1. EU-US eHealth/Health IT Cooperation Initiative Interoperability of EHR Work Group March 26, 2014 0

2. Meeting Etiquette Participants automatically enter the webinar in “listen only” mode. The organizer will then unmute all participants. We ask if you are not speaking to manually mute yourself NOTE: VoIP participants have the ability to “Mute” themselves by clicking on the green microphone. However, if you would like to speak, only you can unmute yourself. If you are dialing in using a telephone and NOT using the VoIP you MUST dial the audio pin in order for the organizer to unmute you – if you do not use the audio pin and just push # when prompted the Organizer cannot unmute you

3. Meeting Etiquette CONTINUED If you are calling from a telephone, please do not put your phone on hold. If you need to take a call, hang up and dial in again when you have completed your other call This meeting is being recorded Another reason to keep your phone or your VoIP on mute when not speaking Use the “Chat” or “Question” feature for questions, comments and items you would like the moderator or other panelists to know. 2

4. Agenda TopicTime Allotted General Announcements5 minutes Final Report Out from Mapping Sub-Workgroup35 minutes Drafting the White Paper15 minutes Next Steps and Logistics5 minutes 3

5. Meeting Times –CHANGE TO SCHEDULE 4 Washington, DC 10:00 am (EDT ) Eastern Daylight Time Washington, DC 10:00 am (EDT ) Eastern Daylight Time London 15:00 (BST) British Summer Time London 15:00 (BST) British Summer Time Germany 16:00 (CEST) Central European Summer Time Germany 16:00 (CEST) Central European Summer Time Athens 17:00 (EEST) Eastern European Summer Time Athens 17:00 (EEST) Eastern European Summer Time Interoperability Work Group will meet every other Wednesday (through mid-May) Next meeting April 9 th, 2014 We will be back on our regular time schedule (1 hour later for EU team). These times are posted to the left.

6. General Announcements To join our weekly webinars, visit the EU-US eHealth Collaboration Wiki Homepage for the latest meeting information: http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative http://wiki.siframework.org/EU-US+eHealth+Cooperation+Initiative 5 To subscribe to our mailing list, simply complete the EU-US MOU Project Signup Form: http://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Sign+Uphttp://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Sign+Up To submit a brief biography of yourself (150 words or less), review the criteria listed at http://wiki.siframework.org/Interoperability+of+EHR+Work+Group #Work Group Members and e-mail your bio and photo (optional) to Gayathri Jayawardena at gayathri.jayawardena@esacinc.com http://wiki.siframework.org/Interoperability+of+EHR+Work+Group #Work Group Membersgayathri.jayawardena@esacinc.com To access current and archived meeting materials, visit the Project Meeting Artifacts section: http://wiki.siframework.org/Project+Meeting+Artifac ts http://wiki.siframework.org/Project+Meeting+Artifac ts

7. 6 (Clinical Summary Form) (Clinical Summary Form) (document ID, author, patient ID…) (document ID, author, patient ID…) [Body] [Procedures] (Colonoscopy) [Gastroscopy] [CABG] … (Colonoscopy) [Gastroscopy] [CABG] … [Current Medications] … [ASA] [Warfarin] [CABG] [ASA] [Warfarin] [CABG] Phase 1 Section level mapping between epSOS and CCD Phase 2 Header’ Data Element mapping Phase 3 Sections’ Data Element mapping Phase 4 Value Set (VS) mapping Completed Data Granularity and Complexity Phases of Harmonization

8. Comparative Analysis – in numbers Analysis/Map ping Type CCDAepSoSStatusGaps Header Data Elements (DEs) ~100 DEs Review complete. All but several epSoS DEs are mappable to CCDA. Mapping and gap details documented in excel (for now) CCDA provides a lot more DEs and attributes than epSoS. epSoS contains some DEs (such as primary health care provider for EU citizen traveling to another EU country) not in CCDA. Section Level18 sections16 sectionsAll sections mapped.epSoS Active Problems and Hx of Past illnesses map to Problem Section in CCDA. CCDA sections such as Advance Directive, Encounters, Family History and Payers are not in epSoS. Section Data Elements (DEs) Significantly more DEs (~2x or more) ~70 DEsFirst Pass completed. Second pass completed. CCDA CCD has significantly more Data Elements than epSoS. There are about 10 epSoS DEs not in CCDA CCD. IG guides on both ends do not specify all information that CDA schema allows. Value Sets74 Value Sets (not used by CCD) 45 Value Sets (not all used by PS form) Review completed. Scope: overlapping VSs. Some for HL7 VS. Many for clinical vocabularies.

9. DE Mapping Review – few highlights Procedures (g): – @code – @displayName – OriginalText Vitals (m/g): – epSoS: syst/dias BP (2 codes) – CCDA CCD: syst/dias BP, HR, weight, height…etc (12 codes) Results (m/g): – epSOS: Blood Group – CCDA CCD: ANY Result 8

10. Value Set mapping - highlights Value Sets mapping completed in last week: – INDRoleClass – documentCode – VitalSigns – Clinical VS: ATC-RxNorm Diseases/Problems: ICD10-SNOMED CT 9

11. Value Set mapping – highlights…cont Common types of issues: – Code system same but different code subsets used (typical for SNOMED CT and HL7 codes) – Code system different AND codes have different granularity (1 to M maps). E.g: epSoSIllnessesandDisorders (ICD10) – CCDA Problem VS (SNOMED CT) epSoSActiveIngredient (ATC) – RxNorm epSoSVaccines - CVX 10

12. Diseases/Problems VS EU VS: 9,529 codes (ICD10CM) US VS: 16,443 codes (SCT) – epSoS -> SNOMED CT 11 epSoS ICD10 codes Mapped SNOMED CT codes 7%1 6%2 5%3 15%4-9 7%10-19 3%20-49 1%50-99 1%~100-350 55%No maps epSoS ICD10 codes Mapped SNOMED CT codes 11%1 7%2 5%3 14%4-9 3%10-19 1%20-49 1%50-99 <0.05%>100 58%No maps Map rule: relaxed vs. strict Map rule Relaxed Strict # SCT codes 1 2 3100 101,… Code “Bandwidth” More spec. ICD10 Less spec. ICD10 Case: relaxed -> strict (one code) RelaxedStrict 360 ->3 250 ->180

13. One-to-many 12 Relaxed (#360) Strict (#3)

14. Next Steps: White Paper/Technical Report – Summarize analysis/mapping outcomes – Provide Mapping: Sections Overlapping Des Overlapping Value Sets Value Set codes – Publish within HL7 and S&I – Guidance for new International Template for Patient Summary INT Template Development and Value Set development IG development – Ballot through HL7 and ISO 13

15. Next Steps (cont.) 1.Identification of most common subsets from the common, international vocabularies — LOINC, ICD10, SNOMED, and ATC/RXNORM (others?). 1.“shrinks the change” and makes it easier for us to do value-set mappings between attributes that use ICD10 in the US and SNOMED in another country. 2.It provides the tools to the industry so that they can internalize these standards, be certified to these standards, and create their own internal mapping constructs/tools based on these subsets. 2.Creation/Harmonization of an internationally recognized, balloted standard for transitions of care. 1.This can start at the intersection of the attributes between US and EU, and expand to include both US and EU attributes. 2.The goal is to ballot internationally recognized standard for transitions of care in HL7 and then in ISO, and for it to be more constrained version of the CCDA CCD. 3.This would mean we can certify EHR products to these specifications, and we should be able to exchange documents on international level. 3.Create policy goals across member states that allows a patient to get an electronic copy of their transition of care document. 1.This empowers patients, makes the infrastructure easier, and avoids many obstacles that exist within existing governments about sharing patient information.

16. New International Patient Summary INT template (HL7/ISO) EU Patient PHR EHR US Physician 1 1 Log on 2 2 Retrieve INT version on Patient Summary 3 3 View INT Patient Summary within EHR 15 INT Patient Summary Header document ID, author, patient ID…etc. Header document ID, author, patient ID…etc. Body Problems/Diagnosis Problem Code & Name Problem Start Date Problem End Date …. Problem Code & Name Problem Start Date Problem End Date …. Medications, Vital Signs…etc. [ASA] [Warfarin] [CABG] [ASA] [Warfarin] [CABG] EHR Problem code SHOULD be SNOMED CT Value Set or ICD-10-CM Value Set MAY have 0..* (local codes) DE vocabulary constraints Top SNOMED CT codes OR Top ICD10 codes (based on SCT to ICD10 cross-maps) Top SNOMED CT codes OR Top ICD10 codes (based on SCT to ICD10 cross-maps) Constrained, HIGH FREQUENCY Value Set 17890003 (Hepatic infarction) <code code=“17890003 ” codeDisplayName=“Hepatic infarction” codeSystem=“SNOMED CT” <code code=“17890003 ” codeDisplayName=“Hepatic infarction” codeSystem=“SNOMED CT” Example HTML Corresponding XML 123XYZ (Leberinfarkt) K76.3 (Infarction of liver) <code code=“K76.3” codeDisplayName=“Infarction of liver” codeSystem=“ICD-10-CM” <code code=“K76.3” codeDisplayName=“Infarction of liver” codeSystem=“ICD-10-CM” 239-2 (Infarkt jetre) Example

17. New Value Set Maintenance (e.g. IHTSDO) 16 17890003 (Hepatic infarction) Today, SNOMED CT is available in US English, UK English, Spanish, Danish and Swedish. Translations into French, Lithuanian, and several other languages are currently taking place! Current SNOMED CT: 400,000 codes High frequency VS: Top 5,000 codes -> focuses translation efforts AND utilization Adopt (eng.) Adopt (sp.)/ Deposit (gn.) Adopt (fr.)/ Complete (fr.) Adopt (eng.)/ Deposit (hr.) Adopt (eng.) Adopt (eng.)/ Deposit (np.)

18. 17 Mar- Apr 4May- Jun ‘14Jul- Aug ‘14Sept- Oct ’14Nov- Dec ‘14 Milestones HL7 Ballot (Aug 8- Sept 8) EU-US HL7 Project Scope Statement (May 18) INT template design Ballot Preview Period HL7 HL7 Notification of Intent to Ballot (June 29) HL7 Initial Content Due (Jul 13) HL7 WG Meeting (Sept. 14-19) HL7 Final Content Due (Aug 3) White Paper Report EU-US Timeline for 2014 Paper published (May) INT template IG (Jul 5) HL7 Ballot Package Development HL7 Ballot Reconciliation Value Set development IG development/Review

19. White Paper Discussion We are going to work be working on a white paper in addition to the harmonized template The white paper will provide an overview of the outcomes of the mapping exercise and incorporate the detailed mapping spreadsheets as well as discuss the differences between epSOS to CCD sections We will be working on the white paper in the Interoperability WG sessions We will NOT meet next week Meetings will resume on Wednesday, April 9 th 18

20. 19 Next meeting will be on Wednesday, March April 9th, 2014 at 10:00 am (ET)/16:00 pm (EET) Now through mid May we will be meeting every other week – During the off weeks we will be drafting the white paper Community Calls will be a review and input of the drafted white paper Community will also be provided updates on the Templates work resulting from the mapping activities Next Meeting

21. 20 US Point of Contacts – Mera Choi, Mera.Choi@hhs.govMera.Choi@hhs.gov – Jamie Parker, jamie.parker@esacinc.comjamie.parker@esacinc.com – Gayathri Jayawardena, gayathri.jayawardena@esacinc.comgayathri.jayawardena@esacinc.com – Amanda Merrill, amanda.merrill@accenturefederal.comamanda.merrill@accenturefederal.com – Mark Roche, mrochemd@gmail.commrochemd@gmail.com – Virginia Riehl, virginia.riehl@verizon.netvirginia.riehl@verizon.net EU Point of Contacts – Benoit Abeloos, Benoit.ABELOOS@ec.europa.eu Benoit.ABELOOS@ec.europa.eu – Frank Cunningham, frank.cunningham@ec.europa.eufrank.cunningham@ec.europa.eu – Catherine Chronaki, chronaki@gmail.comchronaki@gmail.com Project Support Team

22. Initiative Resources EU-US Wiki Homepage – http://wiki.siframework.org/EU- US+eHealth+Cooperation+Initiative http://wiki.siframework.org/EU- US+eHealth+Cooperation+Initiative Join the Initiative – http://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Sign+Up http://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Sign+Up EU-US Initiative Reference Materials – http://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Reference+Materials http://wiki.siframework.org/EU- US+MOU+Roadmap+Project+Reference+Materials Interoperability of EHR Homepage – http://wiki.siframework.org/Interoperability+of+EHR+Work+Gr oup http://wiki.siframework.org/Interoperability+of+EHR+Work+Gr oup 21