Report on eMeasure, Quality Reporting Document
Architecture, and
Neonatal Care Report Compatibility
March 2010
Contents
Introduction ..................................................................................................... 3
Purpose ......................................................................................................... 3
Background ................................................................................................... 3
Clinical Document Architecture (CDA) ........................................................ 3
Neonatal Care Report (NCR) ....................................................................... 4
Health Quality Measures Format (HQMF) ................................................... 4
Quality Reporting Document Architecture (QRDA)...................................... 5
Comparative Effectiveness Research (CER) ................................................. 5
Coordinated Standards for Reporting, Reuse, Research and Improvement ........ 6
Template Reuse and Measure Creation.......................................................... 6
Relationships among NCR, QRDA, and eMeasure .......................................... 6
Conclusion ....................................................................................................... 9
References ...................................................................................................... 10
Figures
Figure 1: Flow Diagram .................................................................................... 7
Report on eMeasure, Quality Reporting Document Architecture, and Neonatal Care
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Introduction
The Children’s Hospitals Neonatal Consortium (CHNC) is a group of 27
children’s hospital Neonatal Intensive Care Units (NICUs) committed to
evaluating the effectiveness of tertiary neonatal intensive care in their unique
patient population. Since 2006, CHNC has developed a consensus set of data
elements related to outcomes of critically ill infants requiring highly specialized
care. CHNC selected The Health Level Seven (HL7) Clinical Document
Architecture (CDA) Release 2 standard to represent a subset of this data for
reporting. Using this subset the Child Health Corporation of America (CHCA)
and Alschuler Associates, LLC created the Neonatal Care Report (NCR)
Implementation Guide for CDA Release 2 that passed HL7 ballot in January
2010. The Child Health Work Group and Structured Documents Work Group
(SDWG) provided support to that effort.
Infants referred from delivery centers to children’s hospital NICUs often include
rare and complex disorders requiring pediatric subspecialty care. Historically,
there has been a profound lack of knowledge regarding best practices in this
population. With the NCR, CHNC aims to systematically collect and analyze
uniform clinical data on infants admitted to children’s hospital NICUs, and
CHNC expects to spearhead benchmarking, quality improvement, and research
initiatives not previously possible in their patient population.
Purpose
This white paper explores the relationship among two HL7 CDA standard
conformance profiles—the Neonatal Care Report (NCR) and the Quality
Reporting Document Architecture (QRDA)—and a complementary HL7 standard
called eMeasure (HQMF). The paper describes how these standards operate in
concert to support end-to-end information capture, reuse, analysis, and
improvement that can spearhead new benchmarking, quality improvement, and
research initiatives in the this patient population.
Background
Clinical Document Architecture (CDA)
CDA Release 2 is a document markup standard that specifies the structure and
semantics of clinical documents for the purpose of electronic health information
exchange. The standards-based approach to reporting simplifies technical
implementation by using a widely implemented data standard and reduces the
burden of reporting among participants through reuse of electronic health
record (EHR) data supported by common models, terminology and templates.
Use of common data definitions and reporting processes based on national
Report on eMeasure, Quality Reporting Document Architecture, and Neonatal Care
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standards reduces the need for providers to reformat data for submission to
multiple recipients. The approach offers a national collaborative and
consensus-based process that includes vendor involvement.
CDA use is expected to increase significantly in the next five years now that the
U.S. Office of the National Coordinator for Health Information Technology (ONC)
has adopted it as a required standard to support meaningful use of certified
EHR technology.
Neonatal Care Report (NCR)
The Neonatal Care Report Implementation Guide (IG) Draft Standard specifies a
standard for electronic submission of NCRs in a CDA Release 2 format.
The CHNC core data set contains around 700 data elements; the NCR draft
standard addresses a subset of approximately 60 data elements, including 37
physiologic and laboratory elements for assessment of illness severity and 21
base data elements (e.g., name, medical record number, birth weight, Apgar
scores, admission weight, birth and discharge head circumference). The data
elements selected for the subset had a previously existing similar template or
had a high probability of reuse. The initial data subset provided the
opportunity to work with the data from the perspective of the underlying model
and electronic format and to explore many design issues thoroughly.
Some of the data elements included in the NCR correspond to the Vermont
Oxford Network (VON); others correspond to data collection sets mapped to
national standards such as the HL7 Continuity of Care Document (CCD). This
NCR Implementation Guide supports reusability and ease of data collection
through a standard data representation balloted through Health Level Seven
(HL7)
Health Quality Measures Format (HQMF)
The Health Quality Measures Format (HQMF) is a standard for representing a
health-quality measure as an electronic document. A quality measure is a
quantitative tool that measures an action, process, or outcome of clinical care
to provide an indication of an individual’s or organization’s performance in
relation to a specified process or outcome.
Through standardization of a measure's structure, metadata, definitions, and
logic, the HQMF provides for consistency and unambiguous interpretation of
quality measures. A health-quality measure encoded in the HQMF format is
referred to as an "eMeasure".
Standardization of document structure (e.g., sections), metadata (e.g., author,
verifier), and definitions (e.g., "numerator", "initial patient population") achieves
a minimal level of consistency and readability across a wide range of measures,
currently existing in a variety of formats, even if not fully machine processable.
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From there, formal representation of the clinical, financial, and/or
administrative concepts and logic within an eMeasure supports unambiguous
interpretation and consistent reporting.1 ONC has recommended eMeasure as a
national standard to support meaningful use of certified EHR technology.
Quality Reporting Document Architecture (QRDA)
Quality Reporting Document Architecture (QRDA) is an XML document format
that defines constraints on CDA Release 2 Header and Body elements for
quality reporting. It provides a standard structure with which to report
endorsed quality measure data to organizations that will analyze and interpret
the data.2 ONCHIT is considering QRDA as a national standard to support
meaningful use of certified EHR technology.
Comparative Effectiveness Research (CER)
The Institute of Medicine (IOM) defines Comparative Effectiveness Research
(CER) (CER) as:
CER is the generation and synthesis of evidence that compares the
benefits and harms of alternative methods to prevent, diagnose,
treat, and monitor a clinical condition or to improve the delivery of
care. The purpose of CER is to assist consumers, clinicians,
purchasers, and policy makers to make informed decisions that
will improve health care at both the individual and population
levels.3
“One important aspect of comparative effectiveness research is that it should
be conducted in ‘real world’ settings, with a full range of patients, not just
those selected for clinical trials, and involve the typical resources available
to physicians and patients,” said Joe Selby, MD, MPH, director of the KaiserPermanente Division of Research, which has pioneered much of the
comparative-effectiveness research and has improved patient care based on
that research. “An important asset for conducting this research is the large
clinical databases generated from the delivery of real world care and
captured in electronic health records.”4 The CHNC database is just such a
database.
HL7 Version 3 Standard: Representation of the Health Quality Measures Format
(eMeasure), Release 1 – September 2009 Ballot
2 Implementation Guide For CDA Release 2 - Quality Reporting Document Architecture
(QRDA)
3 REPORT BRIEF • JUNE 2009 Initial National Priorities for Comparative Effectiveness
Research
4 Health care policy leaders discuss “comparative effectiveness” research, University of
California San Francisco News Office, January 29, 2010
1
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Coordinated Standards for Reporting, Reuse, Research
and Improvement
Template Reuse and Measure Creation
The NCR, QRDA, and eMeasure all contain or specify data about interventions
or results that are associated with patient outcomes.
The NCR contains data compiled throughout an infant’s neonatal ICU
encounter and thought to be related to outcomes of sick infants. The HQMF
eMeasure defines quality measures for consistency and unambiguous
interpretation. The QRDA reports data from EHRs about a specific quality
measure or group of measures to organizations that measure quality.
NCR data-element definitions can be reused within neonatal quality measures.
Vetted measures can inform future iterations of NCR to establish template
reuse between the NCR and QRDA. New eMeasures can ensure capture of the
correct data elements from the EHRs. This approach provides these potential
win-win situations:
 Providers can reuse data structured for NCR when they report on quality
measures using QRDA.
 Researchers can use the collected NCR-compliant data to develop new
measures.
 The care of neonates can be assessed and improved nationwide.
Relationships among NCR, QRDA, and eMeasure
The flow diagram that follows illustrates relationships among NCR, QRDA, and
eMeasure core components.
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Figure 1: Flow Diagram
Data collection, research, measure development
CHCA
Hospital
EHR A
NCR
CDA
2
CHNC
Database
1
1
2
CHCA
Hospital
EHR B
NCR
CDA
3
CHNC
Templates
Database
7
Measure reporting, performance improvement
7
Comparative
effectiveness
research
4
Create QRDAs
Submit
evidence-based
measures to
endorsing
organization
(NQF)
6
7
6
8
Hospital
EHR C
7
5
9 Measure
Quality
6
Create meaningful quality
eMeasures to query EHRs
6
Hospital
EHR D
10
Encourage
evidencebased
interventions
11
Neonatal care/
outcomes
improve
nationwide
1. The CHNC template database stores and indexes data element templates for
reuse by CHNC hospitals. Hospitals use the templates to drive data
collection and reporting.
2. CHNC hospitals use NCR CDAs to send data from disparate systems to the
CHNC database in a standard format.
3. With the received data, CHNC performs CER.
4. Data collected in the CHNC database and CER drives development of new
measures.
5. CHNC submits data-supported evidence-based measures to endorsing
organizations. Measure developers and eMeasure technical groups work
together to develop meaningful quality eMeasures.
6. CHCA hospitals-- potentially all hospitals nationwide with similar patient
populations -- use these eMeasures to query their EHRs.
7. Hospitals create QRDAs using existing NCR templates and new or previously
developed neonatal QRDA templates.
8. Hospitals send QRDAs to Quality organizations or other processing entities.
9. Quality organizations or other processing entities process and analyze the
data from the QRDAs.
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10. Quality organizations and governing bodies encourage evidence-based
interventions nationwide.
11. Neonatal care and outcomes improve nationwide.
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Conclusion
The standardized quality process provided by NCR, QRDA, and eMeasure has
the potential to augment knowledge and standardize the care of sick neonates
nationwide. Any CDA document, including QRDA, can reuse the NCR
templates. The NCR can transmit data from disparate systems using templates
for data elements that provide useful information about infants with rare
disorders as well as those who comprise the majority of the neonatal intensivecare population. Thus, the three specifications described here work together in
an end-to-end process for quality data collection, research, and improvement.
This process will increase knowledge regarding best practices and promote
evidence-based interventions, quality outcomes, and efficient care for all sick
neonates.
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References
1. HL7 Version 3 Standard: Representation of the Health Quality Measures
Format (eMeasure), Release 1 – September 2009 Ballot.
2. HL7 Implementation Guide for CDA Release 2 Quality Reporting
Document Architecture (QRDA) Draft Standard for Trial Use March 2009.
Available at:
http://www.hl7.org/documentcenter/ballots/2008sep/downloads/CDA
R2_QRDA_R1_DSTU_2009APR.zip
3. Dolin RH, Alschuler L, Boyer S, Beebe C, Behlen FM, Biron PV, Shabo A,
(Editors). HL7 Clinical Document Architecture, Release 2.0. ANSIapproved HL7 Standard; May 2005. Ann Arbor, Mich.: Health Level
Seven, Inc. Available through HL7 or if an HL7 member with the
following link:
http://www.hl7.org/documentcenter/private/standards/cda/r2/cda_r2
_normativewebedition.zip
4. HL7 Implementation Guide for CDA Release 2 Neonatal Care Report
(NCR) Draft Standard for Trial use – January 2010 Balloted package
available at
http://www.hl7.org/documentcenter/ballots/2010JAN/downloads/CDA
R2L3_IG_NEONATALRPT_R1_D1_2010JAN.zip
5. Health care policy leaders discuss “comparative effectiveness” research,
University of California San Francisco News Office, January 29, 2010.
6. IOM definition for Comparative Effectiveness Research, available at
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,left=10,width=500,height=400,toolbar=1,location=1,directories=0,status
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egislationTakeAction/upload/CER-report-brief-6-22-09.pdf
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