Standards Harmonization

Clinical Decision Support (CDS) & Electronic Clinical Quality Measures (eCQMs)

Clinical Decision Support (CDS) targets improvement during care delivery and electronic clinical quality measures (eCQMs) targets the assessment of that care after it has been rendered, and therefore standards development for these artifacts are closely related. They share many common data elements, terminology, technical specifications, and requirements, all of which support health care quality improvement. Initially developed separately, the standards for the electronic representation of CDS and eCQMs used different data models and computable expression languages. The use of different standards limited re-use of shared machine-readable logic between eCQMs and CDS specifications, and it created a burden for implementers to align the different artifacts.

To harmonize efforts for quality management, eCQMs specified for use in 2019, Health Level Seven International® (HL7®) replaced the Quality Data Model (QDM) expression logic with Clinical Quality Language (CQL). CQL is an authoring language standard that provides the ability to express clinical logic that is both human-readable and machine-readable via a structured representation. CDS guideline authors can also use CQL which improves harmonization between CDS and eCQMs.

Clinical Quality Framework (CQF) Initiative Harmonization

The CQF Initiative is an HL7 project led by the CDS and Clinical Quality Information work groups to identify, develop, and harmonize standards that promote integration and reuse of technical specifications between CDS and eCQMs.

Harmonization of CDS and eCQM standards improves the ease of implementation and makes it easier to integrate and facilitate health IT-enabled clinical quality improvement since the functions of CDS and eCQMs are complementary. Fast Healthcare Interoperability Resources® (FHIR®), and CQL (both HL7 standards) provide a common foundation for representing CDS and eCQMs to

• suggest care to clinicians and care teams when there are opportunities to improve care quality
• assist with clinical workflow by gathering pertinent information before and during encounters for medication management,  pre-certification, etc.
• measure if appropriate care was provided

Common Shared Standards

The figure shows eCQM-specific standards and CDS-specific standards coming together with common standards.

Current Shared Standards for Quality Management​

The figure (from FHIR Clinical Guidelines) depicts the Clinical Quality Lifecycle with situated standards to address each respective phase. The CPG-IG addresses a critical gap in explicitly formalizing the guideline recommendations and other guideline features as computer-interpretable for downstream consumption and closing the feedback and feedforward loop(s).

The goal is to focus on a Learning Health System such that surveillance and feedback generates new evidence to update the guideline.

• EBM: Evidence Based Medicine on FHIR defines resources, terminology, and guidance for the representation of scientific knowledge, including support for citations, research study design, research results, assessments and aggregation of data, recommendations, and compositions of combinations of these types of knowledge.
• CPG: Clinical Practice Guidelines implementation guide supports the development of standards-based computable representations of the content of clinical care guidelines to support downstream capabilities such as cognitive and decision support, quality measures, case reporting, and documentation templates that direct clinical documentation in support of determining guideline compliance.
• CDS Hooks: CDS Hooks version 2.0 specification for clinical decision support (CDS) outlines services to trigger clinical decision support, to prefetch required data, to analyze relevance to the clinical situation, provide recommendations and suggestions directly to system users (generally clinicians), capture reasons for overrides, and provide feedback to the CDS service.
• CQL: Clinical Quality Language is a high-level, domain-specific language focused on clinical quality and targeted at measure and decision support artifact authors. CQL is the expression language used to represent the logic that represents a measure, a CDS Hooks data request, measure report, practice guideline, case reporting, etc.
• QI-Core: Quality Improvement (QI) Core implementation guide defines a set of profiles that support creation of interoperable eCQMs and CDS artifacts.
• eCR: Electronic Case Reporting implementation guide provides mechanisms for triggering requests to determine if patients presenting with new clinical conditions or findings require reporting to public health.
• QM IG: Quality Measure implementation guide provides criteria tailored for expressing quality measures including requirements for data retrieval and analysis.
• DEQM: Data Exchange for Quality Measures implementation guide addresses reporting data required for a set of quality measures.

Additional implementation guides add more general information about sharing data for aggregate analysis across the multiple guides already identified. These two guides are:

• Canonical Resource Management Infrastructure (CRMI) implementation guide defines comprehensive guidance to facilitate the lifecycle management of FHIR knowledge artifacts such as value sets, profiles, libraries, rules, and measures used in multiple quality improvement and reporting domains.
• Using CQL with FHIR implementation guide provides guidance for using CQL to express data retrieval requirements and to analyze data received across use cases previously defined in domain-specific FHIR IGs (e.g., Quality Measures, Clinical Guidelines, etc.).