1. HITPC Meaningful Use Stage 3 RFC Comments July 22, 2013 Information Exchange Workgroup Micky Tripathi

2. Agenda Review HITPC Meeting Revisit provider directory recommendation Data portability

3. HITPC Review HITPC approved the query for patient record recommendation HITPC approved the provider directory recommendation but requested the IE WG revisit the authentication principle

4. Revisit provider directory recommendation

5. Recommendation on Provider Directories HITPC recommends that: – Search for provider: EHR systems have the ability to query external provider directories to discover and consume addressing and security credential information to support directed and query exchange – Respond to search: EHR systems have the ability to expose a provider directory containing EPs and EH addressing and security credential information to queries from external systems to support directed and query exchange

6. Principles for Provider Directories HITPC recommends that the following guidelines be used for establishing standards for provider directories: 1.Scope: Standards must address PD transactions (query and response) as well as minimum acceptable PD content to enable directed and query exchange 2.Continuity: Build on Stage 1 and 2 approaches and infrastructure for directed exchange where possible and allow use of organized HIE or cross-entity PD infrastructures where applicable and available (ie, remain agnostic to architecture and implementation approaches) 3.Simplification: Set goal of having PD query and response happen in a single (or minimal) set of transactions 4.External EHR system: An EHR system of another distinct legal entity, regardless of vendor

7. Principles for Provider Directories (continued) 5.Transactions: A.Querying systems must have ability to: 1.Present authenticating credentials of requesting entity 2.Present provider-identifying information 3.Securely transmit query message B.Provider directory must have ability to: 1.Validate authenticating credentials of requesting entity 2.Match provider 3.Respond with unambiguous information necessary for message addressing and encryption or acknowledgement of non-fulfillment of request C.Provider directories must have administrative capabilities to: 1.Submit updated provider directory information (additions, changes, deletions) to external provider directories 2.Receive and process provider directory updates from external provider directories 6.Transaction details: a.Provider directories should contain minimum amount of information necessary on EPs and EHs to address and encrypt directed exchange and/or query for a patient record messages b.Provider directories should contain minimum amount of information necessary on EPs and EHs to disambiguate multiple matches (i.e. same provider at different entities, providers with the same name, etc)

8. Data Portability

9. IEWG 103 Data portability RFC Question What criteria should be added to the next phase of EHR Certification to further facilitate healthcare providers’ ability to switch from using one EHR to another vendor’s EHR? Stage 2 Certification Criterion: Enable a user to electronically create a set of export summaries for all patients in EHR technology formatted according to the standard adopted at § 170.205(a)(3) that represents the most current clinical information about each patient and includes, at a minimum, the Common MU Data Set and the following data expressed, where applicable, according to the specified standard(s): (i) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard at § 170.207(a)(3); (ii) Immunizations. The standard specified in § 170.207(e)(2); (iii) Cognitive status; (iv) Functional status; and (v) Ambulatory setting only. The reason for referral; and referring or transitioning provider’s name and office contact information. (vi) Inpatient setting only. Discharge instructions. Comment Summary 56 comments The majority of commenters felt this criterion was important and that further progress needed to be achieved around data portability. A number of commenters felt this criterion was unnecessary or duplicative of other criteria. A few commenters questioned if this criterion would add significant value as substantially more data would need to be migrated to maintain continuity.

10. IEWG 103 Data portability Comment Summary Commenters suggested a number of new data types that should be added: Many commenters suggested new data elements included in Stage 3 should be added to this criterion Many said any historical data that is required to calculate the Stage 3 CQMs In future stages this requirement should be changed to include any additions to objectives and CQMs. Other structured data where possible and document export as readily viewable documents where structured data is not available. All currently accepted elements of the CCD formatted according to the standard. Patient notes Allergies Past medical history Nutrition/diet orders Family/social history data (fluoride status of home water, second hand smoke exposure, alcohol use, drug use, cessation counseling, etc.) Non‐lab screening data (depression screen (PHQ9), asthma screen, hearing screen, autism screen, vision screen, etc.) Free text narrative Consent History of present illness Review of systems documentation Physical examination documentation Progress notes Signed notes Consultations Provider data

11. IEWG 103 Data portability Comment Summary Two commenters expressed a specific concern that the CCDA could not adequately provide/represent the information a provider needs to switch from one EHR to another. One felt that HL7 Quality Reporting Document Architecture (QRDA) category 1 might be better able to populate a patient record for historical quality measurement needs. While the other thought significant work would be required to support this functionality this criterion aims for. A few commenters questioned if this criteria could wait for a future Stage of meaningful use. One commeter requested this criterion be removed from Stage 3. One commenter felt the criterion should require certified EHRs to be able to export data based on either number of encounters of by a specified time period. Another commenter requested the ability to transfer by diagnosis. One commeter raised the point that in the long-term EHRs may not be viewed as the central repository for a patient’s entire medical record as this function might be assigned elsewhere. A few commenters felt more work was needed to ensure EHRs are able to import this data when a provider switches systems.

12. Data Portability Do we still agree that using the CCDA for data portability is the right one to build upon? If so, what additional clinical content should be added to the Common MU Data Set to improve data portability: (i) Encounter diagnoses. The standard specified in § 170.207(i) or, at a minimum, the version of the standard at § 170.207(a)(3); (ii) Immunizations. The standard specified in § 170.207(e)(2); (iii) Cognitive status; (iv) Functional status; and (v) Ambulatory setting only. The reason for referral; and referring or transitioning provider’s name and office contact information. (vi) Inpatient setting only. Discharge instructions. Are their items not included in the CCDA (i.e. claims, other administrative data etc) that are important for data portability?