1. Electronic Submission of Medical Documentation (esMD) Face to Face Informational Session esMD Requirements, Priorities and Potential Workgroups – 2:00pm – 3:00pm October 18, 2011

2. Agenda Charter Review esMD Initiative Priorities esMD Requirements for the Initiative Public Participation/Stakeholder Outreach Workgroup Formation 2

3. esMD DRAFT Charter 3 Challenge Healthcare payers request and receive medical documents from providers in order to perform administrative functions such as identify improper payments. Currently, Medicare Review Contractors request approximately 2 million medical documents per year by sending a paper request letter to the healthcare providers. These providers usually have only 2 options for submitting the requested records: 1) mail paper or 2) send a fax. Scope Statement The Electronic Submission of Medical Documentation (esMD) pilot intends to give providers a new mechanism for submitting medical documentation to Medicare Review Contractors. The S&I Framework esMD Initiative will focus on Interoperability and Nationwide Standards needed to support esMD requirements. Target Outcomes Identify gaps in CDA Structured Document to support Progress Notes and Orders, and other documents as required for Medicare Review and similar activities Leverage work of Provider Directories, Certificate Interoperability, Transitions of Care, and Data Segmentation Initiatives as they apply to esMD Define technical issues and relevant standards associated with Author Level Digital Signatures Identify and address business process and infrastructure issues associated with Author Level Digital Signatures Identify and forward policy issues, if any, to appropriate policy bodies Develop a list of recommended Standards (potentially including new work by SDOs) and Operating Rules, if appropriate, to be incorporated in a reference Implementation for esMD Dependencies CMS & esMD community members to participate in S&I Initiatives that are relevant to the outcomes of esMD NwHIN support for secure transport and other infrastructure Timeline12 months (notional) Standards ASC X12n Administrative Transactions, HL7 CDA, security and digital certificate standards HL7 Records Management-Evidentiary Support (RM-ES) EHR system profile and guidelines Other Standards as appropriate Stakeholders Providers, Provider Organizations EHR Vendors and Vendor Associations (e.g. AHIMA, HIMSS) State HIEs, HIE Vendors HIT Vendors, HIHs, Claims Clearinghouse, HIOs, ROI Vendors Medicare, Medicaid, and Commercial Payers SDOs CAQH CORE

4. esMD Priorities 4 esMD Priority I Submission of Structured Medical Documents Author level Digital Signatures esMD Priority II Request for Medical Records Provider Registration (Trading Partner Agreements) Additional Administrative Transactions Eligibility Verification Claim Status Inquiries Prior Authorization Appeals Claim Submissions Review Results Letters Demand Letters Core Outcomes Identify gaps in CDA Structured Document to support Progress Notes and Orders, and other documents as required for Medicare Review and similar activities Leverage work of Provider Directories, Certificate Discovery, Transitions of Care, and Data Segmentation Initiatives as they apply to esMD Define technical issues and relevant standards associated with Author Level Digital Signatures Identify and address business process and infrastructure issues associated with Author Level Digital Signatures Identify and forward policy issues, if any, to appropriate policy bodies Develop a list of recommended Standards, potentially including new work by SDOs, to be incorporated in a reference Implementation Guide for esMD

5. Requirements: Signatures on Medical Record Documents To support electronic submissions, esMD needs a way to replace wet signatures. Wet Signatures- The Physician signs in ink to authorize the validity of the document’s content; such as, progress notes and orders. 5 To be covered by Medicare, most items and services require the signature of a physician in the patient medical record. Digital Signature must demonstrate that the Provider validated that content within the document is accurate Use of Digital Signature must ensure authenticity of the provider or organization sending the document to CMS is accurate In addition, the transaction must when the document was altered and by whom. (i.e. the electronic equivalent of a hand written strikethrough, initials and date) CMS believes a level 3 digital certificate from a federal bridge CA is the best form of digital signature.

6. Requirements: Provider Name Service CMS required by law to use NPI number to identify providers. Any providers name service solution must contain a reference to the NPI To support electronic submissions, esMD needs to leverage Provider Directories to search for providers To use esMD Phase 2, CMS plans to create a Trading Partner Transaction that a provider would submit through their HIH to CMS. This transaction will require the provider to list their Level 3 Digital Certificate from a Federal Bridge CA. Lesser form of a signature will not meet FISMA requirements. Determine what data elements CMS should collect when a provider registers for esMD Phase 2 Determine how CMS should verify the validity of the digital certificates periodically. Determine the way an HIH should store provider information. 6

7. Requirements: Structured Content esMD is currently accepting only Unstructured (pdf) Documentation from providers CMS wants to expand esMD to accept Structured Content CMS does not need Summary Documents as they do not meet the coverage requirements CMS needs the actual orders, progress notes, discharge summaries and potentially every other part of a medical record. CMS wants to use existing standards; but remember, there must be a field for the digital certificate signature in each standard. Most standards today lack this field. Existing Standards will be discussed in Walter Suarez’s presentation 7

8. Public Participation As an S&I Initiative, esMD is requesting public participation and input to identify and assess existing standards and define requirements Targeted Participants: HIHs HIT/EHR Vendors and Vendor Associations State HIEs, HIE Vendors Claims Clearinghouse, HIOs, ROI Vendors Medicare, Medicaid, and Commercial Payers Providers, Provider Organizations SDOs CAQH CORE Others with Expertise/Interest in Digital Signatures, Provider Directories, or Claims Attachments 8

9. Stakeholder Outreach Which Groups are missing? How can we reach out to the targeted participants? Targeted Participants: HIHs HIT/EHR Vendors and Vendor Associations State HIEs, HIE Vendors Claims Clearinghouse, HIOs, ROI Vendors Medicare, Medicaid, and Commercial Payers Providers, Provider Organizations SDOs CAQH CORE Others with Expertise/Interest in Digital Signatures, Provider Directories, or Claims Attachments 9

10. Workgroup Formation Potential Workgroups for esMD: Requirements: Signatures on Medical Record Documents Provider Name Service Structured Content Policy Technical 10