1. esMD Harmonization WG Meeting Wednesday, June 13 th, 2012

2. The S&I Framework Standards Evaluation Process Goal of the S&I Framework Standards Evaluation Process: To achieve consensus on applicable and relevant standards to be modified or further developed as a resolution to the health information exchange challenge addressed by the Initiative. The process narrows the initial Candidate Standards List toward Selected Standards to be included in the Initiative’s Recommended Standards consensus statement

3. The S&I Framework Standards Evaluation Process 1.Discuss esMD specific harmonization issues Focus on message and transport standards Code sets, vocabularies, and security standards will be discussed in future meetings 2.Evaluate and analyze standards identified by SDS Use Standards Analysis Workbook to capture findings and rate applicability of each standard to esMD 3.Select standards for further development within esMD initiative Choose standards based on use case and data model requirements and community expertise 4.Draft Standards Recommendation Consensus Statement

4. esMD Harmonization Challenges 1.Two Use Cases – Registration Request & Sending the eMDR Goal is to align both use cases to similar sets of standards 2.Two users – CMS & Commercial Payers Different transport requirements – CMS will use NwHIN – Commercial Payers will not be constrained to use NwHIN 3.Two content requirements – Messages & Documents Use Case 1 – Message to send a registration request and response Use Case 2 – Message to send Structured Content Structured Content – Document – The eMDR Object was envisioned as a persistent document, distinct from the message it is sent in 4.esMD Phase 1 is in use Harmonization effort should consider how choices will affect users of esMD Phase 1

5. Findings: Standards Unsuitable for esMD 1.HL7 MFN, A01/A04, MDM Widely used in clinical systems, but we need to span the gap to billing systems where HL7 messages have limited use. 2.IHE PIX PIX is primarily used to exchange patient demographics and to register relationships between patients and providers. Not used for the exchange of provider demographics. To do so will demand changes and customizations that IHE may not be receptive towards. 3.X12 838 Little adoption in health care industry Unlikely to fully support of Use Case 1 data set requirements

6. Findings: Message and Content Standards 1.X12 274 & 277 Used in billing systems Adopted by payers Align well to data set requirements – 274 supports provider information necessary for registration – 277 supports claims related information 2.IHE HPD Used in provider directories Aligns well to Use Case 1 data set requirements – HPD supports provider information necessary for registration 3.HL7 CDA Used in clinical systems Likely to align well to Use Case 2 data set requirements – CDA should support claims related information Potential bridge between clinical and billing systems

7. Findings: Custom XML 1.Custom XML If CDA does not align well to Use Case 2 dataset requirements, the eMDR object could be developed as a custom XML attachment to a CDA document Strengths – Enables group to fully represent eMDR dataset requirements as envisioned Challenges – Creates a new standard – Unsure who would maintain standard moving forward – ONC prefers initiatives focus on existing standards

8. Findings: Content Neutral Transport 1.IHE XDS/XDR/XDM XDS offers broad and extensible metadata to support handling of payload XDR is appropriate for pushing data over Exchange XDM is appropriate for pushing data SMTP as an email attachment 2.CAQH CORE Connectivity Rules 270 rules include use of HTTP/S transport and batch mode processing Adopted by NwHIN for exchange of X12 messages over Exchange

9. Proposed Focus for Use Case 1 X12 274 IHE HPD NwHIN Exchange CAQH CORE Connectivity using NwHIN X12 274 X12 EDI CAQH CORE Connectivity using NwHIN X12 274 NwHIN Exchange XDR HPD NwHIN Direct XDM HPD XDR CMS: Commercial: CMS: Commercial:

10. Proposed Focus for Use Case 2 X12 277 HL7 CDA NwHIN Exchange CAQH CORE Connectivity using NwHIN X12 277 X12 EDI CAQH CORE Connectivity using NwHIN X12 277 NwHIN Exchange XDR CDA NwHIN Direct XDM CDA XDR CMS: Commercial: CMS: Commercial:

11. esMD Harmonization Challenges 1.Two Use Cases – Registration Request & Sending the eMDR Goal is to align both use cases to similar sets of standards – Content Specific Approach for UC1 and UC2 uses X12 messages – Content Neutral Approach for UC1 and UC2 uses same transport/rules/metadata with different payloads 2.Two users – CMS & Commercial Payers Different transport requirements – CMS will use NwHIN Exchange – Commercial Payers will not be constrained to use NwHIN Exchange 3.Two content requirements – Messages & Documents Use Case 1 – Message to send a registration request and response Use Case 2 – Message to send Structured Content Structured Content – Document – Approaches use either X12 messages or CDA documents 4.esMD Phase 1 is in use Harmonization effort should consider how choices will affect users of esMD Phase 1 – CMS scenario uses similar transport/rules/metadata as Phase 1

12. Harmonization Next Steps 1.Use Case 1 Map data set requirements to X12 274 and HPD 2.Use Case 2 Map eMDR object data set requirements to X12 277 and CDA Map eMDR envelope data set requirements to X12 277 and XDS metadata 3.Use Case 1 & 2 Review mappings and identify gaps Discuss gaps with relevant SDOs If necessary, explore additional standards (e.g. custom XML for Use Case 2) Select one or more standards to support for both CMS and Commercial Payers Develop Implementation Guides for selected standards for CMS and Commercial Payers

13. Round Robin Do the proposed approaches narrow the initial Candidate Standards List to a set of standards that are applicable and relevant to the esMD Use Cases?