1. Review of Population and Public Health Objectives Stage 3 MU
Arthur Davidson, MD, MSPH
Meaningful Use Workgroup
December 20, 2013

2. Agenda Progress with Meaningful Use Measures for Public Health
Evidence of PH Efforts with Standards
Cancer
HAI (need notes)
Updates on Current Measures: Immunization & ELR (Jim can give someone info for slides)
Future of PH – Aligning future measures w/S&I Framework
SDC
HeD
DAF
Progress
CSTE Pilots
RCKMS
Big pic diagram (Shu)

3. Hospital 1st v. 2nd v. 3rd year PH Menu Objective Performance
Source: CMS Presentation – Rob Anthony, December 4, 2013

4. Update on Current Measures: - Immunization, ELR, SS
New guide provides improvements
Progress with providers is better
ONC test criteria are making interoperability better
PH moving toward accepting data coming form certified products
Next version (Feb 2014) of IG will include bi-directional w/ History and forecast back to provider
Electronic Laboratory Reporting (ELR)
New version of IG is available to HL7 members and includes many improvements
Syndromic Surveillance (SS)
Successful centralized infrastructure utilizing BioSense

6. Electronic Laboratory Reporting (ELR) – Pattern of Adherence to Standards
Public Health has consistently made efforts to abide by standards and in turn minimize impact on clinical partners
Proof of PH’s commitment to build on standards and processes used for other use cases,.
ELR Release 1 (HL7 Version 2.5.1: ORU^R01)1was built on the HISTP Lab-to-EHR Implementation Guide
ELR Release 2 is the current profile for Electronic Laboratory Reporting to Public Health (MU Stage 1 and 2).
Public health has demonstrated readiness for standards and will credibly achieve that for Stage 3.

8. Key Principle for PH Stage 3 MU
Adhere to Standards and Interoperability Framework Components Whenever Feasible
Component
Purpose
Consolidated CDA
Standard message format
Structured Data Capture
Populate standard forms
Health eDecisions
Define when standard forms should be collected
Data Access Framework
Query data: 1) by provider and 2) across multiple organizations and by population

9. Cancer Reporting
Stage 3 MU Cancer Implementation Guide (IG) should move to consolidated clinical document architecture (c-CDA) because:
EHR vendors are required to use this format for Transition of Care documents in Stage 2 MU
eliminates burden of supporting two different formats for cancer reporting
c-CDA has harmonized and improved templates across multiple sources
cancer program is ready to move to this new standard

10. Cancer c-CDA: Next Steps
Align Cancer IG sections with c-CDA sections (high level completed)
Add a new document-level template c-CDA R2: "Ambulatory Healthcare Provider Cancer Event Report”
Add Cancer Diagnosis Section to c-CDA
Perform Gap and Overlap analysis of entries, data elements, attributes, and value sets
Put new document through HL7 ballot process
Timeline
High level gap analysis performed in November 2013
Detailed gap/overlap analysis work starting in January 2014
Ballot in May 2014

11. Tuberculosis (Delaware)
PH c-CDA Progression
2012
2013
2014+
Pertussis (NY State)
EHDI (N. Dakota)
Cancer Registry
Pertussis (San Diego)
EHDI (Oregon)
Tuberculosis (Delaware)

12. Electronic Healthcare Associated Infection (HAI) Detection and Reporting: Supporting Patient Safety
CDC
Reporting system
publishes facility-specific
HAI data
Specifications:
eMeasures
Decision rules
Computer code
Healthcare
Reporting system provides protocol and algorithm
Public
Health
Publicly Reported HAI data
Executable expressions of detection and case reporting algorithms
Reporting protocol for HAI
CMS
CDA transmission:
Manual upload
Automated send
NHSN
CDC
Programs
HeD
Desire to avoid an unintended consequence as there are more than 1000 hospitals already reporting to NSHN. Tremendous value in driving to an improved quality and safety environment.
May be a perception that this could be a Quality Reporting Document Architecture (QRDA) but given the high participation and current public health infrastructure (to CDC and then retrieved by States or Locals) already we should keep CDA in the standards.
Not ready yet for a transition to the c-CDA, but that might be for a future stage.
Electronic HAI Report
Clinical
Document
Architecture
(CDA)
Electronic
systems:
EHR
Pharmacy
ADT
Lab
Additional rules applied to populate full HAI report
HAI detection rules applied to patient-specific data
Healthcare Facility

13. Public Health Infrastructure Health Information Exchange (HIE)
Progress : What’s been completed
CDA/SDC for Public Health Pilot Projects
Public Health Reporting Architecture
Continuity of Care Document (CCD)
(pre-population data)
Public Health Infrastructure Or
Health Information Exchange (HIE)
CDA-based
Case Reports:
Tuberculossis
Pertussis
Newborn Hearing Screening Outcome Report
Provider
Public Health
Electronic
Health Record
System
Information Systems:
Surveillance Systems
EHDI System
Public Health Information Systems
Delaware Electronic Reporting Surveillance System (DERSS)
New Your State Universal Public Health Node (UPHN)
San Diego County
(Atlas Public Health)
Oregon EHDI System
(Filemaker)
North Dakota EHDI System
(OZ Systems)
EHR Vendors
Core Solutions
Connexin
Allscripts
(Test Harness)
Epic 2012
Public Health Infrastructure
(Orion Rhapsody)
HIE
(OZ Systems)
Request Form
2. Provide pre-population data
Form Manager
Form Manager
Form Filler
3. Pre-populated Report Form
Form Receiver
Form Receiver
4. Populated Report Form
Content Creator
Content Creator
Send–Receive
CDA Report
Content Consumer 13
Sources: Communicable Disease CDA Pilot Project Report URL:
EHDI CDA Pilot Project Report URL:

14. Communicable Disease Reporting – CDA/SDC Pilot in NYC and WI
Parse
Retrieve Form
Pre-populate web form
4. Send URL with pre-populated web form
Electronic Medical Record (EMR) Vendor Test Environ-ment
(i.e., EPIC)
Reporting Module/Form Manager
Continuity of Care Document (CCD)
NYC and WI Public Health Infrastructure
Electronic Disease Surveillance System
Current Progress (as December 2, 2013) – Finalize Testing in Vendor Environment
5. Physician/ICP submits addition information directly to system
Next Steps – Identify, Recruit, and Implement in Hospital using EPIC EMR System
State/Local Surveillance System
Key Outcomes
Shift in tradition al public health case report (PHCR) use case
Leverage existing standard (i.e., CCD -> cCDA)
Light-weight service for EMR vendors to connect to various jurisdiction reporting end-points
Minimize development in EMR System
Extensibility/ portability to other EMR vendors
State and LHD can configure forms based on reporting and business needs specific to jurisdiction

15. Structured Data Capture - Tiger Team and Selected Pilots
Public Health Tiger Team
Community based effort to identify, develop, and implement SDC Public Health Pilots
Public Health Pilots
EHDI
Cancer Reporting
Case Reporting
Are these really SDC pilots or CDA pilots 15

16. Define the necessary requirements (including metadata) which will drive the identification and harmonization of standards that will facilitate the collection of supplemental EHR-derived data
Develop and validate a standards based data architecture so that a structured set of data can be accessed from EHRs and be stored for merger with comparable data for other relevant purposes to include:
The electronic Case Report Form (eCRF) used for clinical research including PCOR
The Incident Report used for patient safety reporting leveraging AHRQ ‘Common Formats’ and FDA form 3500/3500a
The Surveillance Case Report Form used for public health reporting of infectious diseases
The collection of patient information used for determination of coverage, as resources permit

17. Health eDecisions - Use Cases
Use Case 1: standard format for sharing CDS knowledge artifacts
Rules, order sets and documentation templates
Goal: CDS knowledge authored in standard format can be imported and used in any EHR system
Use Case 2: standard interface for accessing CDS Web services
Goal: CDS capability encapsulated using standard interface can be integrated with any EHR system 17

18. Health eDecisions – Use Case 1 (CDS Artifact Sharing)
Use Case 1 Focuses on three artifact types:
Event Condition Action Rules
Order Sets
Documentation Templates 18

19. Health eDecision - Use Case 1: Pilot Partnerships
EHR
Pilot
Content Supplier
Design Clinicals
Order Set – Heart Failure
Zynx Health
Allscripts
Rule – NQF 068 (Million Hearts)
newMentor
RCKMS - San Diego Pertussis
CDC/CSTE VA
Documentation Template – UTI
Wolters Kluwer Health
RCKMS: Reportable Condition Knowledge Management System 19

20. Knowledge Management System (RCKMS)
RCKMS Long term Scope
Reportable Condition
Knowledge Management System (RCKMS) PH
Reports
Public Health State, Local, Territorial Agencies
Authoring Framework
PH Reporters (Clinicians)
Hospital Labs
LIMS
EHR
National, Clinical & Public Health Laboratories
Ambulatory Care
Web Service
(3) Open CDS
Local
Query/View
Database
Who, What, When, Where, How
Subscription Management
Including Notifications
Other Web Services
Structured Output
Generator
DSS Web Service
(2) Open CDS
HeD
HeD Compliant format
- Triggering Criteria
- Reporting Actions
- Links
(1) Health eDecision (Hed)
Output file Options
HeD file download
OpenCDS in Cloud
OpenCDS Locally Deployed 20

21. S&I Data Access Framework Use Cases21

22. Data Access Framework - examples
A primary driver/leader of the query health project in NYC is Dr. Michael Buck. This slide presents a map generated using aggregated Query Health data that shows obesity prevalence in 13 areas of NYC that includes multiple boroughs. In this study, obesity was defined as individuals whose body mass index (BMI) was over When the data were mapped, it was clear that the prevalence of obesity was not evenly distributed across the areas studied. Populations living west of the East River had a higher prevalence of obesity than populations living east of the river. This is a real-life example of how query health data can be used by local public officials to design interventions to target populations at highest risk.

23. Improving population and public health: Stage 3 Priorities
Stage Functional Objectives
Stage 3 Functionality Goals
MU Outcome Goals
Target Outcome Goals
MU Outcome Goals
Patient lists
Sharing immunization data
Cancer and specialty registry
Electronic lab reporting
Submission of electronic syndromic surveillance data
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange
Providers know the health status of their patient population
Public health officials know the health status of their jurisdiction
Providers and specialty societies can track and manage domain specific events related to practice and devices
Providers and public health officials share information to improve individual and population health 23

24. Improving population and public health: Case Reports
Functionality Needed to Achieve Goals
Stage 3 Functionality Goals
CEHRT uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.
Recommended as certification criteria only
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange 24

25. Improving population and public health: Registries
Functionality Needed to Achieve Goals
Stage 3 Functionality Goals
EPs/EHs use CEHRT to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources)
EP/EH Registries examples: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. EHs Only: health-care associated infections
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange 25

26. Improving population and public health: Immunization history
Functionality Needed to Achieve Goals
Stage 3 Functionality Goals
Eligible Professionals, Hospitals, and CAHs receive a patient’s immunization history supplied by an immunization registry or immunization information system, allowing healthcare professionals to use structured historical immunization information in the clinical workflow
Recommended CEHRT Functionality
Ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange 26

27. Improving population and public health: Electronic lab reporting
Functionality Needed to Achieve Goals
Stage 3 Functionality Goals
No Change from Stage 2 EH Objective: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice Measure: Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period.
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange 27

28. Improving population and public health: Syndromic Surveillance
Functionality Needed to Achieve Goals
Stage 3 Functionality Goals
No Change from Stage 2 EP MENU Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice EH Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice EP/EH Measure: Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period
Efficient and timely completion of case reports
Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement
Shared information with public health agencies or specialty societies
Bidirectional public health data exchange 28

29. Former Objective Details Proposed Merged Registry Objective (404, 405, 407 - EH objective)
EH Objective: Capability to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) from the Certified EHR Technology, except where prohibited, and in accordance with applicable law and practice. This objective is in addition to and does not replace prior requirements for submission to an immunization registry. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of standardized reports from the CEHRT to two registries (either mandated or voluntary)). Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. Registries include: cancer, health-care associated infections, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community) should maintain the registry Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to an external mandated or voluntary registry, maintain an audit of those reports, and track total number of reports sent.

30. Former Objective Details Case reports – 402B
Stage 3
Proposed for Future Stage
Certification criteria: The EHR uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.
EP Objective: Capability to use externally accessed or received knowledge (e.g. reporting criteria) to determine when a case report should be reported and then submit the initial report to a public health agency, except where prohibited, and in accordance with applicable law and practice. Measure: Attestation of submission of standardized initial case reports to public health agencies on 10% of all reportable disease or conditions during the entire EHR reporting period as authorized, and in accordance with applicable state/local law and practice.
Certification criteria only – is there linkage to 209?
Certification ONLY