1. Exploring the
combination of BPM+
and HEDIS
A COLORECTAL CANCER SCREENING (COL-E) EXAMPLE
John Svirbely, MD
Chief Medical Informatics Officer
(CMIO),
Trisotech
jsvirbely@Trisotech.com
Denis Gagne
Chief Executive Officer (CEO),
Trisotech
dgagne@Trisotech.com
Ben Hamlin, DrPH
Senior Research
Informaticist,
NCQA
hamlin@ncqa.org

2. Exploring the combination of BPM+ and HEDIS
Abstract
Many quality measures for healthcare function at the level of a population, with analysis often
delayed months or even years after the event. To impact the quality of individual patient care in
real-time, while preserving the ability to monitor a population, may require new approaches to
current metrics.
In this presentation we would like to open a discussion on how BPM+ might be used to measure
and improve patient care, using screening for colorectal cancer as the example. We invite the
audience to share their thoughts and experience on how this BPM+ can provide meaningful
feedback to behaviors of both providers and patients.
® 2021 Object Management Group. All Rights Reserved.
2
A Colorectal Cancer Screening (COL-E) Example

3. Today’s Discussion
1. The Value Proposition for Quality
2. Introduction to Digital Quality Measures (dQMs) and the LHS cycle of Evidence to Action
3. Colorectal Cancer Screening (COL-E) – Traditional to NextGen
4. dQM Representation using the KEM and DMN using COL-E as example
5. Modeling COL-E as an person-specific quality measure
6. A side-by-side comparison of a measure in CQL and BPM+

4. Just because you can
measure something,
doesn’t necessarily mean
you ought to….
® 2021 Object Management Group. All Rights Reserved.
4

5. THE VALUE PROPOSITION FOR QUALITY MEASUREMENT
• The art and science of quality measurement
• Clinical guidelines are almost never perfectly aligned – good quality measures solve that
problem
• Augmenting measurement capability through digitalization allows measure authorities
(authors) to create high-value measures, able to deliver critical info to the right place at the
right time and in the right format.
• NextGen measurement concepts are NOT digital translations of traditional measure
narratives. Measure evolution must include a consistent and reliable representation of
decision processes that align to the clinical pathways represented by the evidence-based
guidelines the measures (are supposed to) represent.
• Digital measure authoring is still not a standardized process - programmers are still manually
interpreting narrative in consultation with each measure owner to ensure accurate
representation of the concept.
® 2021 Object Management Group. All Rights Reserved.
5

6. • How do we ensure the reliability, validity and scientific soundness of NextGEN measure
concepts not explicitly detailed in published clinical guidelines?
• How do the various stakeholders collaborate to ensure above criteria met while still being flexible to accommodate
their unique perspective?
• What outcomes are most important to track? At what frequency?
• Will doctors have to enter all this new information into the EHR to make the NextGen
measures function?
• How do we know that measure reports/results returned to the PoC are meaningful, useful or
timely?
• If the standard, measure specified code already exists within the system, do implementors
have to map to a FHIR resource to make it work?
® 2021 Object Management Group. All Rights Reserved.
6
THE VALUE PROPOSITION FOR DQMS

8. 8
THE LHS AND DIGITAL QUALITY MEASURES (dQMs)
Using technology to augment our ability to gain better insights
Analyze
Data
Interpret
Results
Represent
Knowledge
Manage
Knowledge
Apply
Knowledge
Take
Action
Collect
Data
Assemble
Data
Increase dissemination
of best practices
through Quality use
cases
• Collaborative knowledge
engineering
• User groups, community
development
• Consensus mechanisms
• Digital artifacts support
communication and
decision making
• Flag opportunities
• Technology assisted
verification
• More relevant data
sources
• RWE Generation
dQMs

9. 9
OMOP CDM
BPM+
Measure
Development
•FHIR CDM
•BPM+
•CQL Logic
dQM
Specification
CCDs
OMOP
Data
Validation
Measure
Submission
Standard cohort
definitions
Mapping various digital standards to complete the dQM value chain
Standard measure
expression
Standard data quality
assessment
Standard submission
templates
INNOVATION IN THE QUALITY ECOSYSTEM
Actionable
Knowledge

10. HEDIS® Colorectal Cancer Screening

11. HEDIS® Colorectal Cancer Screening

12. HEDIS® Colorectal Cancer Screening

13. Limitations of “Traditional” COL-E dQM:
• Measure process in traditional manner -> Goal = “Yes|No” for presence of test
• No focus on significance of test result in terms of value to patient, meaning to clinician,
or contribution to understanding care quality.
• No incentive to collect/document additional observations or investigate results any further
• uses whole population approach-> general "rule of averages" for screening
frequency regardless of individual risk or other exposure to positive screening
results.
• does not address whether follow-up is necessary or recommended

14. The NextGen COL-E and dQMs in General
• Process measures still very relevant/useful tools in Quality assessment
• First step in their evolution must be to change the dQM target
• Instead of the “presence” of test in record, focus on the result of the test
• If you are looking at the result, you still are confirming the test was performed
• Keying Quality scoring off result “value” allows understanding of immediate need (or not) for
additional services/tests
• Second step is to increase specificity of the denominator cohort to include risk profile
• Patients already get in based on age criteria, but are dumped into a universal bucket for screening
frequency, type, etc.
• Adding specificity to inclusion criteria and segmenting the den into relevant (risk based) cohorts will
improve the quality of care for individuals at higher risk
® 2021 Object Management Group. All Rights Reserved.
14
And how we might represent it in BPM+

15. Additional Considerations
• dQMs have yet to meet the promise of reduced burden and improved reliability
• Partly this is due to the “Source of Truth” for the specification still being a narrative
• Narrative specs must be interpreted by expert coders to yield a reliable measure calculation
• Expertise in this area is not only evolving, but highly subjective depending on the measure
programs these programmers are producing the specs.
• Standard Concept Maps offer a much better blueprint for both programmers and
quality implementors to understand the various nodes of the measure specification
• As we move quality measure specs closer to a prospective model that supports clinical decision
making (rather than a retrospective (punitive) accountability model, measure authorities must use
templates that align with clinical pathways and clinical reasoning.
® 2021 Object Management Group. All Rights Reserved.
15

16. Trisotech.com
Development of
BPM+ Models

17. Trisotech.com
Stages of BPM+ Model Development
EXPLORING THE COMBINATION OF BPM+ AND HEDIS
Step 1
• Develop subject matter with concept models, standardized terminology and
rules.
Step 2
• Identify essential processes and decisions.
Step 3
• Recognize any inherent patterns.
Step 4
• Build the models.
Step 5
• Analyze performance and refine

18. Trisotech.com
Screening Methods in Average Risk
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

19. Trisotech.com
Knowledge Entity Model (KEM) - Terminology
EXPLORING THE COMBINATION OF BPM+ AND HEDIS
Disambiguated Term
via Medical Coding
Disambiguated Term
via Concept relations
(Fact types)
Not just terms
and definitions

20. Trisotech.com
Knowledge Entity Model (KEM): Rules
EXPLORING THE COMBINATION OF BPM+ AND HEDIS
Disambiguated via
business rules
(Deontic)

21. Trisotech.com
Risk Categories
(based on recommended colonoscopy frequency)
Risk Categories Risk Factors Percent of
Population
Colonoscopy
Frequency
Number of
Process Models
Required
Standard None > 85% Every 10 years 1
Intermediate Family history; 1
or 2
adenomas/SSP
< 10% Every 5 or 7 years 4
High Everything else < 5% Every 0.5 to 3
years
14+
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

22. Trisotech.com
Evolving COL-E to Individual Assessment Level
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

23. Trisotech.com
Process Model for Average Risk Screening
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

24. Trisotech.com
Process Model for Intermediate Risk Screening
EXPLORING THE COMBINATION OF BPM+ AND HEDIS
 Colon cancer 1st degree relative
 High grade dysplasia 1st degree relative
 1 or 2 low-grade adenomas
 1 or 2 sessile serrated polyps

25. Trisotech.com
Process Model for Intermediate Risk Screening
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

26. Trisotech.com
High Risk Categories – Each a Separate CPG
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

27. Trisotech.com
Endpoints from Models That Can Be Analyzed
 Total population
 Total eligible (after exclusions)
 Number not needing screening during time interval
 Number negative on screening
 Number positive on screening without follow-up
 Number with significant findings
 Number of patients who refused screening
 Number of provider failures to screen
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

28. Trisotech.com
Points of Failure (and Points for Intervention)
 Patient refusal.
 Patient has testing done, but it is done beyond the recommended time interval.
 Follow-up of a positive screening result not performed.
 Failure to adjust future risk, based on changing clinical status.
 Assigning to an inappropriate risk level.
 Differences in the sensitivity and specificity of the various screening methods.
 Multiple providers.
 Early-onset colorectal cancer (EOCRC).
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

29. Trisotech.com
We foresee a future where measures will be
• Near real time data rather than retrospective look at logs
Leading indicators rather than Lagging
indicators
• Real time feedback to practitioners
Informing partitioners on best practices
results
• Continuous virtuous cycle
An integral part of a Learning Healthcare
System
EXPLORING THE COMBINATION OF BPM+ AND HEDIS

30. Thank you!