1. Beacon Community Program Build and Strengthen – Improve – Test innovation Beacon-EHR Vendor Full Affinity Group September 13, 2013

2. Roll call – Greg Dengler Review of Results from MU 2 ToC Numerator/Denominator Calculation Meeting 8/30 – Chuck Tryon/Adele Allison Discussion – In Person vs. Virtual MU 2 ToC Numerator/Denominator Calculation Follow Up Meeting – Chuck Tryon/Adele Allison – Meeting Goals – Meeting Outputs – Who is vital for attendance – Who can actually attend – Location Wrap Up/Next Steps – Chuck Tryon/Adele Allison Today’s Goals 1

3. MU 2 ToC Numerator Denominator Questions for ONC/CMS 2 1. Will the CHPL list out what certifications and types of transports each Vendor is certified in? – Paul tuten –Yes 2. In the following scenario, how do we count the referral: Provider A refers a patient to provider B, provider B receives the referral order but cannot accept the patient for any number of reasons. The patient is referred then to provider C by provider A, provider C receives and accepts the referral, and ultimately treats the patient. Does this referral count twice in the numerator and denominator for provider A since each referral was sent and received in the specified manner, even though the patient was not seen by provider B? 3. Would a referral count that was sent from Provider A to a specific provider (B), but provider B was not able to treat the patient, so the referral was forwarded (by provider B) to another provider (C) which is within the HIE network count in provider A’s numerator? – In other words, if a patient is referred to a specific doctor by their PCP but choose to go to another specialist, who is part of the HIE, and that specialist pulls the most up to date information from the HIE, does this ToC still count in the numerator of the referring PCP? 4. Can the types of transfers for ToC be better defined? Meaning, do transfers such as from an ICU to an inpatient hospital bed count in the ToC measures? A transition from a PCP to a physical therapist?

4. MU 2 ToC Numerator Denominator Questions for EHR/HIE Vendors 3 1. What is the specific data available which can be used for numerator/denominator calculations? 2. Who will do the numerator/denominator calculation, and when will this calculation occur? 3. When does a ToC order get calculated in the numerator? When it is placed, or when the ToC is sent to an HIE/another party? 4. What can your specific EHR/HIE software produce in respect to an audit log? Can you produce an excel spreadsheet listing the ToCs that occurred and when they occurred? Can you intake an excel spreadsheet listing the ToCs and when they occurred? 5. How do you identify the providers internally? NPID? Proprietary Solution? Tax ID? – How can this identification system be used to help track ToCs made by each specific EP or EH? 6. How do you identify patients for which a ToC was created? 7. How do you define who the recipient of a ToC is, and what counts as a ToC as related to MU 2 measures?

5. MU 2 ToC Numerator Denominator Discussion Next Steps 4 1. Work through the logistics of a face to face, virtual, or combination meeting with ONC/Beacon Communities/EHR/HIE Vendors 2. Send out targeted questions which were developed during the working session to both HIE/EHR vendors and ONC/CMS for comments and feedback 3. Send out meeting recap and relevant questions to Beacon Communities, ONC/CMS, and HIE/EHR vendors for comment 4. Develop a list of technical questions for HIE/EHR vendors which will help inform the next numerator/denominator working session (technical questions which occurred during the first working session which vendor’s representatives on the call could not answer) 5. Work with ONC/CMS to have their representatives join the next working session 6. Work with ONC/CMS to gain a larger list of HIE/EHR vendors who may be able to add value to the next working session

6. Possible Pilot Scenarios 1 - 5 5 Pilot # Query OR Push Provider A Transport Method Certified Transport Entity Transport Method To Provider B C-CDA Generation MU 2 Metric Reporting Description Pilot 1 PushDirect (SMTP + S/MIME) EHR TechnologyTransport is directly from provider A Provider A EHR EHR Supports all aspects of DIRECT Transport Pilot 2 PushAny Edge Protocol HISP /HIE/HIODirect (SMTP + S/MIME)HISP/HIE/HIOHISP/HIO/HIEHISP/HIE/HIO must be certified to the TOC objective, i.e. support The Direct Applicability statement/produce a C-CDA Pilot 3 PushAny Edge Protocol EHR module Certified with Associated HISP/HIO (relied upon software) Direct (SMTP + S/MIME)EHR Vendor and relied upon software EHR vendor + relied upon software must meet MU2 criteria Pilot 4 PushDirect (SMTP + S/MIME)+ XDR/XDM EHRTransport is directly from provider A Provider A EHR Same as Pilot 1, except adding the optional XDR/XDM transport Pilot 5 PushAny Edge Protocol HISP /HIE/HIODirect (SMTP + S/MIME)+ XDR/XDM HISP/HIE/HIOHISP/HIO/HIEHISP/HIE/HIO must be certified to the TOC objective, i.e. support The Direct Applicability statement/produce a C-CDA

7. Possible Pilot Scenarios 6 - 10 6 Pilot # Query OR Push Provider A Transport Method Certified Transport Entity Transport Method To Provider B C-CDA Generation MU 2 Metric Reporting Description Pilot 6PushAny Edge Protocol EHR module Certified with Associated HISP/HIO (relied upon software) Direct (SMTP + S/MIME)+ XDR/XDM EHR Vendor and relied upon software EHR vendor + relied upon software must meet MU2 TOC criteria Pilot 7PushSOAP + XDR/XDM EHR – Must be certified for optional SOAP transport Transport Directly From Provider A Provider A EHR EHR Hosted SOAP + XDR/XDM Pilot 8PushAny MU2 Certified Transport (Direct or SOAP) CEHRT natively or with relied upon software Repackage by HIE/HIO and send to Provider B using any transport Provider A EHRHIO/HIE/HISP must provide delivery assurance Content may be repackaged by HISP/HIO for provider B Pilot 9Push OR Query Any TransportHIO as an eHealth Exchange participant Query or push to provider via eHealth Exchange certified protocol Provider A EHRHIO or CEHRTHIO must be a certified eHealth Exchange participant Pilot 10 QueryAny MU2 Certified Transport (Direct or SOAP) CEHRT natively or with relied upon software Any transport via an HIE/HIO/HISP Provider A EHRHISP/HIO/HIE must report Numerator Provider A must be using CEHRT

8. ToC Measure 2 Query Pull Method for EPs, EHs, and CAHs 7 Measure 2: The EP, EH or CAH that transitions or refers its patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals ToC Measure 2 Transport Methods Electronically transmitted using CEHRT to a recipient NumeratorDenominator Number of transitions of care in the denominator where a summary of care record was electronically transmitted using CEHRT or received by provider B via eHealth exchange. The organization can be a third-party or the sender’s own organization Number of transitions of care and referrals during the CEHRT reporting period for which the EP, EH, or CAH’s inpatient or emergency department was the transferring or referring provider Numerator Calculations Recipient receives the summary of care record via exchange facilitated by an organization that is an eHealth Exchange participant Option 1 EP/EH CalculatesOption 2 HIO/HIE Calculates HIO/eHealth provides: 1. List of patients for which the EP/EH contributed data 2. Dates when the data was contributed (so the contribution can be associated with referrals/transitions in the denominator 3. List of providers that queried the patients’ records (data contributed by the EP/EH) 4. The date of each query/view HIO/eHealth needs the following information: 1. EP/EH’s denominator, however the EP/EH defines it 2. Which patients the EP/EH contributed data for (data must be sent via CCDA summary document from CEHRT) 3. Which providers queried the patients’ records 4. The date of each query/view Important Notes 1. EPs/EHs need to confirm that the date of the referral in the denominator predates the date of the query 2. An EP/EH’s approach to calculating the denominator for TOC measure #1 and #2 must be same 3.EP/EH may only count transmissions in the numerator that are accessed by the intended provider 4.Receipt occurs when either the clinician or the practice/facility where they work receives/queries the ToC 5.The unit of measure for TOC measure #1 and #2 is transition/referral and not individual patient 6.CEHRT vendors must determine how to provide customers with transmission receipt assurance 7.Eps/EHs that contribute data to a CCDA may receive credit when that document is exchanged

9. Numerator Denominator Deep Dive Deep Dive Numerator/Denominator Calculations – Technical Scenarios and Permutations of eHealth Exchange/Query Retrieve » Push from sender to receiver through eHE/HIE/HISP (no N/D issue) » Push to eHE/HIE/HISP from single provider, only content contributor » Push to eHE/HIE/HISP from single provider – multiple contributors to C- CDA » Push to eHE/HIE/HISP – stored as single document » Push to eHE/HIE/HISP – stored as longitudinal record (multiple providers contribute) » Query by recipient – no electronic notification » Query by recipient – electronic notification from HIE – Requirements from CEHRT for denominator – Measure 1, Measure 2 – Requirements from HIE to be able to calculate eHE/HIE/HISP numerator contribution – Exchange of information between CEHRT and HIE/HIO required for Numerator and Denominator Calculation 8

10. MU 2 Numerator Denominator Discussion - Questions 9 1.How will a CEHRT distinguish a CCD that is tied to the ONC definition of a TOC. For CEHRTs that trigger a CCD to the local exchange based on some trigger event, how will the system determine that a CCD is part of the TOC denominator vs. other reasons (lab data, update registry, immunization, ED discharge without follow-up, etc.) 2.How will the CEHRT “count” the denominator based on the TOC definition as well as the time frame for reporting the measure 3.Option 1 – HIE will calculate numerator and denominator (CEHRT passing the denominator) a)How will the CEHRT export to an HIE/HIO the patient, sending provider, intended recipient, and date stamp for referral, transition or discharge (or DOS) to an HIE? b)What format would be used to provide that to the HIE? c)How might the CEHRT time bound denominator information to be sent based on the providers preference for their 90 day reporting period? d)The assumption is that if the CEHRT provides this information to the HIE, the HIE could then match to “receipt/view/query” of TOC which would count as the numerator 4.Option 2 – HIE will send CEHRT the numerator. CEHRT will calculate the measure and will already have documented patient transitions in the denominator a)If an HIE/HIO sends to the CEHRT a numerator file, what will be needed at a minimum to count the numerator – how will patient and provider matching happen? b)If more than one provider views the TOC as a recipient is there a mechanism to account for that? c)What does the CEHRT need for date/time stamp to match to the denominator reporting window? d)How will the CEHRT system determine if an EP/EH TOC denominator counts toward more than one sending provider (i.e. in a multi specialty practice both the PCP and a specialist contributed to the CCD that will be sent to the receiver)

11. Wrap Up/Next Steps 10 Final comments – All attendees – Co-Chairs: Chuck Tryon and Adele Allison Next steps Conclusion