HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 2: Care Coordination and Patient and Family Engagement Co-Chairs: Jeff Donnell and Larry Garber Members: Peter DeVault, Jonah Frohlich, Arien Malec

Agenda Review Recommendation Language on: – Query for patient record – Notification of utilization event – Data portability Discuss – Specifying transition content – Exchange of electrocardiography 2

IE Workgroup Timeline DateTopic Wednesday, August 29 th 10:00- 11:00am ET Goals and Objectives for stage 3 Specifying transition content Exchange of electrocardiography Tuesday, September 4 th, 2:00-3:00pm ET Goals and Objectives for stage 3 Query Provider Directory (if time permits) Finalize recommendations in all areas IE WG Call - Wednesday, September 5 th, 3:00-4:00pm ET Review SubWG recommendations IE WG Call - Week of September 10 th Finalize recommendations September 18 th MU WG meeting 3

Recommendation Options The Subgroup is tasked with reviewing and developing prioritized recommendation in four key areas. The Subgroup has a number of options for addressing these areas including: – Stage 3 – Certification only – Explore in RFC – Push to Stage 4 – No recommendation 4

Query for patient record Review existing recommendation language and comments received How does the subgroup want to move forward with this recommendation? Certification only Because while this is extremely important functionality, it is difficult to measure whether or not a query should have been performed for the denominator 5

Query for Patient Information Proposed Phase 3 IE WG 1.The EHR must be able to query another entity for outside records and respond to such queries. This query may consist of three transactions: Patient query based on demographics and other available identifiers Query for a document list based for an identified patient Request a specific set of documents from the returned document list 2.When receiving in inbound patient query, the EHR must be able to tell the querying system whether patient authorization is required to retrieve the patient’s records. (E.g. if authorization is already on file at the record-holding institution it may not be required). 3.The EHR must be able to query an outside entity for the authorization language to be presented to and signed by the patient or her proxy in order to retrieve the patient’s records. Upon the patient signing the form, the EHR must be able to either: Send a copy of the signed form to the entity requesting it Send an electronic notification attesting to the collection of the patient’s signature 6

Notification of Utilization Event A number of HIEs across the country are developing event notifications. For example when a patient presents at the ED a notification would be sent to the patient’s PCP. Should this be the triage note? This functionality can help support PCMHs, ACOs and other new health care delivery models. Other possible Event Notifications: Hospital Discharges Death What should our recommendation be for each? Stage 3 Because these should be easy to automate and easy to measure 7

Collaborative Care Communication (New, Menu) Proposed Phase 3 IE WG EH OBJECTIVE: The EH/CAH will send electronic notification of a significant healthcare event in a timely manner to the patient’s referring provider and, with the patient’s consent, primary care provider. EH MEASURE: The eligible hospital or CAH will send electronic notification within 2 hours of a patient’s arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death, to the patient’s referring provider if known, and with the patient’s consent, primary care provider, more than 10 % of the time. Corresponding certification criteria will also include the ability for all (EP and EH) certified EHRs to be able to receive these notifications. Request for Comment for Meaningful Use with these additional questions: Is the mere notification that the event has taken place sufficient, or is more detail needed at a minimum? For instance should the ED Triage note be the minimum ED Arrival Notification? Should the patient discharge instructions with disposition be the minimum Facility Discharge Notification? Is the cause of death required at a minimum for the Death Notification? Are there sufficiently mature standards to define the content and vocabulary for these notifications? Timeliness of notification must be balanced against the practical ability to produce these notifications, for example, in a busy ED. Is 2 hours a reasonable balance, or should it be shorter or longer? Should more or fewer members of the patient’s care team be notified? Is consent implied for notification of referring providers? Is specific consent required for notification of PCP or other members of the patient’s care team? 8

Stage 2 Final Rule Language on Data Portability For the purposes of certification and for all of the patients on which an EP’s, EH’s, or CAH’s CEHRT maintains data, the EHR technology must enable a user to electronically create a set of export summaries for all patients in EHR technology formatted according to the Consolidated CDA that includes each patient’s most recent clinical information. While this is the minimum capability required for certification, we encourage EHR technology developers to include patients’ longitudinal information for laboratory test results, immunizations, and procedures, and intend to consider including this broader requirement in the next edition of this certification criterion. We believe this initial capability provides a strong starting point for the fluid transition from one EHR technology to another. Primarily, we anticipate that this capability will be enable transitions to be more efficient by reducing the need for EPs, EHs, and CAHs to manually re-enter all of their patients’ recent data into a new EHR system. 9

Data Portability How does the language on data portability in the final rule impact the proposal outlined? Data that are not migrated need to be maintained in an accessible format and system for reference or medicolegal purposes: Non-migrated clinical data Audit trails Billing information What should our recommendation be? Explore further in RFC Too much uncertainty regarding standards and whether “flattening” data into a transportable format will lose clinically significant contexts and/or relationships 10

Data Portability Between EHR Vendors Request for Comment for EHR Certification: ONC recognizes the importance of enabling healthcare providers to switch from using one EHR to another vendor’s EHR. It also recognizes that not all data can be migrated from one EHR to another. For instance, it is unreasonable to expect audit trails to be able to be imported from one EHR into another vendor’s EHR because EHR audit trails are so intimately tied to the EHR’s internal data structure and function. In the MU2 Certification Rule, ONC required at a minimum the capability to export C-CDA summaries on all patients which includes their most recent clinical information. ONC also encouraged, although did not require, including historical laboratory test results, immunizations, and procedures. ONC wishes to advance data portability further, and thus seeks comment to help identify reasonable actions that may further facilitate data portability. Should all of the provider’s visit notes, telephone notes, procedure notes, letters, and test results (including lab, radiology, etc…) be included in the exported data? Should this included provider-generated or ordered data that was saved in the EHR as an image or waveform? Should all immunization history and all childhood growth data be exported? Should there be different standards for EP versus EH EHRs with regards to which data elements to export and how far back historically to include? ONC recognizes that some data elements do not need to be transferred into the new EHR but instead need to be archived and made available through some other non-EHR mechanism. What non-EHR mechanisms for storing, retrieving and displaying these archived data are available? Are there standards and services available to accomplish this? What are the risks and harms of requiring EHR vendors to provide data portability beyond C- CDA summaries? What are the risks and harms of not advancing the current state of data portability beyond C- CDA summaries? 11

Specifying Transition Content Existing MU2 recommendation language for a “Transition of care/referral summary” CCD/C32 (for backward compatibility) CCR (for backward compatibility) Consolidated CDA (CCD, Discharge Summary, or Consult Note) Problems: C-CDA has no “Referral” document type Nursing homes and home health agencies receive these but these document types weren’t designed to meet their needs 12

February 2011 – HHS/ONC awarded $1.7M grant to Massachusetts: I mproving M assachusetts P ost- A cute C are T ransfers ( IMPACT) 13

IMPACT Data Element Survey Gathered input from numerous LTPAC stakeholders and referral/transfer forms ~300 Data elements evaluated 46 Organizations completing evaluation 1135 Transition surveys completed 14

Five Transition Datasets 1.Report from Outpatient testing, treatment, or procedure 2.Referral to Outpatient testing, treatment, or procedure 3.Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) 4.Consultation Request Clinical Summary (Referral to a consultant or the ED) 5.Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency Five Transition Datasets 15

Five Transition Datasets Type 3 Dataset: Office Visit to PHR Consultant to PCP ED to PCP, SNF, etc… Type 4 Dataset: PCP to Consultant PCP, SNF, etc… to ED Type 5 Dataset: Hospital to SNF, PCP, HHA, etc… Hospital, SNF, etc… to HHA PCP to new PCP Five Transition Datasets 16

IMPACT Learning Collaborative: Testing the Care Transitions Datasets 16 organization, 40 participants, 6 meetings over 2 months and several hundred patient transfers… 17

Analyzing Data Elements Helped 18

Comment from Pilot Site Survey “While we knew what ED's and hospitals required, we didn't realize Home Health Agencies needed much more than what we typically sent.” - Skilled Nursing Facility 19

Expanded Transfer of Care Dataset Includes Collaborative Care Plan data elements CCD: ~175 Data Elements Transfer of Care Dataset: ~450 Data Elements Next steps: November 2012 Preliminary Implementation Guide completed December 2012Pilot full Transfer of Care Dataset in 16 facilities March 2013Finish Implementation Guide in S&I Framework May 2013 HL7 Balloting of Implementation Guide for inclusion in Consolidated CDA 20

S&I Framework is a Key Tool in the Standards Toolkit Office of the Chief Scientist National Coordinator for Health IT The Standards and Interoperability (S&I) Framework is a forum for implementers and experts to establish standards and guidance for HIE. The S&I Framework Create a collaborative, coordinated incremental standards process, guided by ONC, with input from Federal Advisory Committees, enabled and led by an open community of industry participants who are interested in solving real-world problems guided by use cases Office of the Deputy National Coordinator for Operations Office of the Chief Privacy Officer Office of Economic Analysis & Modeling Office of the Deputy National Coordinator for Programs & Policy Office of Policy & Planning Office of Science & Technology (formerly known as the Office of Standards and Interoperability) Office of Provider Adoption Support Office of State & Community Programs 21

Longitudinal Coordination of Care Workgroup Patient Assessment Summary Sub- Workgroup LTPAC Care Transition Sub-Workgroup Longitudinal Care Plan Sub-Workgroup Providing subject matter expertise and coordination of SWGs Developing systems view to identify interoperability gaps and prioritize activities Establishing the standards for the exchange of Patient Assessment Summary (PAS) documents Providing consultation to transformation tool being developed by Geisinger to transform the non- interoperable MDSv3 and OASIS-C into an interoperable clinical document (CCD) Identifying the key business and technical challenges that inhibit long-term care data exchanges Defining data elements for LTPAC information exchange using a single standard for LTPAC transfer summaries Near-Term: Developing an implementation guide to standardize the exchange of the Home Health Plan of Care (former CMS 485 form) Long-Term: Identify and develop key functional requirements and data sets that would support a longitudinal care plan Longitudinal Coordination of Care WG 22

Specifying transition content Expand “Summary of Care” to 3 datasets being defined by S&I LCC (which include Care Plan): 1) Consultation Request (Referral to a consultant or the ED, including referral ID#) 2) Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility, including referral ID#) 3) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency) 23

Exchange of electrocardiography What priorities will the exchange of EKGs support? Is the market ready to support the sharing of EKGs? How does the subgroup want to proceed? – Stage 3 – Certification only – Explore in RFC – Push to Stage 4 – No recommendation 24

Next Steps Any resources that should be provided to the subgroup for future calls? DateTopic Tuesday, September 4 th, 2:00-3:00pm ET Goals and Objectives for stage 3 Query Provider Directory Finalize recommendations in all areas 25