Quality Reporting Document Architecture
Quality Reporting Document Architecture (QRDA) is an HL7 Clinical Document Architecture designed for transmission of electronic clinical quality measures (eCQM).[1]
History
Demonstration of healthcare quality has become a priority in the transition from fee-for-service to value-based care in the United States. Historically, quality measurements were tabulated manually from paper charts and unstructured data within EHRs. One of the rationale for implementation of EHRs in healthcare was to create an automated method for reporting key quality metrics. Such is evident in the Electronic Health Record Incentive Program (Meaningful Use). Increasingly, regulatory and accreditation agencies such as Centers for Medicare and Medicaid Services and the Joint Commission have required hospitals and providers to submit quality data in electronic format captured in structured fields of the EHR, known as eCQM. Electronic Clinical Quality Measures (eCQM) help track a variety of measures including patient engagement, patient safety, care coordination, population health, healthcare resource utilization, and clinical process.[2] The information is exported in a file format known as Quality Report Data Architecture (QRDA). The Office of the National Coordinator for Health Information Technology adopted QRDA as the standard to support individual patients and aggregate patient data submissions for Meaningful Use 2.
Since passage of the 21st Century Cures Act, a strong emphasis on interoperability has been issued by CMS. There is ongoing consideration for adoption of HL7's FHIR standard by CMS. The Data Exchange for Quality Measures is a framework (DEQM) that was created for exchanging quality information and reporting. The goal of the DEQM framework is to enable automated collection and transmission of data. QRDA was used in development of the DEQM framework.[3]
Technical
Since QRDA is an instance of HL7 CDA, its templates are adopted from CDA and coded in XML Format. There are two categories of QRDA. QRDA Category I report is designed for individual patient quality reporting. QRDA Category III report is designed for aggregate quality measures for a patient population. QRDA Category I data contain specific measure(s) and raw patient data in controlled vocabulary such as ICD-10 and SNOWMED CT. Importantly, PHI are removed from QRDA III documents.
QRDA I report derives ERH data based on the standard Quality Data Model, which is the electronic representation of quality measures. [4] The Quality Data Model describes specific patient data elements in context of the clinical information system. The Quality Data Model is implemented in both HQMF (Health Quality Measures Format) and QRDA in HL7. HQMF is an HLF7 standard for representing health quality measure in an XML document format. The HQMF allows the user to query quality measurement data, while the QRDA allows the user to submit the data. [5] For each Quality Data Model datatype, there is a direct linkage between QRDA I template to a corresponding HQMF template. [6]
To create a QRDA I instance: Quality Data Elements are identified, matching data from an individual patient's chart is found, then data is filtered to find specific desired measures. [7]
Data from QRDA Category I can be transferred to an intermediary analytical engine to calculate a corresponding QRDA Category III document.
QRDA I and III instance contains: Document header that describes relevant organization information, Reporting parameters section such as the measurement period, and contains a Measures section describing results of the metric under discussion.
Implementation and Submission
CMS published implementation guides annually to support health organizations and clinicians in quality reporting activities. By following the specific requirements and constraints, a successful submission to CMS may ensure compliance. [8]
Clinicians and providers will submit QRDA III data to CMS for Primary Care First and Merit-Based Incentive Payment System (MIPS). Primary Care First is a alternative payment model offered by Medicare Innovation Center. MIPS is another CMS Quality Payment Program aimed at eligible clinicians who participate in Medicare Part B. Both of these programs heavily utilize quality metrics to determine incentive payments for participating clinicians.
Hospitals will Submit QRDA I data to CMS for Hospital Inpatient Quality Reporting Program, Hospital Outpatient Quality Reporting Program, and MIPS for Critical Access Hospitals (CAH). Reimbursement rates and reputation (hospital compare website) are influenced by the quality metrics submitted.
The Joint Commission has an application known as eHCD (eMeasure Hospital Clinical Data) that accepts eCQM data via QRDA-I file format for hospital reporting. Similar to CMS, the Joint Commission also published implementation guide and Schematron to facilitate compliance. [9]
References
1. CMS. (2014, Jan 15). Quality Reporting Document Architecture. Centers for Medicare & Medicaid Services. https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/guide_qrda_2014ecqm.pdf
2. Centers for Medicare & Medicaid Services. (2022, September 16). Electronic Clinical Quality Measures Basics. https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/clinicalqualitymeasures
3, 6. Electronic Clinical Quality Measures (eCQMs) Specification, Testing, Standards, Tools, and Community. (2022, May). CMS. https://mmshub.cms.gov/sites/default/files/eCQM-Specifications-Testing-Standards-Tools-Community.pdf
4. HealthIT. (2022, June 30). QDM - Quality Data Model | eCQI Resource Center. eCQI Resource Center. Retrieved October 16, 2022, from https://ecqi.healthit.gov/qdm
5, 7. Sethi, K. (2015, August 12). Introduction to QRDA. HealthIT. https://ecqi.healthit.gov/system/files/qrda_basics_08_12_2015_a_508.pdf
8. Centers for Medicare & Medicaid Services. (2022, May 26). CMS Implementation Guide for Quality Reporting Document Architecture Category I Hospital Quality Reporting. https://ecqi.healthit.gov/sites/default/files/QRDA-HQR-2023-CMS-IG-v1.508.pdf
9. Biglari, M. (2016, October 25). Pioneers in Quality™ The Joint Commission eCQM Data Submission. https://www.jointcommission.org/-/media/tjc/documents/accred-and-cert/hap/pioneers-in-quallity/pioneers-_ecqm_data_submission-technicalpdf.pd
Author
Submitted by Jay Shi
