1. Meaningful Use Panel: Stage 3 Update Arthur Davidson, MD, MSPH Denver Public Health Council of State and Territorial Epidemiologists Annual Conference Pasadena, CA June 10, 2013 1

2. Agenda Overview of Stage 3 policy perspectives – Review of HIT Policy Committee progress Consolidation and Deeming Public health agency opportunities: on- boarding CSTE and member role during this phase 2

3. Stages of Meaningful Use (MU) Improving Outcomes Stage 1: Data capture and patient access Stage 2: Information exchange and care coordination Stage 3: Improved outcomes Stage 1 2011-13 Stage 2 2014-15 Stage 3 2016-17 3

4. Original Principles for Stage 3 Recommendations New model of care: support team-based, outcomes-oriented, population management National health priorities: address National Prevention/Quality Strategies, Partnerships for Patients, and Million Hearts Campaign Broad applicability (since MU is a floor) – Provider specialties (e.g., primary care, specialty care) – Patient health needs – Areas of the country Not "topped out" or not already driven by market forces Mature standards widely adopted or could be widely adopted by 2016 (for stage 3) 4

5. Lessons from Stages 1 Implications for Stage 3 5 Stage 1 ExperienceImplications for Stage 3 Substantial increase in adoption rates and effective use Creating critical mass of users and data in electronic form Mandatory floor creating network effectsRising tide is floating boats (e.g., setup for patient engagement, HIE) Thresholds consistently exceededOnce MU functionality is implemented, it is used Consistent use across the yearsGains from stage 1 (and 2) will persist Reporting requirements have considerable costs and burden Simplify and reduce reporting requirements Prescriptive, “forced march” impacts available resources for innovation or to address local priorities Rely more heavily on market pull (e.g., new payment incentives); promote innovative approaches i.e., reward good behavior

6. Additional Goals for Stage 3 Address key gaps (e.g., interoperability, patient engagement, reducing disparities) in EHR functionality that the market will not drive alone, but are essential for all providers: – to create level playing field – to create network effects – to fulfill need for a public good Consolidation: combine MU objectives where higher level objective implies compliance with subsumed process objectives Deeming: consider alternative pathways to meet performance and/or improvement thresholds; satisfaction of subset of relevant MU functionality implicitly required to achieve performance/improvement 6

7. Proposed Stage 3 Population and Public Health MU Objectives/Criteria 7 No.Stage 3 RecommendationsMethodTarget* 104Occupation and industry codesCertificationEP/EH 401aImmunization registriesMeasureEP/EH 401b Immunization Clinical Decision Support (CDS) MeasureEP/EH 402aElectronic lab reportingMeasureEH 402bCase reports to public healthFutureEP 403Syndromic surveillanceMeasureEH 404Cancer registryMeasureEH/EP 405Additional (e.g., specialty) registryMeasureEH/EP 407Healthcare acquired infectionMeasureEH 408Adverse event reportingFutureEH/EP *EH= eligible hospital; EP=eligible Provider

8. Consolidation Summary 43 MU Workgroup objectives proposed in stage 3 Request for Comment (RFC) Consolidated to 25 objectives Assumptions – Full MU Workgroup will consider RFC feedback and update criteria – All criteria will be included in certification Focus on advanced uses – e.g., recording data vs. use data Give credit for MU objectives that should be standard of practice once passed stages 1 and 2 Identify what needs to be “used” and certified 8

9. Types of Consolidation Advanced within concept of another objective – (no current PH example) Duplicative concepts -objective becomes certification only – immunization forecasting -> clinical decision support Demonstrated use and can trust that it will continue – patient lists, population management, ACO and quality reporting 9

10. Consolidation Overview Reconciliation eRx – formulary CDS Pt list/dashboard Reminders EH: eMAR EH: Lab results EP PGHD Clinical summary Patient education Secure Messaging Notify of health event Care plan* Immunization registry Adverse event* Case reports to PHA VDTToC – Care summary Advanced directive Registries Syndromic Surveillance Electronic Lab Reproting Identify clinical trials Quality, safety, reducing health disparities Referral loop Test tracking Imaging results Electronic notes Engaging patients & families Improving care coordination Population & public health eRx transmission Certification Criteria Maintained Objective Key: * Proposed for future stage of MU Demographics CPOE - meds CDS for immun Comm preference CPOE - rad CPOE - lab Amendment Family Hx Prob, med, allg list Structured lab Vitals Smoking status Comm preference Cancer registry Specialty registry HAI reports Demographics Amendment Family Hx Prob, med, allg list Structured lab Vitals Smoking status CPOE - referrals Inter prob list* RxHx PDMP* CPOE - meds

11. Deemed MU Objectives Deemed in Satisfaction of: Clinical decision support e-Prescribing – formulary, generic subs Reminders Electronic notes Test tracking Clinical summary Patient education Reconcile problems, meds, allergies *View, download, transmit (VDT), consider adding if stage 2 reports good uptake *Secure patient messaging, consider adding if stage 2 reports good uptake Remaining Items: Advance directive E- medication administration record Imaging results EH: provide lab results Patient generated data *View/download/transfer *Secure patient messaging Care summary Care plan Referral loop Notification of health event Immunization registry Electronic laboratory reporting Case reports to public health agency Syndromic surveillance Reporting to 2 registries Adverse event reporting 11

12. Stage 2 MU: On-Boarding 12 EP/EH Registration of intent PH requests provider action PH on-boards EP/EH PH capable? Provider acts? MU objective met? 1 st Time Failure? EP/EH fails EP/EH passes: Letter for attestation No Yes Provider must: register intent by the deadline participate in on- boarding process respond to PHA written requests for action within 30 days on two separate occasions. Yes No Yes EP/EH exclusion No Yes CMS Final Rule: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf

13. 13 Formed to discuss and develop consensus around standardization of the new processes across domains and across jurisdictions Representatives from: ASTHO, NACCHO, AIRA, ISDS, CSTE, JPHIT, NAACCR, state PHAs, ONC, CDC, PHII, others Stage 2 MU Public Health Reporting Requirements Task Force

14. Secure Portal Eligible Provider Eligible Hospital Eligible Provider Eligible Hospital Registries 14 Standard Data Warehouse Query Service Standard Data Warehouse Secure federated query Secure federated query BMI CVD risk Tobacco Mental health

15. Query Health Pilots Pilot DescriptionFocusOwners NYC/NYS: Primary Care Information Project of the NYC Dept of Health and Mental Hygiene and the NYS Dept of Health Chronic disease, reportable, syndromic M Buck FDA Mini-Sentinel: with 17 large data providers with 126M covered lives, Harvard Pilgrim and HMO research network. Diagnoses, drugs, procedures J Brown MDPHnet: MA Dept of Public Health, MA Leagues of Community Health Centers and Atrius Health ILI, DM surveillance J Brown, K Benson BioSense 2: Cloud based systemSyndromic surveillance T Kass-Hout, M Alletto Clinical Quality Measures: Allscripts and MITRE Group using Health Quality Measure Format (HQMF) for Stage 2 CQM reporting. Clinical quality measures in EHR P Rao 15 http://wiki.siframework.org/Query+Health+Pilots+Team

16. CSTE Position Statements 16 Area2010201120122013 Infectious Diseases2814915 Surveillance/Informatics5513 Cross Cutting11 Occupational11 Environmental11 Chronic Disease21 TOTAL34211321

17. 17 Conclusions Stage 3 MU will push for improved outcomes with greater emphasis on health information exchange Public health agencies will demonstrate their capacity/desire to participate through on-boarding in Stage 2 CSTE can provide new data regarding functionality and standards to influence policy decisions CSTE and its members have a unique opportunity to be more strategic, with cross-cutting approaches to informatics investments