Monday, January 31, 2011

PQRI XML Submissions Required for Certification

One of the challenging aspects of Complete EHR Certification is the PQRI XML needed for submission of quality measures to CMS.

There are 15 required hospital quality measures but the 2 Emergency Department measures are stratified for reporting and must be presented in 3 different ways, so a total of 19 PQRI XML files need to be generated for Complete EHR Certification of hospital systems.

Each of the files uses identical XML.  The only parameters that change are

pqri-measure-number which is set to the NQF measure being submitted such as NQF 0435 (see the graphic above for the list of NQF hospital measure names)

eligible-instances which is the number of patients who meet eligibility requirements to be measured for the time period being submitted

meets-performance-instances which is the numerator of the measure i.e. those patients who had the appropriate treatment or outcome

performance-exclusion-instances which is the number of patients removed from eligible-instances for specific clinical reasons.  The denominator of the measures is always (eligible-instances minus performance-exclusion-instances)

performance-not-met-instances which is the number of eligible patients who did not have the appropriate treatment or outcome.  It can be calculated as (eligible-instances minus meets-performance-instances minus performance-exclusion-instances)

reporting-rate which is a multiplier i.e. for a percentage the reporting rate is 100

performance-rate which is the calculated performance level and is equal to meets-performance-instances/(eligible-instances minus performance-exclusion-instances)*reporting-rate

Let's do a real example so this becomes clear.   If we want to create PQRI XML for NQF Measure 0435, which is "Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge", we need to go the HITSP TN906 document and gather the definition from pages 48-52

In this case,

eligible-instances is defined as "Patients admitted to and discharged from the hospital for inpatient acute care with a diagnosis of ischemic stroke (ICD9 433.00-438.99)"

meets-performance-instances is defined as "eligible-instances patients prescribed anti-thrombotic therapy(page 355-358 of HITSP specification) at hospital discharge"

performance-exclusion-instances is defined as
"Patients with age < 18
Patients with length of stay >120 days
Patients with comfort measures only documented
Patients enrolled in clinical trial
Patients admitted for elective carotid intervention
Patients discharged/transferred to another hospital for inpatient care
Patients who left against medical advice or discontinued care
Patients who expired
Patients discharged/transferred to a federal healthcare facility
Patients discharged/transferred to hospice
Patients with a documented reason for not prescribing anti-thrombotic therapy at discharge"

Suppose that 110 patients are eligible, 80 received anti-thrombotic therapy, and 10 were excluded.

performance-not-met-instances would be (eligible-instances minus meets-performance-instances minus performance-exclusion-instances) or  110-80-10=20

performance-rate would be meets-performance-instances/(eligible-instances minus performance-exclusion-instances)*reporting-rate or 80/(110-10)*100 = 80%

The PQRI XML generated would be

<submission xmlns:xsi="" xmlns:noNamespaceSchemaLocation="Registry_Payment.xsd" type="PQRI-REGISTRY" option="TEST" version="1.0">
    <create-by>Your Organization Name Goes Here</create-by>
    <registry-name>Your Application Name Goes Here</registry-name>
  <measure-group ID="X">
        <pqri-measure-number>NQF 0435</pqri-measure-number>

For the ED measures, which capture time measurement rather than patient counts, you need to create 3 files for each measure, stratified by

1. All patients that were admitted via the ED, excluding the ICD-9 range for PSYCH (ICD9 290-319) and Observation Patients.

2. All observation patients that were admitted via the ED, excluding the ICD-9 range for PSYCH (ICD9 290-319)

3. All psychiatric patients that were admitted via the ED, including only the ICD-9 range for PSYCH (ICD9 290-319)

eligible-instances is recorded in the same way as other measures.

meets-performance-instances is used to record the median time data.

performance-exclusion-instances, performance-not-met-instances, reporting-rate, and performance-rate are set to zero.

Hopefully this explanation makes it easier for hospitals and vendors to create the necessary PQRI XML for certification.


Anonymous said...

Hi -

First, thanks for the great post. This is very helpful.

Couple of quick questions for you:

1) The PQRI 2009 XML spec notes that the "pqri-measure-number" tag is defined as numeric with maximum of 3 characters. During your review, did your example non-numeric value "NQF 0435" validate?

2) The spec notes that dates are to be formatted as "MM-DD-YYYY" - did you receive any feedback on using dates outside of that format?

3) I noted you're not using the "measure-group-stat" tag as defined in the PQRI 2009 XML spec. Was there any mention of the necessity of that tag for Meaningful Use?

4) How did you output the 3 ED sub-measures?

Sorry for the questions - mainly curious to know how much scrutiny we'll be under when presenting the XML files.

Anonymous said...

Thanks for this post - we are struggling to figure this out.

I would also benefit from some more information on how to output the ED measures. Do we report the median value directly in ?

I thought there were only 2 ways to report ED info - the Observation patients method and the All ED Patients method. What's the 3rd method?

Thanks so much.

John Halamka said...

I've added the ED measure detail to the post itself. We did not receive any validation questions about pqri-measure-number,date formats, or measure-group-stat. Certainly it would not be a problem to output "435" instead of "NQF 0435" and change dates to mm-dd-yyyy.

Anonymous said...

Thanks for adding the ED measures detail to the post.
My confusion lies in CMS FAQ answer 10126, here:

This clarification from 12/1 appears to change the stratification from 3 groups to 2.

What do you think?

John Halamka said...

The CMS clarification is unrelated to the stratification. The question many have asked is around Meaningful Use metrics in general - should all ED patients or just admitted ED patients be including in computations like CPOE use, problem list documentation etc. PQRI computations are defined in the HITSP 906N document, not the CMS clarification.

Anonymous said...

Thanks for this post. How did you report ED numbers. PQRI only supports discrete measure but ED measures are continuous measures.

Ferdinand Velasco said...

Dr. Halamka,
Thanks for sharing this helpful information.
As you know, in 2012, CMS is expected to require submission of CQM data electronically. Do you know when we can expect additional details about this? Some specific information that would be helpful are: 1. Will CMS be ready to accept CQMs electronically on 10/1/2011? 2. Will PQRI XML in fact be the format for electronic submission of CQMs? 3. What wil be the frequency of data submission? For those of us planning to attest in FY11, we are concerned with the limited and shrinking time available to get ready for Year 2 of the EHR incentive program.

Anonymous said...

The HQM module in NextGen will do this

Anonymous said...

Dr Halamka

As always, Thank you for all the information. Your input has been of more help then CCHIT.

Question 1: Are we required to do calculation (internally or 3rd party) for CQM or can we create sample PQRI files and send it to CCHIT.

Question 2: On Security, When we spoke with CCHIT, They told us to download a encryption program and copy and paste data from the database to the encryption program and show that it will encrypt the data. Is this what you did?

Any help on above questions will be great.

Anonymous said...

First of all thanks a lot for the great post!!!
And sorry for asking a silly question.
1. Can you please let me know some registries where we can submit these XML files?

Bambi Rose, CCHIT Testing and Certification Director said...

We want to set the facts straight on an earlier misstatement made by Anonymous that is in conflict with both CCHIT and NIST procedures with regard to use and testing of 3rd party encryption tools.

CCHIT requires that EHR systems seeking ONC-ATCB 2011/2012 certification demonstrate the capability to encrypt and decrypt health information in accordance with the NIST Test Procedures, v1.1, for §170.302(u) and §170.302(v) and the standards in the Final Rule specified in §170.210(a)(1) and §170.210(a)(2) respectively. EHR systems are allowed to utilize 3rd party tools and solutions to comply with these requirements. However, such 3rd party solutions must be fully integrated within the EHR system and CCHIT must determine that the EHR system itself possesses the capability to encrypt and decrypt data. CCHIT does not test 3rd party solutions independent of the system seeking certification. Using a 3rd party encryption tool that is not integrated within the EHR being tested would not be acceptable to demonstrate compliance with the NIST Test Procedures and criteria for §170.302(u) and §170.302(v).

Please note that CCHIT has made a number of resources such as Guidance documents and Frequently Asked Questions (FAQ’s) accessible to those applying for certification and those documents clearly reflect the requirements outlined above. We invite you to visit CCHIT’s website for more information:

Tony O said...

Do you know where the PQRI XML specifications are defined? I am having an aweful time trying to find them. The CMS site seems to have broken links. A link would be incredibly useful. Thank you in advance.

John Halamka said...

Check out my followup blog on PQRI Testing

I recommend contacting the Iowa Foundation for Medical Care

Anonymous said...

Hello John,

In the HITSP document, there are lot of places where SNOMED is used as a reference. For e.g. to determine the following , HITSP document has given SNOMED to identify Carotid Intervention

Patients admitted for Elective Carotid Intervention

We are currently using CPT and ICD-9-CM codes for the procedures. Two questions which come up:

1) How to get the CPT/ICD-9-CM codes corresponding to the SNOMEDs mentioned in the document
2) Is the certification particular about the correctness of the CPT codes used, as HITSP document doesn't state it clearly sometimes?

Much thanks...

Anonymous said...

Hello John,

Excellent blog, I appreciate it a lot. I had the same question as the previous person who posted on June 1 about SNOMED and ICD/CPT mapping. Any idea if we are required to map or is there some PQRI documentation that provides the appropriate ICD/CPT codes to use?
Thanks in advance!

Anonymous said...

Hi John,

I would also like to thank you for such a informative post of Clinical Quality Measure XML Submissions.

In submission, I am wondering how does one know what Measure Type CQM falls under? Does it vary? Would it be MFK, ORU, OBX, or something else?

Please kindly advice...Thank you very much!