Encounter to Health Center Link

[anthonygalba]

How does HRSA expect to link a specific encounter resource back to a Health Center where it happened? Encounter can have references to location and organization, but neither of those resources have any direct link back to the Health Center. It feels like one of those should have a field for UEI or grant number, so they can be associated with the Health Center.

For example, the eCQMs can include data elements that did not happen in the Health Center. If a measure includes a diagnosis from an encounter outside the Health Center, and we send a resource for the encounter that diagnosis came from, how would HRSA know whether or not to use that encounter resource when validating UDS+ measure outcomes?

[nbashyam]

How would diagnosis from an outside encounter end up within the EHR ? (Is it through external documents or data received ?) A Follow on question: Do all encounters happening at the health center point back to the same Organization resource ? I am hoping the answer is yes. We could look at adding the UEI # for the HC.

[nbashyam]

Also if one HC becomes part of another HC, how would it work in that case ?

For eCQM calculation, would the diagnosis captured elsewhere be invalid to consider ? we can ask this to the eCQM team and the HRSA team also

[anthonygalba]

I can think of a couple scenarios. 1 - If a health center is also doing MIPS, they can import quality measure data using a QRDA I import. This is standard practice among organizations with multiple EHRs, or those transitioning EHRs during the reporting period. At least in Epic's solution, we will also count imported QRDA I data when calculating quality measures for UDS. 2 - There may be multiple FQHCs sharing a single EHR instance, or sharing with non-FQHC organizations. In Epic, we call this our "Connect" program. The FQHC could see a patient that was also seen by another organization on the same instance of Epic. So the patient may meet the denominator when seen in the FQHC, but the action from the numerator/exclusion could have happened on an encounter outside the FQHC. A good example of this is the hospice exclusions from several of the quality measures. That will exclude a patient if they had an inpatient encounter. That encounter is not likely to happen in a FQHC, as most of those are Ambulatory-only, however we'll need to send the encounter resource for that inpatient stay as part of our UDS+ data. 3 - External data is commonly pulled into the chart through networks like TEFCA, Care Everywhere, etc. It will only be more common going forward to have more and more outside data in the EHR as physicians are looking to get the full picture of their patient's care.

Our general approach to quality measure calculation is to use all data available, unless the manual/measure logic explicitly says otherwise (and I know it does require certain things to happen in the FQHC).

We are not currently sending an organization on our encounter resources, because we weren't clear on what level of the organization that was mean to represent. I think it would make sense to clarify that in the IG. I agree that having the encounter.serviceProvider Organization represent the FQHC, and adding a UEI element to Organization would be a good solution for that.

[nbashyam]

This is a very tricky issue. We will discuss further with eCQM teams supporting CMS and also HRSA on whether external data should or should not be considered for eCQM calculations.

Some of our thoughts on the other aspects are as follows: In the Encounter profile, specify more details on the ServiceProvider data element to be the organization representing the FQHC's, which should convey the right information for encounters performed by the FQHC. For external data being imported, would a Provenance resource not get created which has the details of the origination of the data. Since Provenance should contain the organization where the data originated (source), hopefully it will get created and populatd appropriately and may be required to be sent in the future. Also the UEI is just a business identifier that can go into the identifier field. We can add a slice for Organization to specify how to add a UEI number to the Organization profile to help implementers.

[anthonygalba]

I would caution against putting any type of limit on counting external data during eCQM calculations. That is not how any of the other programs using eCQMs operate, plus it would fundamentally violate the spirit of a lot of the measures. For example, patients with an allergy to statin are excluded from the statin therapy measure. They should be excluded regardless of where the allergy was documented as it wouldn't make clinical sense to prescribe statin knowing they are allergic. Same goes for the hospice exclusions used in a lot of measures - those are virtually guaranteed to be external, as I doubt any FQHCs have hospice facilities.