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Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
Cypress:
New Features, Clinical Quality Language
Support, and Burden Reduction
David Czulada
The MITRE Corporation, Lead Software Systems Engineer
March 2018
The MITRE Corporation operates the Centers for Medicare & Medicaid Services (CMS) Alliance to
Modernize Healthcare (CAMH), a federally funded research and development center (FFRDC)
dedicated to strengthening the nation’s health care system. MITRE operates CAMH in partnership
with CMS and the Department of Health and Human Services.
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Agenda
▪ Background
▪ 2015 Edition Certification Overview
– Single-measure Tests: C1, C2, C3
▪ Cypress Features to Reduce Burden
– Pre-certification Testing
– Cypress Application Programming Interface (API)
– Cypress Validation Utility
▪ Cypress V4
– Clinical Quality Language (CQL) Implementation
▪ Open Discussion: Feedback from Vendors and Authorized Testing Laboratories (ATL)
▪ Resources
▪ Other Related Presentations at HIMSS 2018
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Background
Cypress
▪ Cypress is the rigorous and repeatable testing tool for Electronic Health
Records (EHR) and EHR modules in calculating electronic clinical quality
measures (eCQM).
▪ Cypress serves as the official testing tool for the EHR Certification
program supported by the Office of the National Coordinator for Health IT
(ONC).
▪ The Cypress tool is open source and freely available for use or adoption by
the health IT community, including EHR vendors and testing labs.
▪ Cypress v4 will support the eCQMs released in the Annual Update for
2019 Reporting/Performance, which will all be defined using CQL logic.
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Background
How is Cypress made available?
▪ Cypress is developed as Open Source
– Source code is made freely available and may be redistributed and modified.
▪ Cypress releases are distributed as a:
– Virtual Machine
▪ A fully enclosed version which can be installed as-is on an organization’s network
– Amazon Machine Imagine
▪ A virtual machine that can be run on Amazon’s Elastic Compute Cloud
– Demo Server
▪ Publicly available instances of Cypress
• https://cypress.healthit.gov/
• https://cypressvalidator.healthit.gov/
▪ Distribution model allows for EHR’s vendors to install and use Cypress locally within their
organization’s firewalls to prior to certification
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Background
Cypress Software Release Timeline
Cypress 2.6.0 (2.6.1)
2015 Reporting/Performance Period
Cypress 2.7.02016 Reporting/Performance PeriodPrecertification Testing Only
Cypress 3.0.0 (3.0.1, 3.0.2, 3.0.3, 3.1.0)
2017 Reporting/Performance Period, 2015 Edition Certification
Cypress 3.2.0 (3.2.1, 3.2.2, 3.2.3)
2018 Reporting/Performance Period
Cypress 4.0.0 2019 Reporting/Performance Period, CQL
2015 2016 2017 2018
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
Background
Certified Health IT Products and Vendors
Cypress v3
Cypress v3.2.3 released December 2017, supporting both 2014 and 2015 Edition Certification, allowing retirement of Cypress v2.
The Certified Health IT Product List (CHPL) lists all certified Health Information Technology which has been successfully tested and certified by the ONC Health IT Certification program. https://chpl.healthit.gov/#/resources/overview
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Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
2015 Edition Certification Overview
The CMS/ONC eCQM Lifecycle of Testing & Certification
CMS defines eCQMs that EHs & EPs must
meet to demonstrate Meaningful Use (MU) of
Health Information Technology (HIT)
ONC specifies standards and certification criteria
for HIT
CMS, ONC, & MITRE develop technology to
test standards and certification criteria
ONC-ATLs oversee testing events of HIT
ONC-Authorized Certification Bodies
(ONC-ACB) grant certification to HIT that
passes testing
Providers using certified HIT submit eCQMs to
CMS
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2015 Edition Certification Overview
Using Cypress to Reduce Vendor and Provider Burden
CMS defines eCQMs that EHs & EPs must
meet to demonstrate MU of HIT
ONC specifies standards and certification criteria
for HIT
CMS, ONC & MITRE develop technology to
test standards and certification criteria
ONC-ATLs oversee testing events of HIT
ONC-ACBs grant certification to HIT that
passes testing
Providers using certified HIT submit eCQMs to
CMS
Cypress, the Cypress Validation Utility, and the
Cypress test decks are made freely available for pre-
certification testing.
Cypress is developed using agile methodologies to quickly incorporate improvements to
certification workflow.
Cypress Validation Utility provides early access to
CMS Implementation Guides and schematron for pre-submission validation.
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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2015 Edition Certification Overview
2015 EHR Certification Rule
▪ Cypress Certification Criteria – 170.315(c)
– C1 - Record and Export
– C2 - Import and Calculate
– C3 - Report
– C4 - Filter
▪ Goals
– Increased Test Rigor
– Modular/Optional Certification
– Automated Import/Export of Quality Reporting Document Architecture (QRDA) Category I
– eCQM Filtering
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2015 Edition Certification Overview
How Does Cypress Test the 2015 Certification Rule
▪ Given a set of patients and eCQMs, Cypress tests the ability of an EHR to:
Capture the information required to calculate the selected eCQM
QRDA
Export the information required to calculate the selected eCQM
Patient
recordPatient
record
QRDA
Calculate the results of the selected eCQM
Patient
record
Report the calculated result of the selected eCQM
QRDA
1 2
3 4Report eCQM data that has been filtered
QRDA
5
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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2015 Edition Certification Overview
Single-measure Tests: C1, C2, C3
▪ Document Duplication
– Randomization of Name and Demographics
– Patient record split into multiple files
▪ Additional validations based on common submission requirements
▪ Program-specific submission errors displayed as warnings
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Cypress Features to Reduce Burden
Pre-certification Testing
▪ Controlled Testing
– Non-randomized patient data
– Disable de-duplication
– Sample files provided
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Cypress Features to Reduce Burden
Cypress Application Programming Interface (API)
▪ JSON API for performing certification tests
▪ Allows vendors to perform all tests using only the API
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Cypress Features to Reduce Burden
Testing with the Cypress Validation Utility
▪ The Cypress Validation Utility (CVU) allows users to validate their own test patients against:
– HL7 QRDA Cat I and III Implementation Guide and Schematron
– CMS QRDA Cat I and III Implementation Guides
▪ CVU Supports testing to the requirements for the 2016, 2017, and 2018 performance/reporting periods
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Cypress Features to Reduce Burden
Testing with the Cypress Validation Utility (continued)
▪ Record Import and Calculation built into Cypress Validation Utility
– Can be used to debug measure calculation and QRDA generation
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Cypress v4
▪ Release planned for July 2018
– Alpha and Beta releases in Spring 2018
▪ Support for Clinical Quality Language (CQL) and CQL-based measures
– CQL is an HL7 standard. It is part of the effort to harmonize standards used for eCQMs and clinical decision support (CDS).
– CQL replaces the measure logic expressions currently defined in the Quality Data Model (QDM).
– The eCQMs released in the Annual Update for 2019 Reporting/Performance will all be
defined using CQL logic.
▪ No planned certification process changes
▪ Seeking community input on features
– Pre-Certification
– Certification
– Debugging
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Cypress v4
CQL and Cypress
▪ CQL will not directly impact the certification workflow
– Standardized information exchanges (QRDA) insulate systems from change
▪ However, CQL will greatly impact the internal measure calculation for Cypress and vendor systems
Cypress Web Application
Vendor System
Sends Test Data
Sends Test Results
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
QRDACat I
QRDACat I
QRDACat III
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Cypress v4
Transitioning from QDM to CQL in Cypress
Cypress v3
Measure Calculation and
QRDA Cat I export
QRDA Cat I import and Measure Calculation
QDMeCQM
HQMFParser
MeasureData Store
RecordData Store HDS
Model
MeasureEvaluator
QRDAGenerator
QRDACat I
CalculationResult
MeasureData Store
RecordData Store
QRDAParser
MeasureEvaluator
QRDACat I
HDSModel
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved. Changing in Cypress v4
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Cypress v4
Transitioning from QDM to CQL in Cypress
Cypress v4
Measure Calculation and
QRDA Cat I export
QRDA Cat I import and Measure Calculation
CQLeCQM
ELMParser
MeasureData Store
RecordData Store QDM
Model
QRDACat I
CalculationResult
MeasureData Store
RecordData Store QDM
Model
QRDAParser
MeasureEvaluator
QRDACat I
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
MeasureEvaluator
QRDAGenerator
New in Cypress v4
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Open Discussion: Feedback from Vendors and ATLs- Provider attribution
- CQL
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Resources
▪ Cypress Talk List
– project-cypress-talk@googlegroups.com
▪ Cypress Bi-Weekly Tech Talks
– Next session March 13, 2018
– https://attendee.gotowebinar.com/register/8110364277730751489
▪ ONC JIRA
– http://oncprojectracking.healthit.gov/
▪ GitHub
– https://www.github.com/projectcypress/cypress
▪ Website
– https://healthit.gov/cypress
▪ Demo Server
– https://cypressdemo.healthit.gov
– https://cypressvalidator.healthit.gov
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Other Related Presentations at HIMSS 2018
March 7, 2018
2:00 PM – 3:30 PM PT
CMS eCQM Strategy: The Future of eCQMs
March 8, 2018
10:30 AM – 12:00 PM PT
CMS eCQM Strategy: The Future of eCQMs
Sessions will be held in the MITRE Government Relations Room (Zeno 4608)
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Follow up
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
To download a copy of this presentation, visit:
https://health.mitre.org/himss18
Data Interoperability to Reduce Clinician Burden
Follow us on social media: @MITREhealth
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Questions?
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Backup Slides
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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Standards Supported (Cypress and CVU)
CMS Measure
SpecificationQRDA Implementation Guides
eCQM Specifications for Eligible
Professionals May 2017
• CMS Implementation Guide for Quality Reporting Document Architecture Category III,
Implementation Guide for 2018
• HL7 CDA® R2 IG: Quality Reporting Document Architecture Category I (QRDA I);
Release 1, DSTU Release 4
• HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture (QRDA
III), Release 1, STU Release 2.1
eCQM Specifications for Eligible
Hospitals May 2017
• CMS Implementation Guide for Quality Reporting Document Architecture Category I,
Implementation Guide for 2018
• HL7 CDA® R2 IG: Quality Reporting Document Architecture Category I (QRDA I);
Release 1, DSTU Release 4
• HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture (QRDA
III), Release 1, STU Release 2.1
eCQM Specifications for Eligible
Professionals April 2016
• 2017 CMS QRDA III Implementation Guide for Eligible Clinicians Reporting v1
• HL7 CDA® R2 IG: Quality Reporting Document Architecture Category I (QRDA I);
Release 1, DSTU Release 3.1
• HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture (QRDA
III), Release 1, STU Release 2.1
eCQM Specifications for Eligible
Hospitals April 2016
• 2017 CMS QRDA Implementation Guide for Hospital Quality Reporting
• HL7 CDA® R2 IG: Quality Reporting Document Architecture Category I (QRDA I);
Release 1, DSTU Release 3.1
• HL7 CDA® R2 Implementation Guide: Quality Reporting Document Architecture (QRDA
III), Release 1, STU Release 2.1
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Cypress Test Deck
2016 2017 2018
# of Measures 93 71 71
Eligible Clinicians
Patients
81 205 205
Eligible Hospitals
Patients
81 78 78
Minimum
Coverage
80% 95% 95%
Populations Every patient population covered by test deck
Approved for Public Release; Distribution Unlimited. Case Number 18-0578. © 2018, The MITRE Corporation. All Rights Reserved.
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