1. Stage 3 Update Paul Tang, Chair George Hripcsak, Co-Chair Meaningful Use Workgroup January 28, 2014

2. Workplan DateMeeting Tasks 1/28/14 1:00-3:00 ET PGHD follow-up discussion Review of care coordination & population/public health priorities 2/4/14 Present to recommendations to the HITPC 2/11/14 10:00-12:00 ET Review feedback from HITPC Discuss 2014 workplan 2/19/14 10:00-12:00 ET Possibly cancel? 3/3/14 10:00-12:00 ET MU3 Listening session 3/18/14 10:00-12:00 ET Review feedback from listening session Hearing planning 1

3. Patient Generated Health Data Recommendations John Halamka, HITSC vice chair Leslie Kelly Hall, HITSC Consumer Technology WG, chair 2

4. Engaging patients and families in their care: Patient Generated Health Data 3 Functionality Needed to Achieve Goals *New* Menu: Eligible Professionals and Eligible Hospitals accept provider-requested electronically submitted patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, medication adherence surveys, intake forms, risk assessment, functional status) or secure messaging. Although not a part of the certification criteria, if an organization’s EHR accepts patient-generated information using interfaces to remote devices, such data will count as patient-generated health information. Threshold: Low Stage 3 Functionality Goals Enabling active participation by patients and families to improve health and care Provide ability to contribute information in the record, including patient reported outcomes (PRO) Patient preferences recorded and used

5. PGHD Recommendations Consumer Technology and Clinical Ops WG (I) Overarching recommendations – Concern regarding certification only items, as systems must be engineered to incorporate standards/processes which may not yet be mature – Standards application should be constrained to where they are needed and useful 4

6. PGHD Recommendations Consumer Technology and Clinical Ops WG (II) Where there is a need for patient data sharing, the C-CDA is suitable. C- CDA is recommended as a container for certain types of templates that are well understood (e.g. problems, meds, allergies). – C-CDA over existing (Direct, Exchange) and other modes of transport are reasonable ways to get data in and out of EHRs, PHRs, and patient facing applications – C-CDA should not be required as the architecture that organizations (e.g. ACOs) have to use. The outcome goal is for the entire care team (patient/families/providers) to be able to contribute to an integrated medical record – If unable to integrate, systems must have the functionality to receive C-CDA containing specific templates (e.g. to accomplish the same goal of patients participating in problems, med, and allergy reconciliation) – Need to allow for innovation and flexibility in this space to not unduly constrain options for individuals to connect with their care teams in the ways they prefer in the future. Suggest using the C-CDA template payloads that are sufficiently mature, but not over- specify how they are to be moved about 5

7. PGHD - Devices Need to allow for innovation, as the marketplace is still rapidly evolving – Continua standards are directionally appropriate, but need to align with FDA guidance and other regulatory or sub-regulatory policy without constraining the marketplace – Due to the immaturity of the market, need to allow for the flexible adoption of device data and other remote data source 6

8. Improving care coordination: Stage 3 Priorities 7 Stage 3 Functional Objectives Medication reconciliation Summary of care for transfers of care Summary of care for consult requests and reports Notifications MU Outcome Goals All members of a patient’s care team (including professional healthcare team, patient, and caregivers), as authorized, participate in implementing coordinated care plan Stage 1 + 2 Functional Objectives Medication reconciliation Summary of care for transfers of care Red: Changes to objective Blue: Newly introduced Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

9. Improving care coordination : Medication reconciliation 8 Functionality Needed to Achieve Goals Core: Eligible Professionals, Hospitals, and CAHs who receive patients from another setting of care perform medication reconciliation. Threshold: No Change FAQ: Reconciliation may also be performed for all encounters Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

10. Improving care coordination: Summary of care for transfers of care 9 Functionality Needed to Achieve Goals Eligible Professionals/Eligible Hospitals/Critical Access Hospitals provide a summary of care* record during transfers of care from one site of care to another (e.g., Hospital to SNF, PCP, HHA, home, etc…; SNF, PCP, etc… to HHA; PCP to new PCP) Summary of care may (at the discretion of the provider organization) include: – A narrative that includes a synopsis of current care and expectations for consult/transition – Overarching patient goals and/or problem specific goals – Patient instructions, suggested interventions for care during transition – Information about known care team members (including a designated caregiver) Threshold: No Change Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

11. Improving care coordination: Summary of care for consult requests and reports 10 Functionality Needed to Achieve Goals *NEW* (Related to order tracking objective for tests, images, and consult requests (referrals)) Menu: Eligible Professionals/Eligible Hospitals and CAH provide a summary of care* record that pertains to the type of care transition as indicted below: Types of transitions: – Consult (referral) request (e.g., PCP to Specialist; PCP, SNF, ED, public health etc.) – Consult result note (e.g. ER note, consult note) Summary of care may (at the discretion of the provider organization) include: – A narrative that includes a synopsis of current care and expectations for consult/transition – Overarching patient goals and/or problem specific goals – Patient instructions, suggested interventions for care during transition – Information about known care team members (including a designated caregiver) Threshold: Low *An electronic summary is preferred Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

12. Improving care coordination: Notifications 11 Functionality Needed to Achieve Goals *NEW* Menu: Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to key members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required Significant events include: – Arrival at an Emergency Department (ED) – Admission to a hospital – Discharge from an ED or hospital – Death Notifications should be automatically sent to the provider of record Low threshold Modular certification is encouraged, this does not need to be an EHR function Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

13. Improving population and public health: Stage 3 Priorities 12 Stage 3 Functional Objectives Case reports Registries Sharing immunization data Electronic lab reporting Submission of electronic syndromic surveillance data MU Outcome Goals Providers know the health status of their patient population Public health officials know the health status of their jurisdiction Providers and specialty societies can track and manage domain specific events related to practice and devices Providers and public health officials share information to improve individual and population health Stage 1 + 2 Functional Objectives Patient lists Sharing immunization data Cancer and specialty registry Electronic lab reporting Submission of electronic syndromic surveillance data Red: Changes to objective Blue: Newly introduced Stage 3 Functionality Goals Efficient and timely completion of case reports Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement Shared information with public health agencies or specialty societies Bidirectional public health data exchange

14. Improving population and public health: Case Reports 13 Functionality Needed to Achieve Goals *NEW* Certification criteria CEHRT is capable of using external knowledge (i.e., CDC/CSTE Reportable Conditions Knowledge Management System) to prompt an end-user when criteria are met for case reporting. When case reporting criteria are met, CEHRT is capable of recording and maintaining an audit for the date and time of prompt. CEHRT is capable of using external knowledge to collect standardized case reports (e.g., structured data capture) and preparing a standardized case report (e.g., consolidated CDA) that may be submitted to the state/local jurisdiction and the data/time of submission is available for audit. Stage 3 Functionality Goals Efficient and timely completion of case reports Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement Shared information with public health agencies or specialty societies Bidirectional public health data exchange

15. Improving population and public health: Registries 14 Functionality Needed to Achieve Goals EPs/EHs reuse CEHRT data to electronically submit standardized (i.e., data elements, structure and transport mechanisms) reports to two registries (e.g., local/state health departments, professional or other aggregating resources) Reporting should use one (or more) of these mechanisms: – For uploading information on individual cases to registries, use standard or enhanced (e.g., structured data capture) c-CDA (e.g., early hearing detection and intervention, cancer, or healthcare associated infections), – For large-scale (population-wide) reporting of common conditions, use a modified consolidated CDA to limit protected health information release to community-based, high priority condition registries (e.g., obesity or hypertension), or – Leverage national networks (e.g., FDA Mini-sentinel or DARTNet Institute) or local (e.g., NYC Primary Care Information Project) federated query technologies. CEHRT is capable (certification criteria only) of allowing end-user to configure standard c-CDA file to determine which data will be sent to the high priority condition registries (#2 mechanism above). Registry owners (e.g., health department, professional societies, other aggregating resources) provide participation proof (e.g., letter) Stage 3 Functionality Goals Efficient and timely completion of case reports Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement Shared information with public health agencies or specialty societies Bidirectional public health data exchange