Observation Status: Aggregate Measure Report Definition

The QRPH Domain has reviewed the report-out of patient-level data consistent with requirements for a single measure or a set of measures. The standards currently in development with respect to that effort, such as Quality Reporting Document Architecture (QRDA), are under review. The ability to report out the aggregate performance of a provider or a group of providers requires further analysis with respect to the information model.

HIMSS EHRVA Request

The US National Health Information Network II implementation site in New York State (Taconic) approached the HIMSS Electronic Health Record Vendor Association (EHRVA) for assistance in communicating the need for an aggregate performance measurement structure for interoperability. The patient-level reporting expects that each data element type is populated in a single patient report to enable calculation of adherence with respect to expected performance. Adherence signifies that the patient meets the defined population (as expressed by the denominator of a quality measure) and has had the expected interventions performed or whose results meet the clinical care expectations expressed in the numerator of the measure. Data representing that an individual patient has characteristics representing exceptions allows removal of that individual from the measured population and the reason for exclusion and, therefore, to enable such exclusion, the appropriate data are provided with the patient-level data. Patient-level data reporting includes some data elements present within existing clinical documents and a specific patient-level report is under development in the HL7 Structured Documents Workgroup, titled Quality Reporting Document Architecture (QRDA). The QRDA draft is planned for HL7 balloting in September 2008 as a Draft Standard for Trial Use (DSTU).

While the individual patient-level reporting has value, the Taconic group and others have specific needs to report the overall performance of a physician, of a practice group (or, in some cases of a hospital) in which individual patient-level data are not specified. Rather, the report is expected to specify the number of patients meeting the population criteria (denominator), the number of that population for which each of the expected interventions or outcomes, or exclusions is true, and the calculated performance. To inform the review, the QRPH Domain requested a discussion with the National Committee for Quality Assurance (NCQA) to understand some of the requirements and NCQA participated on a call on March 13 to inform the Domain about some of the issues. The current schema for reporting in aggregate for health plans was reviewed. The schema informs greatly the content requirements for aggregate reporting. The investigation was performed based on the Electronic Health Record Vendor Association (EHRVA) request on behalf of US National Health Information Network implementer questions. NCQA also indicated some interest in becoming more involved in the process by adding the aggregate view (potentially) to the work of the Collaborative for Performance Measure Integration with EHRS. For informational purposes, this link has been provided by NCQA: NCQA Informational Site for Aggregate Reporting Schema.

Aggregate Reporting Discussion

A summary of the discussion, performance reporting at a clinician level, practice level, hospital level, or other organizational level is addressed as an "aggregate" report requirement. While there is no specific standard for "aggregate" reporting as discussed in the use case provided, there are two organizations that commonly receive aggregate report data from organizations. The Joint Commission receives both patient-level and aggregate reporting from organizations (usually hospitals or outpatient practices). The National Committee for Quality Assurance (NCQA) receives only aggregate reporting from health plans and clinician practices for accreditation as part of HEDIS (Health Evaluation Data Information Set) reporting. The QRPH Domain will investigate, for informational purposes, schema used by The Joint Commission for aggregate reporting. Rick Moore (Chief Information Officer), Jonathan Cook (Director of Information Systems), and Thomas Otterson (Application Developer) of NCQA joined the meeting on Thursday, March 13 to provide general information about the aggregate schema used by NCQA for healthplan reporting of aggregate HEDIS data to NCQA. The schema was developed as an interative process and provides a mechanism for aggregate reporting by organization. The link to the schema is provided for informational purposes with permission from NCQA. The valuable lessons identified during the schema development will be helpful in the identification of requirements for a standard for aggregate reporting. One issue was that of reporting on exceptions. The detail for identifying exceptions in the HEDIS is listed in the specification and includes stepwise identification of exclusion criteria for each patient such that if one exclusion is identified, further exclusions are not captured for that patient. The same applies to each subsequent exclusion. Hence, no patient can be represented more than once in the aggregate exclusion report. NCQA will share this information with the Collaborative for Performance Measure Integration with EHRS to inform creation of a model for aggregate reporting and, subsequently, inform the creation of a standard within the structure of a Standard Development Organization (SDO). QRDA is a possible structure which could incorporate the aggregate model, informed by currently used proprietary schema specific to individual measure developers and measurement evaluation organizations.