Overview of the popHealth® open source population health and CQM Reporting system. Discussion about CCDs and QRDAs. Background and history of popHealth® open source software. Includes data flows and screen shots. Presented to Quinnipiac Medical School students.

1. popHealth Overview
9-11-14
Jackie Mulhall, eHealthConnecticut

2. Acronyms
■HL7 - Health Level Seven International
■CDA – Clinical Document Architecture (An architecture
with templates for clinical documents e.g. CCDs)
■CCDA – Consolidated Clinical Document Architecture
(Similar to CDA)
■CCD – Continuity of Care Document (A summary
document for a single patient)
■QRDA – Quality Reporting Document Architecture
■HQMF - Health Quality Measure Format (eMeasure)
■eCQM – Electronic Clinical Quality Measure
■CIPCI – Connecticut Institute for Primary Care
Innovation

3. popHealth Overview
■ popHealth is an Open-Source Clinical Quality Measure database
and reporting engine presented through a web-based interface
■ Centralized repository of clinical data
■ Data is sent from EHRs via nationally recognized standards
– Consolidated Clinical Data Architecture (C-CDA) Architecture Continuity of
Care (CCD)Document
– QRDA (Quality Reporting Data Architecture) Cat 1 or 3 Document
■ Clinical Quality Measures (CQMs) are calculated for providers
and presented through a web-based interface
– Drill down ability to the provider and patient-level data
■ Track trends in quality and health over time
■ Capture CQMs for Meaningful Use Reporting

4. ■ September 2009 - popHealth started as a prototype, proof-of-
concept for a Clinical Quality Measure (CQM) reporting module:
popHealth v0.1
■ September 2010 - popHealth formally supported by ONC as a
MU Stage 1 reference implementation
■ 2011 – popHealth certified
■ January 2012 – v1.4 support for multi-provider with enhanced
functionality released
■ December 2012 - v2.0 support for MU Stage 2 CQMs for EPs
released
■ February 2013 – v2.1.2 with enhanced functionality released
■ June 2014 - v3.0 with upgraded UI, enhanced technical
architecture, support for QRDA import released
■ Spring 2014 v3 certified
■ Fall 2014 – transition to Open Source Community from ONC
History of popHealth

5. ■Entities are using popHealth in a variety of ways
■Active User Community
– Monthly user group meetings
– Includes active users and interested users
■Currently Managed by ONC, Moving to Open Source
Community
– OSEHRA selected to manage Open Source Community
– Process of moving to OSEHRA has begun, will take place
over the next few months
■ EHR Upgrades to 2014 CEHRT impacting popHealth
– QRDA Documents becoming available but issues due to being a
new standard
– CCD v1.1 not always working, additional testing required
Current Status

6. ■popHealth Server
– Ruby (version 2.1.1) on Rails (version 4.1.2 or higher)
■Database
– MongoDB (version 2.0.1) *depends on the host server
■CQM Calculation
– Leverages MapReduce framework in MongoDB
■popHealth Internal Measure Representation
– Uses JSON and JavaScript
Technology Stack

7. ■ popHealth is Open Source prototype software that was
developed by MITRE through a grant from ONC
■ Pros
– No cost to purchase
– Active Open Source Community
– All users benefit from enhancements/contributions back to the Open
Source Community
■ Cons
– “Free like a puppy”
– Documentation is lacking and support is voluntary through Open
Source Community
– Requires skill set that is unusual:
 HL7, QRDA standards  Mongo DB  Ruby on Rails  JSON
Implementation Challenges

8. CQM Reporting for Meaningful Use
■ Northwestern University Medical System
– Feed data from various EHRs (through their data warehouse) to
popHealth for CQM reporting for all entities in health system
■ VA
– MITRE working to connect popHealth to VA’s Corporate Data
Warehouse (CDW) forCQM reporting
■ Wyoming Medicaid
– Database for QRDA Cat 3 data (CQM data) that is entered by
providers
– Ability to rank providers into tiers for payment based on CQM rates
– Future plans for eCQM submission by accepting QRDA Cat 3
documents
Current popHealth Use Cases

9. Current popHealth Use Cases
CQM Reporting for Other Purposes
■ eHealthConnecticut (CT Regional Extension Center)
– FQHCs (CHCs) send CCD data to popHealth database
– Centralized clinical database data from FHQCs
– Use for CQMs and other clinical data reporting needs
– Unexpected outcome is workflow improvement to resolve data
issues
– Used for CQM measurement for CT DPH SHAPE grant
■ IL DPH
– FQHCs (CHCs) send CCD data to popHealth database
– Used for CQMs and popHealth dashboards to drive clinic
improvements in hypertension management

10. Consolidated CDA
■ Output of the effort to create one guide that could be used for
implementation and analysis of documents within the CDA standard
■ The Consolidated CDA solution is a library of reusable CDA
templates
■ Templates can be utilized at multiple levels within a CDA document:
– Level 1: Document Level Templates, such as CCD or Discharge
Summary, can be utilized to define a template for the document as a
whole.
– Level 2: Section Level Templates, such as Allergies or Medications, can
be utilized to define what specific information will be included in each
section.
– Level 3: Entry Level Templates, such as specific Observations or
Procedures, can be utilized to define how the information is encoded
within each section.
■ Consolidated CDA has a document level template for CCD
■ QRDA uses parts of C-CDA framework but is not a template

11. ■ Part of C-CDA Architecture
■ Extensive clinical data
– Allergies: RxNorm*, SNOMED-CT*
– Care Goals, Social History, Medical Equipment: SNOMED-CT*
– Conditions: SNOMED-CT*, ICD-9-CM, ICD-10-CM
– Encounters: CPT
– Immunizations, Medications: RxNorm*, CVX*
– Procedures: CPT, ICD-9-CM, ICD-10-CM, SNOMED-CT*
– Vitals, Results, Assessments: LOINC*, SNOMED-CT*
– Communications: SNOMED-CT
■ * preferred
■ All continuity of care entries are time-stamped
■ Results and vitals must be provided structured with units and
values
Continuity of Care Document

12. QRDA Architecture
■ HL7 QRDA is a standard document format for the exchange of
electronic clinical quality measure (eCQM) data.
■ QRDA reports contain data extracted from electronic health
records (EHRs) and other information technology systems.
QRDA reports are used for the exchange of eCQM data
between systems for a variety of quality measurement and
reporting initiatives.
■ QRDA makes use of CDA templates, which are business rules
for representing clinical data consistently. Many QRDA
templates are reused from the HL7 Consolidated CDA (C-CDA)
standard.
■ Templates defined in the QRDA Category I and III enable
consistent representations of quality reporting data to streamline
implementations and promote interoperability.

13. QRDA Documents
■ A QRDA Category I report is an individual patient quality report.
Each report contains quality data for one patient for one or more
eCQMs, where the data elements in the report are defined by
the particular measure(s) being reported. A QRDA Category I
report contains raw applicable patient data (e.g., the specific
dates of an encounter, the clinical condition) using standardized
coded data (e.g., ICD-9-CM, SNOMED CT®). When pooled and
analyzed, each report contributes the quality data.
■ A QRDA Category III report is a standard structure to use in
reporting aggregate quality measure data. Each report contains
aggregate quality data for one provider for one or more eCQMs.
a necessary to calculate population measure metrics.

14. CCD vs. QRDA Cat I
CCD/CCD 1.1
■ Clinical summary document
for patient history of
procedures, encounters,
allergies, medications, etc.
■ Main body of data contains
different sections for
different clinical data
components e.g. medical
history, procedures,
medications, etc.
■ The data sections are larger
and have more general
templates for procedures,
encounters, etc.
QRDA Cat 1
■ QRDA reports are
generated based on a CQM
request. The data contained
in the QRDA file is specific
to certain CQMs.
■ Main body of data is divided
into three segments: -
reporting measure(s) -
reporting parameters (rep
period) - patient data
■ Templates are more specific
and thorough, with smaller
general sub groups.
■ Newer standard – less
tested

15. CCD and QRDA Comparison
Header (template IDs)
Author, Custodian,
Informant, etc
Patient Information
Provider Information
Structured sections
- Procedures
- Medications
- Problems/Allergies
- Encounters
- Results
Etc.
Header (template IDs)
Author, Custodian,
Legal Authenticator, etc.
Patient Information
Provider Information
Structured sections:
- Procedures
- Medications
- Problems
- Allergies
- Encounters
- Results
Etc.
CCD (CDA) CCD 1.1 (CCDA)
Header (template IDs)
Author, Custodian,
Legal Authenticator, etc
Patient Information
Provider Information
Three 'components'
- Measures
- Reporting parameters
- Patient Data
(aggregate of entries
for various sections)
QRDA Cat 1

16. Data Flow for Population Health
Management
Population Health
Reporting Tool
Providers
Collaborate on
Patient Health
Electronic Medical
Records Database for
Practice
Clinicians
Enter Patient
Data into EMR
Secure Transfer of
Patient Data

17. popHealth Today for FQHCs in CT
CCD Data
Aggregate Data
popHealth Database
FQHC 1 Data
FQHC 2 Data
FQHC 3 Data
FQHC 4 Data
popHealth
Reporting Tool
 Role-based web access
 MU Stage 1 and 2
Reports
 Overall measures with
ability to drill down
 HIPAA compliant
 Aggregated population
health reports
FQHC 1
EHR
CCD DataFQHC 2
EHR
CCD DataFQHC 3
EHR
CCD DataFQHC 4
EHR

18. CCD via Batch
Aggregate Data
popHealth Database
Provider Data
Hospital Data
FQHC Data
Other Data
popHealth
Reporting Tool
 Provider CQMs
 DPH Reporting
 DSS/Medicaid
 Cat 3 Docs
 Comparison to cohort
 Grant CQMs
 PCMH
 ACO
EHR 1
CCD via DirectEHR 2
QRDA Cat 1EHR 3
QRDA via DirectEHR 4
popHealth Next Generation in CT

19. Main Dashboard

20. Individual Provider Statistics

21. Individual Provider Dashboard

22. Measure Criteria

23. List of Applicable Patients for a Measure

24. Patient Summary

25. Contact Information
Jackie Mulhall, Director
eHealthConnecticut
c/o SMC Partners LLC
Hartford Square North
10 Columbus Boulevard, 9th Floor
Hartford, CT 06106
203-695-1030
jmulhall@smcpartners.com
jmulhall@ehealthconnecticut.org