Beacon Community Program Build and Strengthen – Improve – Test innovation Beacon-EHR Vendor Full Affinity Group August 16, 2013

Full AG Roll call – Lynda Rowe Meaningful Use Stage 2 Numerator/Denominator Discussion – Lynda Rowe HealtheWay Question and Answer Discussion – Lynda Rowe/Chuck Tryon/Adele Allison ONC White Paper Discussion “Key Considerations For Health Information Organizations Supporting Meaningful Use Stage 2 Patient Electronic Access Measures” – Lynda Rowe Wrap up/Next Steps – Adele Allison/Chuck Tryon Today’s Goals 1

MU 2 Numerator Denominator Discussion - Questions 2 1.How do you plan to distinguish a CCD that is tied to the ONC definition of a TOC. For those of you who trigger a CCD to the local exchange based on some trigger event, how will you know that a CCD is part of the TOC denominator vs. other reasons (lab data, update registry, immunization, etc.) 2.How do you plan to “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 (you are passing the denominator) a)Do you have a way to export to an HIE the patient, sending provider, intended recipient, and date stamp for referral (or DOS) to an HIE? b)What format would you provide that to the HIE? c)Could you time bound this based on the providers preference for their 90 day reporting period? d)The assumption is that if you provide this to the HIE they could then match to “receipt” of TOC which would count as the numerator 4.Option 2 – HIE will send you the numerator, you will calculate the measure and will have the denominator a)If an HIE/HIO sends you a numerator file, what will you need at a minimum to count the numerator – how will you do patient and provider matching. b)If more than one provider views the TOC as a recipient do you have a mechanism to account for that? c)What do you need for date/time stamp to match to the denominator reporting window? d)How will you determine if an EP/EH TOC denominator counts toward more than one sending provider (i.e. in a multi speciality practice both the PCP and a specialist contributed to the CCD that will be sent to the receiver)

Beacon Pilot Progress Tulsa – In Progress Working on developing pilot option 9+ as well as the details behind numerator denominator calculations Mississippi – Not able to run pilots at this time South East Michigan – In Progress Went online with one Allscripts practice this week using XDS.b as the transport mechanism in an effort to work toward eHealth exchange – Looking to add an additional Allscripts practice in the next week as well In reference to User Story 2b, SE Michigan is working with Success EHS to pilot PIX and XDS.b Query & Retrieve, with automatic triggers to query our MPI and XDS.b repository to retrieve a longitudinal CDA Keystone – In Progress Developed Technical Script this week RIQI – In Progress Pilot: ToC: CEHRT to an HIO/HIE/HISP - Query by Provider B – Currently: data is being sent from Provider A, Blackstone Valley, and it is being stored within the HIE (discrete data and the document itself). – To be completed as soon as next week: Quantifying view of the data by Provider B. WNY – In Progress Direct accounts have been established for Elmwood and staff training has commenced on the use of Direct . Mirth is working on the automation process, in the meantime Neva will send files to Elmwood. Go live is planned for 07/23 with Direct function to be implemented shortly there after. 3

Possible Pilot Scenarios 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

Possible Pilot Scenarios 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 8QuerySOAP + XDR/XDM EHR – Must be certified for optional SOAP transport Any Transport via an HIE/HIO/HISP Provider A EHRHISP/HIO/HIEContent 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 eHealth exchange participant HIO must be a certified eHealth Exchange participant Pilot 10 QueryAny Certified Transport CEHRT natively or with relied upon software None- Query basedProvider A EHRHIO/HIE/HISPProvider A must be using CEHRT

Vendor Pilot Options 6 PilotSendReceive BeaconVendorBeaconVendor 1: Direct - EHR vendor complete certification Crescent City, Tulsa,SE MISuccess EHS (not yet in production) Cincinnati, Inland NW, RIQI, Tulsa, UtahNextGen UtahVitera Crescent City, SE MI, TulsaSuccess EHS 2: Direct - HIE/HIO/HISP modular certification Inland NW, ? Tulsa & KeystoneGreenwayCincinnati, Inland NW, RIQI, Tulsa, UtahNextGen Cincinnati, Inland NW, RIQI, Tulsa, UtahNExtGenUtahVitera UtahViteraCrescent City, SE MI, TulsaSuccess EHS Crescent City, SE MI, TulsaSuccess EHS Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) To HIO Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) Need HISP 3: Direct - EHR vendor + relied upon software Cincinnati, Inland NW, RIQI, Tulsa, UtahNExtGenCincinnati, Inland NW, RIQI, Tulsa, UtahNExtGen UtahVitera UtahVitera Crescent City, SE MI, TulsaSuccess EHS Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) Need HISP Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) Need HISP 4: Direct + XDR/XDM - EHR vendor complete certification Not Technologically Feasible at This Time 5: Direct + XDR/XDM - HIE/HIO/HISP modular certification Inland NW, ? Tulsa & KeystoneGreenwayCincinnati, Inland NW, RIQI, Tulsa, UtahNextGen Cincinnati, Inland NW, RIQI, Tulsa, UtahNExtGen UtahVitera Crescent City, SE MI, TulsaSuccess EHS Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) To HIO Keystone, Southeast MI, WNY, Utah (Pro Only)AllScripts (Pro & Ent.) Need HISP

Vendor Pilot Options 7 PilotSendReceive BeaconVendorBeaconVendor 6: Direct + XDR/XDM - EHR vendor + relied upon software Cincinnati, Inland NW, RIQI, Tulsa, UtahNextGenCincinnati, Inland NW, RIQI, Tulsa, UtahNExtGen Keystone, Southeast MI, WNY, Utah (Pro Only) Allscripts (Pro & Ent.) Need HISP Keystone, Southeast MI, WNY, Utah (Pro Only)Allscripts (Pro & Ent.) Need HISP 7: SOAP + XDR/XDM - Push from EHR to EHR Inland NW, ? Tulsa & KeystoneGreenway (XDS & XDR) Inland NW, ? Tulsa & KeystoneGreenway (XDS & XDR) Cincinnati, Inland NW, RIQI, Tulsa, UtahNExtGenCincinnati, Inland NW, RIQI, Tulsa, UtahNExtGen Crescent City, SE MI, TulsaSuccess EHS (XDS & XDR) Crescent City, SE MI, TulsaSuccess EHS (XDS & XDR) Keystone, Southeast MI, WNY, Utah (Pro Only) Allscripts (Pro & Ent.)Keystone, Southeast MI, WNY, Utah (Pro Only)Allscripts (Pro & Ent.) 8: SOAP + XDR/XDM - Push to HIO/HISP/HIE who forwards to Provider B Inland NW, ? Tulsa & KeystoneGreenway (XDS & XDR) Inland NW, ? Tulsa & KeystoneGreenway (XDS & XDR) Cincinnati, Inland NW, RIQI, Tulsa, UtahNextGenCincinnati, Inland NW, RIQI, Tulsa, UtahNextGen Crescent City, SE MI, TulsaSuccess EHS (XDS & XDR) Crescent City, SE MI, TulsaSuccess EHS (XDS & XDR) Keystone, Southeast MI, WNY, Utah (Pro Only) Allscripts (Pro & Ent.)Keystone, Southeast MI, WNY, Utah (Pro Only)Allscripts (Pro & Ent.) 9: EHR to an eHealth Exchange push to or query from Provider B Possible in All Environments as Long as Transport From eHealth Exchange Participant is Supported. 10: CEHRT to an HIO/HIE/HISP - Query by Provider B Possible in All Environments With Differences in the Types of Transport Supported. EHR sending vendor must support one CEHRT transport

VDT Objective Measure 1 for EPs and EHs 8 Objective: Provide patients the ability to view online, download and transmit their health information within four business days (EP) or 36 hours (EH/CAH) of the information being available to the EP VDT Measure 1 More than 50 percent of all unique patients seen during the EHR reporting period are provided timely (within 4 business days after the information is available (EP) or 36 hours after discharge(EH/CAH)) online access to their health information NumeratorDenominator The number of patients in the denominator who have timely online access to their health information Number of unique patients seen during the EHR reporting period; Calculations Option 1Option 2 HIO calculates the numerator/denominator. HIO’s CEHRT must know the total number of unique patients seen during the reporting period. To calculate the numerator, an HIO’s CEHRT must be able to ascertain if the required MU data elements were added to the patient portal from an EP within four business days of the information being available HIO Creates a report that lists patient names or identifiers for patients that have had the MU required data elements provided to the CEHRT (potentially a patient portal) and provides the report to the EP. EP verifies which patients to include in their numerator. Important Notes The patient is REQUIRED to receive/view/download information using CEHRT. the EP Does Not need to use CEHRT to send initial information to patient. In the event an HIO decides to seek certification for EHR technology to support EPs/EHs in achieving their MU objectives for patient electronic access, certification will require that the EHR technology can at least calculate the numerator for these measures and the EP/EH should expect that this ability be available to them.

VDT Objective Measure 2 for EPs and EHs 9 Objective: Provide patients the ability to view online, download and transmit their health information within four business days (EP) or 36 hours (EH/CAH) of the information being available to the EP VDT Measure 2 More than 5 percent of all unique patients seen/discharged during the reporting period (or authorized rep.) view, download, or transmit (VDT) to a third party their health information. NumeratorDenominator The number of unique patients (or authorized rep.) in the denominator who have viewed online, downloaded, or transmitted to a third party the patient's health information/discharge information Number of unique patients (or authorized rep.) seen/discharged during the EHR reporting period; Calculations Option 1Option 2 HIO calculates the numerator, denominator, and resulting percentage and provides a report to EPs/EHs. To calculate the denominator, the HIO’s CEHRT must know the total number of unique patients seen during the reporting period. To calculate the numerator, an HIO will need to ensure that only unique patients seen during the reporting period are counted in the numerator. Additionally, the HIO’s CEHRT would need to count authorized representatives who access the patient information in the numerator, without any double counting of the unique patient and authorized representative. HIO creates a report that lists patient names or identifiers. HIO provides the report to the EP/EH to allow them to verify which patients to include in their numerator. Important Information: Enough data will be needed in the report to match each patient to their list of unique patients seen during the reporting period (their denominator), in order to calculate their numerator. Depending on the connection between the HIO’s CEHRT and the EP/EH’s CEHRT, the report may need to include time stamps that the data was viewed, downloaded, or transmitted. Important Notes The patient is REQUIRED to receive/view/download information using CEHRT. the EP Does Not need to use CEHRT to send initial information to patient. The patient may but is NOT REQUIRED to use CEHRT to transmit information to the provider.

Secure Messaging Objective Measure 1 10 Objective: Use secure electronic messaging to communicate with patients on relevant health information Secure Messaging Measure 1 A secure message was sent using the electronic messaging function of CEHRT by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. NumeratorDenominator The number of patients or patient-authorized representatives in the denominator who send a secure electronic message to the EP that is received using the electronic messaging function of CEHRT during the EHR reporting period. Number of unique patients seen by the EP during the EHR reporting period. Calculations Option 1Option 2 HIO provides EPs and patients/authorized representatives with a CEHRT mailbox to send and receive secure messages. Important Considerations The HIO must have the capability to either generate a report of patients an EP has received secure messages from in the CEHRT, or calculate the numerator and denominator and provide a report to the provider. HIOs should keep in mind that EPs may desire to have a report of the patients included in the numerator to support their attestation information during an audit. HIO provides patients/authorized representatives with a mailbox to send and receive secure messages, potentially via Direct protocols that connects with a provider’s CEHRT. EP utilizes CEHRT (not provided by the HIO) to receive a secure message from the HIO- provided patient mailbox. An HIO can provision a patient with a Direct address and mailbox. Important Considerations The HIO is NOT REQUIRED to provide a report to EPs to assist them with calculating the measure, NOR is the HIO required to calculate the numerator for the EP. However, HIOs should consider that EPs may ask them to provide reports that may be used to support their attestation during an audit. Important Notes The patient may but is NOT REQUIRED to use CEHRT to transmit information to the provider. This measure requires the EP’s system that receives the secure message to BE CERTIFIED. If an HIO provides a mailbox outside an EP’s CEHRT, the mailbox REQUIRES CERTIFICATION. If an HIO is providing patients with the ability to create and send a secure message, possibly via Direct, it would NOT REQUIRE CERTIFICATION

HIOs that intend to support EP’s/EH’s patient electronic access measures by offering an online portal must use a certified portal with the following capabilities : View: display the common MU dataset, EPs (provider’s name/office contact information), EHs (Admission & discharge dates & locations; discharge instructions; & reason(s) for hospitalization). 2. Download: ability for patients (or authorized caregiver) to download the data listed in item number one above in human readable or consolidated clinical data architecture (CCDA) format. 3. Transmit: ability to send the data listed in item number one above to a third party in human readable or CCDA format, via the Direct SMTP standard. 4. Utilize Web Content Accessibility Guidelines (WCAG) 2.0, Level A Conformance for the online site. 5. Utilize any encryption and hashing algorithm identified by the National Institute of Standards and Technology (NIST) as an approved security function in Annex A of the FIPS Publication Depending on the type of certification, modular or complete, perform one or both of the following: – a. Create a report or file that enables a user to review the patients or actions that would make the patient or action eligible to be included in the measure’s numerator. The information in the report or file created must be of sufficient detail such that it enables a user to match those patients or actions to meet the measure's denominator limitations when necessary to generate an accurate percentage; and/or – b. Electronically record the numerator and denominator and create a report including the numerator, denominator, and resulting percentage associated with each applicable meaningful use measure. 11 HIO Online Portal Certification Requirements

Other Considerations for HIOs Providing VDT Functionality 12 Single Sign-on to Multiple Patient Records HIO may provide users with access to not only their own records, but also those for whom they are an authorized representative (a spouse’s, children’s, and elderly parents’ records through a single sign-on to the patient portal. Each individual’s record that is viewed through the single sign-on can be counted in an EP/EH’s numerator provided each individual is in their denominator HIO providing single sign-on must have the capability to ascertain which records were viewed and provide the right EP/EH with either a numerator/denominator calculation or a report of the patients whose records were viewed. Adolescent Patient Records HIOs supporting the patient engagement Stage 2 measures must carefully craft policies for providing access to adolescent patient records. HIPAA protects adolescent health information from parental access under specific circumstances HIOs must account differing state and federal laws through policies and technological solutions. Meaningful use regulations also give EPs considerable discretion in deciding what information to make available to adolescents. EPs must be careful not to make policy decisions which differ from their HIOs because it may hamper their ability to attest to VDT Measure 2 Providing Audit Documentation EPs/EHs may need a list of the patients that are counted in the numerator (including those whose records were accessed by an authorized representative for VDT Measure 2) VDT Measure 2: The list may need to include the date patients or their representatives accessed the online system, which will help EPs/EHs demonstrate that it transpired during the reporting period Any information used to determine the meaningful use performance of the EP should be kept in such a way that it can be provided during a desk audit in the future.

Wrap Up/Next Steps 13 Final comments All attendees Co-Chairs: Chuck Tryon/Adele Allison Next steps – Adele Allison Conclusion