2014 Edition Test Scenarios Development Overview Presenter: Scott Purnell-Saunders, ONC November 12, 2013 DRAFT

Contents Development3 Workflow Review4 Overview5 Overview: Workflow6 Overview: Workflow Descriptions7 Overview: Workflow Assumptions8 Group 1: Scenarios9 Encounter: Intake Workflow10 Encounter: Interoperability Intake Workflow11 Encounter: Care Ordering Workflow12 Encounter: Care Results Workflow13 Encounter: Post-Care Workflow14 Example: Encounter: Intake15 Group 2: Scenarios16 Next Steps17 2 ReviewOverviewGroup 1Group 2Next Steps DRAFT

Development 3 ONC plans to develop the 2014 Edition Test Scenarios in two groups ONC released the Group Edition Draft Test Scenarios in September They are available on ONC’s websiteONC’s website Group 2 will be developed in 2014 ReviewOverviewGroup 1Group 2Next Steps Script Development Proof of Concept Group 1 Draft Scenarios Released Pilot Approved Group 1 Scenarios Available Group 2 Development DRAFT

Workflow Review 4 After the test scenario pilot this spring, ONC outlined a larger workflow for the 2014 Edition Test Scenarios The workflow follows a patient from their initial contact with a provider’s office or hospital through their care and follow up It also follows a provider or hospital through public health and clinical quality measure reporting The workflow is a framework for testing products using a series of clinically-plausible scenarios ONC has outlined what criteria could be met by each scenario The pilot scenario is included in this workflow The workflow was reviewed with ONC clinical experts ReviewOverviewGroup 1Group 2Next Steps ONC is asking for your feedback on the concept, structure, and usability of the following Group 1 Draft Test Scenarios. DRAFT

Overview 5 Group 1 #Scenario Name Criteria Included 1Encounter: Intake a3, a5, a6, a7, f1, a11, a13, a17, f5, a4 2Encounter: Interoperability Intakeb1, b4 3Encounter: Care Ordering a1, a2, b3, a10, a16 4Encounter: Care Results a12, b5, a8, a15, a9, e2 5Encounter: Post-Carea14, b7, b6, e3, e1, b2 Development: July 2013 – February 2014 Group 2 #Scenario Name Criteria Included 6Reporting c1, c2, c3, f2, f3, f4, f6 7Privacy & Security d1, d2, d3, d4, d5, d6, d7, d8, d9 8System g1, g2, g3, g4 Development: 2014 ReviewOverviewGroup 1Group 2Next Steps DRAFT

Overview: Workflow ONC has drafted a clinically-plausible workflow to guide the development of the 2014 Edition Test Scenarios This workflow is intended to represent one way that all of the 2014 Edition EHR Certification Criteria could be included in a clinically-plausible workflow The draft workflow includes 8 scenarios 6 ReviewOverviewGroup 1Group 2Next Steps Considerations: It does not represent the only way unit tests could be linked in a clinical workflow It does not imply anything about how providers should use CEHRT It only addresses the 2014 Edition EHR Certification Criteria Future editions of the certification criteria could allow ONC to develop scenarios addressing other concerns DRAFT

Overview: Workflow Descriptions 7 Group 2 Group 1 scenarios represent activities that are largely towards the clinical end of the spectrum and could be performed by members of the care team and/or patient Group 2 scenarios represent activities that are largely towards the administrative end of the spectrum and could be performed by administrative users ReviewOverviewGroup 1Group 2Next Steps Scenario 1 Encounter: Intake Scenario 2 Encounter: Interoperability Intake Scenario 3 Encounter: Care Ordering Scenario 4 Encounter: Care Results Scenario 5 Encounter: Post-Care Scenario 6 Reporting Scenario 7 Privacy & Security Scenario 8 System Group 1 Development: July 2013 – February 2014 Development: 2014 DRAFT

Overview: Workflow Assumptions 8 ONC has outlined what criteria could be included in each scenario In the outlines on the following slides, ONC assumes that testing will proceed sequentially through each scenario The test scenario procedures provide additional guidance for what additional criteria are required if a scenario is not tested in sequence Workflow is the core of each test scenario procedure and guided the development of the test scenario data ReviewOverviewGroup 1Group 2Next Steps DRAFT

Group 1: Scenarios 9 Group 1 includes five scenarios Group 1 Scenario 1 Encounter: Intake Actions which could be performed by any member of the care team or patient before the patient sees a provider. 10 criteria Scenario 2 Encounter: Interoperability Intake Actions which could be taken to incorporate a summary of care document received from another provider or hospital before treating the patient. 2 criteria Scenario 3 Encounter: Care Ordering Actions related to ordering care for the patient (medications, laboratory or imaging) during the care episode. 5 criteria Scenario 4 Encounter: Care Results Actions related to the results of earlier care orders for the patient, provision of resources for the patient and provider, and visit notes. 6 criteria Scenario 5 Encounter: Post-Care Actions which could be performed after the encounter with the patient has ended, but are directly related to the provision of care to the specific patient, including the creation of summary of care records. 6 criteria ReviewOverviewGroup 1Group 2Next Steps DRAFT

Encounter: Intake Workflow 10 The Patient arrives for a visit with a Provider (ambulatory) or at a Hospital (inpatient). The following information about the Patient is recorded in the Provider’s or Hospital’s EHR: Scenario 1 Encounter: Intake Actions which could be performed by any member of the care team or patient before the patient sees a provider. 10 criteria Workflow: Demographics Vital signs, BMI, and growth charts Problem list Medication list Medication allergy list Smoking status Family health history Advance directives Immunization information Cancer case information Tests: Demographics Medications Medication allergies Problems Immunization information Smoking status Family health history Inpatient only: Advance directives Ambulatory only: Cancer case information Vital signs, BMI, and growth charts DRAFT

Encounter: Interoperability Intake Workflow The Provider or Hospital receives a transition of care or referral summary for the Patient from a recent Hospital admission (ambulatory) or ambulatory visit (inpatient). The transition of care / referral summary for the Patient is received, displayed, and incorporated in the Provider’s or Hospital’s EHR. Clinical information reconciliation is performed between the medication, medication allergy, and problem lists stored in the EHR and those contained in the transition of care / referral summary Workflow: Transitions of care: receive, display, and incorporate transition of care / referral summaries Clinical information reconciliation Tests: Scenario 2 Encounter: Interoperability Intake Actions which could be taken to incorporate a summary of care document received from another provider or hospital before treating the patient. 2 criteria 11 DRAFT

Encounter: Care Ordering Workflow 12 During a visit (ambulatory) or admission (inpatient), the following orders are recorded for the Patient: Workflow: Computerized provider order entry Drug-drug, drug-allergy interaction checks Electronic prescribing Drug-formulary checks Electronic medication administration record Tests: Scenario 3 Encounter: Care Ordering Actions related to ordering care for the patient (medications, laboratory or imaging) during the care episode. 5 criteria The EHR indicates drug-drug, drug-allergy contraindication interventions. The Provider or a member of the care team generates prescriptions for electronic transmission, and checks whether a drug formulary exists for the Patient and given medication. In the inpatient setting only, a member of the care team administers medication and documents the medication administration in the Patient’s record in the Hospital’s EHR. Medication Laboratory Radiology/imaging orders DRAFT

Encounter: Care Results Workflow 13 During a subsequent visit (ambulatory) or at a later point in the hospital admission (inpatient), the following occurs: The EHR indicates that image results for the Patient are available, and they are accessed. Clinical laboratory tests and values/results for the Patient are received and accessed. The EHR electronically identifies diagnostic and therapeutic reference information for the Provider and education resources for the Patient. Electronic notes for the Patient’s visit or admission are recorded in the EHR, and, in the ambulatory setting only, a clinical summary for the Patient is created. Workflow: Image results Incorporate laboratory tests and values/results Clinical decision support Patient-specific education resources Electronic notes Clinical summary Tests: Scenario 4 Encounter: Care Results Actions related to the results of earlier care orders for the patient, provision of resources for the patient and provider, and visit notes. 6 criteria DRAFT

Encounter: Post-Care Workflow 14 In the ambulatory setting: After the visit, the Provider exchanges messages with the Patient In the inpatient setting: A member of the care team sends the Patient’s electronic laboratory results to the Patient’s ambulatory providers In both settings: The Patient views, downloads, and transmits health information to a 3rd party A transition of care / referral summary for the Patient is created and transmitted A list of patients including the Patient is created, as well as a set of export summaries for all the patients in the EHR. Workflow: Patient list creation Data portability Transmission of electronic laboratory tests and values/results Secure messaging View, download, and transmit Transitions of care – create and transmit Tests: Scenario 5 Encounter: Post-Care Actions which could be performed after the encounter with the patient has ended, but are directly related to the provision of care to the specific patient, including the creation of summary of care records. 6 criteria DRAFT

Example: Encounter: Intake 15 Cover Page Workflow / Script ReviewOverviewGroup 1Group 2Next Steps DRAFT

Group 2: Scenarios 16 Group 2 will include three scenarios ONC has outlined the workflow for these scenarios, and plans to develop them in 2014 Group 2 Scenario 6 Reporting Actions which relate to reporting to CMS and other bodies, and which could be performed by administrative users of the EHR. 7 criteria Scenario 7 Privacy & Security Privacy and security requirements to be fulfilled by EHR systems. 9 criteria Scenario 8 System Automated actions to be performed by EHR systems and actions related to system design. 4 criteria ReviewOverviewGroup 1Group 2Next Steps DRAFT

Next Steps 17 November Feedback on draft test scenarios to Scott Purnell-Saunders before November Please include “2014 Edition Test Scenarios” in the subject line Copy Seon Davis ONC can work with Michelle Consolazio to schedule a follow-up meeting depending on the volume of feedback received before November 15 December ONC revises the draft test scenarios for use in pilots ReviewOverviewGroup 1Group 2Next Steps DRAFT