1. Supporting Meaningful Use Stage 2 Transition of Care Requirements

2. Meaningful Use Stage 2 (MU2)
CEHRT & MU Relationship
Meaningful Use Stage 2 (MU2)
CMS: Medicare and Medicaid EHR Incentive Programs Stage 2
outlines incentive payments (+$$$) for early adoption
outlines payment adjustments(-$$$) for late adoption/non-compliance
Reference: CMS Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Stage 2 Final Rule 495.6
ONC: Standards, Implementation Specifications & Certification Criteria (SI&CC) 2014 Edition
Specifies the data and standards requirements for certified electronic health record (EHR) technology (CEHRT) needed to achieve “meaningful use”
Reference: ONC Health Information Technology : Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology (b)(1)&(2)

3. MU2 Electronic Exchange Requirements
MU2 focuses on actual use cases of electronic information exchange
Measure #1 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals.
Measure #2 requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals
Measure #3 requires at least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR

4. Meaningful Use Stage 2 (MU2) – Care Coordination
CEHRT & MU Relationship
Care Coordination / Transitions
Meaningful Use Stage 2 (MU2) – Care Coordination
CMS: Medicare and Medicaid EHR Incentive Programs Stage 2
Measure #2 : Provide an electronic ‘‘summary of care record for more than 10 percent of such transitions and referrals” using one of the accepted transport mechanisms specified in the rule.
Reference: CMS Medicare and Medicaid Programs; Electronic Health Record Incentive Program – Stage 2 Final Rule 495.6
ONC: Standards, Implementation Specifications & Certification Criteria (SI&CC) 2014 Edition
Electronically receive and incorporate a transition of care/referral summary Electronically create and transmit a transition of care/referral summary
Reference: ONC Health Information Technology : Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent Certification Program for Health Information Technology (b)(1)&(2)

5. CEHRT Criterion 170.314(b)(2) – Transition of Care (Send)
In order for a certification criterion to be met, all specific capabilities expressed as part of it need to be demonstrated.
For example, in 45 CFR (b)(2) there are two:
Create CCDA with requisite data specified for MU
Enable a user to electronically transmit CCDA in accordance with:
Direct (required)
Direct +XDR/XDM (optional, not alternative)
SOAP + XDR/XDM (optional, not alternative)
Thus, whatever EHR technology is presented for certification must demonstrate compliance with both (i) and (ii) under (b)(2) to meet the certification criterion.
This also means that there’s no certification for ‘transport only’ as part of MUS2 / CEHRT 2014 Edition

6. Valid Certification Scenarios for EHR Technology (Sending with Direct)
45 CFR (b)(2)
Create CCDA with requisite data specified for MU
Enable a user to electronically transmit ToC in accordance with Direct (or Direct +XDR/XDM; or SOAP + XDR/XDM)
Whatever EHR technology is presented for certification must demonstrate compliance with both (i) and (ii) under (b)(2) to meet the certification criterion.
Scenario 1
EHR generates CCDA
EHR performs as STA and sends Direct msg
Complete EHR or EHR Module certification issued.
STA/HISP function integrated into EHRs; no separate certification testing for HISP.
Scenario 2
EHR sends “data” to HISP
HISP generates CCDA
HISP performs as STA and sends Direct msg
EHR Module certification issued
HISP certified independently as EHR Module.
Scenario 3
EHR sends CCDA to HISP
Complete EHR or EHR Module certification issued
HISP certified as “relied upon software” with the EHR. Certification given to the pair, not EHR and HISP separately.
Provider A
Provider B
Direct (SMTP + S/MIME)
HISP
Provider A
Provider B
Any Edge
Protocol
Direct (SMTP + S/MIME)
Provider A
EHR Affiliated HISP
Provider B
Any Edge
Protocol
Direct (SMTP + S/MIME)
What gets presented for certification

7. MU Transition of Care
Measure #2: The eligible provider, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either:
(a) electronically transmitted using CEHRT to a recipient, or
(b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network.

8. Approach #1 -- Send with CEHRT Required Transport: Using Direct
Scenario 1
EHR generates CCDA
EHR performs as STA and sends Direct msg
Complete EHR or EHR Module certification issued.
STA/HISP function integrated into EHRs; no separate certification testing for HISP.
Scenario 2
EHR sends “data” to HISP
HISP generates CCDA
HISP performs as STA and sends Direct msg
EHR Module certification issued
HISP certified independently as EHR Module.
Scenario 3
EHR sends CCDA to HISP
Complete EHR or EHR Module certification issued
HISP certified as “relied upon software” with the EHR. Certification given to the pair, not EHR and HISP separately.
Provider A
Provider B
Direct (SMTP + S/MIME)
HISP
Provider A
Provider B
Any Edge
Protocol
Direct (SMTP + S/MIME)
Provider A
EHR Affiliated HISP
Provider B
Any Edge
Protocol
Direct (SMTP + S/MIME)
CEHRT

9. Approach #2 -- Send with CEHRT Optional Transport: SOAP + XD (Example)
EHR generates CCDA
EHR (certified to include optional SOAP + XDR/XDM transport) sends message to Provider B using SOAP + XDR/XDM
In this scenario, the EHR must be certified to support both Direct (required) and SOAP + XDR/XDM (optional) as transport standards.
Provider A
Provider B
SOAP +
XDR/XDM
CEHRT
Note: This is one example of how a provider may use EHR technology that has been certified to include optional transport standards. The CEHRT could support a different optional transmission mechanism (e.g., Direct + XDR/XDM). Also, as with the required Direct transport, the CEHRT has architectural flexibility to use relied upon software in their solution, seek modular certification, etc.

10. Approach #2 -- Send with CEHRT Optional Transport: SOAP + XD via Intermediary (Example)
EHR generates CCDA
EHR (certified to include optional SOAP + XDR/XDM transport) sends message to Provider B (via HISP) using SOAP + XD
HISP repackages content as Direct message and sends to Provider B
In this scenario, the EHR must be certified to support both Direct (required) and SOAP + XDR/XDM (optional) as transport standards.
The HISP does not need to be certified.
This meets the MU requirement for using CEHRT.
HISP
Provider A
Provider B
Direct (SMTP
+ S/MIME)
SOAP +
XDR/XDM
CEHRT
Because Provider A is sending to Provider B using their CEHRT’s SOAP + XDR/XDM transport option, the fact there’s a “HISP in the middle” is irrelevant with respect to Provider A meeting MU requirements.
This allows any EHR vendor supporting the SOAP + XDR/XDM option to interoperate with any HISP that also offers SOAP + XDR/XDM support.
Under this approach, HISPs do not have to be certified
If EHRs implement SOAP/XD support and then partner with a HISP (i.e., use the HISP as relied upon software for certification), they can also fulfill their Direct requirement under Scenario #3 with minimal (or no) additional development/technical work on their part.

11. NwHIN Exchange Participant
Approach #3 – Send via NwHIN Exchange Participant
NwHIN Example
EHR generates CCDA
EHR sends CCDA to NwHIN Exchange Participant
NwHIN Exchange Participant sends to Provider B
Complete EHR or EHR Module certification issued.
NwHIN Exchange participant does not get certified.
Provider A
NwHIN Exchange Participant
(now eHealth Exchange)
Provider B
CEHRT
CEHRT
Note: the regulation also permits an EP, eligible hospital, or CAH to count in their numerator instances where a summary care record for transitions of care or referrals was received via electronic exchange facilitated in a manner consistent with the governance mechanism ONC establishes for the nationwide health information network. ONC has not yet established a governance mechanism for the nationwide health information network. Until ONC establishes such a governance mechanism, this specific option will not be available.

12. Key Points
HIEs providing HISP services have multiple options for supporting providers in meeting the MU Stage 2 ToC requirements:
Allow EHRs to connect using SOAP + XDR/XDM (HISPs do not need modular certification under this model to support MUS2)
Become NwHIN Exchange participant
Partner with an EHR vendor and get certified as pre-coordinated bundle
Get modular certification for CCDA translation and Direct
HIEs should analyze the options and select one (or more) that best serve the needs of their stakeholders/communities

13. Want to learn more? State HIE Direct CoP Call
Monday, 3PM Eastern
MU Stage 2 interoperability training modules coming soon

14. Reference

15. Key Terms / Acronyms
SMTP (Simple Mail Transfer Protocol): is an Internet standard for electronic mail ( ) transmission across Internet Protocol (IP) networks.
S/MIME (Secure/Multipurpose Internet Mail Extensions): an Internet standard for public key encryption and signing of MIME data.
MIME (Multipurpose Internet Mail Extensions): an Internet standard that extends to support other content types, including non-text attachments
SOAP (Simple Object Access Protocol): a protocol specification for exchanging structured information in the implementation of web services in computer networks
XDR / XDM: IHE standard for supporting XML-based detailed metadata along with SMTP- or SOAP-based transport options. See XDR/XDM for Direct to learn more.
CCDA (Consolidated Clinical Document Architecture): an XML-based markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange
XML (eXtensible Market Language): defines a set of rules for encoding documents in a format that is both human-readable and machine-readable

16. CEHRT Definition
(2) For FY and CY 2014 and subsequent years, the following:
EHR technology certified under the ONC HIT Certification Program to the 2014
Edition EHR certification criteria that has:
(i) The capabilities required to meet the Base EHR definition; and
(ii) All other capabilities that are necessary to meet the objectives and associated measures under 42 CFR and successfully report the clinical quality measures selected by CMS in the form and manner specified by CMS (or the States, as applicable) for the stage of meaningful use that an eligible professional, eligible hospital, or critical access hospital seeks to achieve.