonus point: Handle error scenarios including:
- Unauthorized: Perform the request with an invalid organization ID
- Incomplete: Perform the request without providing birth date or gender. The response will still provide an immunization schedule, but with appropriate warnings about the use of clinical judgement in administering immunizations.
- Malformed: Perform the request with invalid data. The response will be an OperationOutcome with an appropriate description of the error that occurred.
- Bonus point: Place immunization orders in the system based on the results
The primary focus of this scenario is a "quality spike" that exercises both the decision support and quality measurement aspects of health care delivery. The scenario involves orchestration of services to illustrate the use of various existing and emerging HL7 standards, including FHIR and CQF-on-FHIR, to faciltate evidence-based care. The following slides provide a diagram illustrating the overall scenario: Exclusive Breastmilk Feeding Scenario
The scenario involves ensuring that mothers receive appropriate education regarding exclusive breastfeeding and makes use of the CMS9v4 measure definition, as well as decision support rules related to ensuring education is delivered and that the mother's intention is documented.
After birth, if the mother's intention regarding breastfeeding has not been documented, place unsigned orders for appropriate education regarding exclusive breastfeeding as well as assessment of mother's intention regarding breastfeeding, and notify the provider that the orders need to be signed.
When the provider receives the notification, they sign the order to indicate the charge nurse and/or bedside nurse should provide appropriate education to the mother regarding exclusive breastfeeding, and ensure that the mother's intention is documented. The physician may also chose to cancel the order, indicating rejection of the recommendation.
If the mother's intention has still not been documented by the time the infant is admitted to recovery, and the physician did not reject the recommendation, either the order has not been signed, or the procedures have not been performed. If the order has not been signed (or cancelled), remind the provider that the order needs to be signed. If the procedures have not been performed, remind the charge nurse and bedside nurse to perform the procedures.
Note that the scenario is explicitly leaving discharge workflows out of scope.
Finally, as part of an overall quality assessment, the exclusive breastfeeding quality measure is evaluated to determine adherence.
Bonus Point: Because the UCS system supports escalation, the reminder to perform the procedures could be sent to the bedside nurse first, and then escalated to the charge nurse if the bedside nurse does not acknowledge receipt and/or perform the procedures within a specified window.
This scenario makes use of the following components:
- EPS - Event Publish/Subscribe service as described by the SOA EPS track
- EPS Subscriber
- Guidance Service
- UCS - Unified Communication System service as described by the SOA UCS track
- UCS Client
- Order Set Service
- Order Set Client
This scenario consists of three subsections:
- 1. After a live birth, ensure that the mother has documented intention regarding exclusive breastfeeding, or received appropriate education
- 2. After an infant's admission to recovery, ensure that the mother has documented intention regarding exclusive breastfeeding, or received appropriate education
- 3. As part of quality assessment, a quality administrator evaluates adherence to the exclusive breastfeeding measure
The first section consists of the following steps:
- An EPS system surfaces one of the following events, indicating a birth:
- Registration of baby after birth
- Mother's transfer to post-partum ward
- Persistence of nurse's notes indicating successful delivery and/or mother's transfer
- An EPS Subscriber subscribed to one of these events issues a request for guidance based on the "live birth" topic
- The EPS Subscriber receives the following guidance:
- A ProcedureRequest to offer appropriate education regarding exclusive breastfeeding to the mother
- A ProcedureRequest to document the mother's intention regarding breastfeeding
- A CommunicationRequest to the provider to sign the orders for education and assessment
- The EPS Subscriber places the unsigned orders with an OrderService
- The EPS Subscriber issues the CommunicationRequest to the primary care provider via the UCS
- The UCS notifies the primary care provider via the appropriate channel
- The primary care provider opens the communication request in a UCS client
- The primary care provider signs the orders, placing them within the patient's care plan
The second section consists of the following steps:
- An EPS system surfaces an event indicating that an infant has been admitted to recovery
- An EPS Subscriber subscribed to the "infant admitted to recovery" topic issues a request for guidance on that topic
- The CDS system receives the request and determines the appropriate guidance
- If the orders have not been placed (or cancelled) the CDS system responds with guidance to remind the provider to sign the orders
- If the orders have been placed, but have not been fulfilled, remind the charge nurse and bedside nurse to fulfill the orders
- The EPS Subscriber receives appropriate guidance in the form of a CommunicationRequest and uses the UCS system to fulfill the request
- The UCS notifies the charge nurse and bedside nurse via the appropriate channel
- The charge nurse and bedside nurse open the communication request in a UCS client and fulfill the orders
The third section consists of the following steps:
- As part of an overall quality assessment, a quality administrator evaluates the Exclusive Breastmilk Feeding measure to determine adherence
Knowledge Management Repository
- Action: A Knowledge Artifact Consumer uses a Knowledge Management Repository to locate and retrieve a decision support rule, order set, library, and measure related to a specific condition.
- Precondition: The Knowledge Management Repository must contain the artifacts and be able to respond to the search requests.
- Success Criteria: The Artifact Consumer receives the knowledge management artifacts and is able to use them to drive decision support and quality measurement within their system.
OrderSet Sharing and Evaluation
- Action: An order set, expressed as a FHIR PlanDefinition resource is made available by a knowledge producer via a Knowledge Management Repository. The order set is retrieved and ingested by a knowledge consumer, and then placed for a specific patient in a given context.
- Precondition: The PlanDefinition is available in the Knowledge Management Repository, and the knowledge consumer is capable of ingesting the order set, and then applying it to an appropriate patient in context.
- Success Criteria: The knowledge consumer ingests the order set and is able to correctly apply it to a particular patient.
Measure Reporting Service
- Action: A Measure Reporting Service uses a previously retrieve knowledge artifact definition to drive measure evaluation and reports the results using the MeasureReport resource.
- Precondition: The Measure Reporting Service has ingested a measure retrieve from a knowledge management repository.
- Success Criteria: The MeasureReport result contains the results of evaluating the measure, and there is evidence within the reported results of having followed the related decision support artifacts at the point of care.
- Action: A client issues an InfoButton call to an InfoButton decision support service module, and receives the information as actions in a GuidanceResponse.
- Precondition: The InfoButton service is available and populated with relevant documents for a specific condition, and the consuming system has an appropriate patient.
- Success Criteria: The consuming system is able to display the InfoButton content retrieved from the InfoButton service via the $evaluate operation call.
The supporting TestScripts and corresponding fixtures have been committed to the FHIR SVN repository at: http://gforge.hl7.org/svn/fhir/trunk/connectathons/BaltimoreSep2016/Connectathon13/CQF-on-FHIR