October 2, 2008 | 2:00 – 3:30 pm (Eastern)

1. Quality • October 2, 2008 | 2:00 – 3:30 pm (Eastern) • Presenters HITSP Population Perspective Technical Committee • Floyd Eisenberg, MD, MPH, Senior Key Expert, Siemens Healthcare and co-chair of the Population Perspective TC • Lori Fourquet, e-HealthSign, LLC

2. Learning Objectives During this 90-minute webinar, participants will explore the population perspective of health information sharing for quality, gaining a basic knowledge of: quality measure specification data element types and value sets defining and selecting a sub-population of patients (measure denominator) defining and identifying expected interventions (measure numerator) terminology issues in identifying inclusion and exclusion criteria a webinar series on U.S. healthcare interoperability (continued)

3. Learning Objectives (continued) expectations for information transfer from EHRs to quality reporting organizations HITSP specifications for quality information sharing the relationship of the quality use case and interoperability specification to other efforts for public health and for data repurposing a webinar series on U.S. healthcare interoperability

4. Quality Quality Measure Specification Clinical Data for Analysis Inclusion Criteria Exclusion Criteria Quality Reporting Security and privacy requirements for Quality HITSP Interoperability Specification for Quality (HITSP IS 06) Units of Exchange Health Information Summary Documents Health Information Messages Conformance Subsets Questions and Answers Agenda a webinar series on U.S. healthcare interoperability

5. Introduction: Steve’s Story . . . part six Patient is a 26-year-old male coping with the long-term effects of a brain tumor that was removed during his childhood Patient is assisting with home care for his grandfather, a recent widower and diabetic who has become despondent and non-compliant with self-care requirements The family is becoming concerned about the quality of care Steve’s grandfather is receiving A search for new providers and a successful diabetes program is being conducted by the family Fact-based information is needed, more than practice locations, hours of operation, frequency of procedures and anecdotes based on reputation, e.g., Critical care information such as comparative outcomes of care for diabetic patients and those with depression General preventive care success factors

6. HITSP is a volunteer-driven, consensus-based organization that is funded through a contract from the Department of Health and Human Services. The Panel brings together public and private-sector experts from across the healthcare community to harmonize and recommend the technical standards that are necessary to assure the interoperability of electronic health records. Overview

7. The HITSP Standards Harmonization Framework Identify a pool of standards for an AHIC (American Health Information Community) Use Case Identify gaps and overlaps in the standards for this specific Use Case Make recommendations for resolution of gaps and overlaps Select standards using HITSP-approved Readiness Criteria Develop Interoperability Specifications (IS) that use the selected standard(s) for the specific context Test the IS Deliverables and Mode of Operation

8. Each HITSP Interoperability Specification defines a set of “constructs” that: specify how to integrate and constrain selected standards to meet the business needs of a Use Case; and define a Roadmap to use emerging standards and to harmonize overlapping standards when resolved. In essence, a HITSP IS represents a suite of documents that integrate and constrain existing standards to satisfy a Use Case Deliverables and Mode of Operation

9. HITSP construct types, in decreasing breadth of scope, include: Interoperability SpecificationsIntegration of all constructs used to meet the business needs of a Use Case Transaction PackagesLogical grouping of transactions TransactionsLogical grouping of actions that use components and/or composite standards to realize the actions ComponentsLogical grouping of base standards that work together, such as messaging and terminology Deliverables and Mode of Operation

10. IS Status = State in the acceptance process ReleasedPanel approved for submission to HHS AcceptedSecretary of HHS has accepted for a period of testing RecognizedSecretary of HHS has recognized the IS for immediate implementation Revisions and updates may mean that multiple versions of some Interoperability Specifications exist with differing status levels Deliverables and Mode of Operation

11. Current Interoperability Specifications (IS)

12. IS 06 Quality This Interoperability Specification defines specific standards that capture the integration of data to support quality measurement feedback and reporting into electronic health records (EHRs), use of quality measures to support clinical decision making, and public reporting of healthcare quality through the exchange of data between healthcare organizations and providers and public health via an electronic network. Version: 1.0 Recognized Version 1.0.1 Panel Review Healthcare Provider Quality Reporting Organizations IS 06 VIA AN ELECTRONIC NETWORK

13. Hospital-based quality measures Automate data capture and reporting of Hospital Quality Alliance (HQA) measures through EHRs in support of provider workflows Communicate HQA measure data to external agencies Clinician-level data Automate data capture and reporting of Ambulatory Quality Alliance (AQA) measures through EHRs in support of provider workflows Communicate AQA quality measure data to external entities for aggregation and reporting IS 06 QualityOverall Objectives

14. IS 06 QualityOverall Objectives(continued) • Feedback to Clinicians • enable real-time or near-real-time feedback regarding specific quality indicators which are relevant for a particular patient • enable provision of tailored performance information to clinicians on quality measures for specific patient groups (continued)

15. IS 06 QualityOverall Objectives(continued) • Public Reporting • Aggregate data across multiple sources (claims data, medication data, laboratory data, etc.) • Support quality measurement, promote accountability among providers, and aid consumers in making informed choices • Communicate quality measurement data quickly and clearly in a manner that makes it useful to a wide variety of decision makers (patients, healthcare providers, payers, health plans, and regulators who are involved with this process)

16. Ancillary Entities Clinicians Consumers Government Healthcare Agencies Healthcare Delivery Organizations Health Information Exchange Health Information Management Personnel Health Information Technology System Developers Healthcare Payers Healthcare Purchasers Health Researchers Processing Entities Public Health Agencies Quality Organizations IS 06 QualityStakeholders

17. IS 06 QualityRequirements • Quality Measure Specification • Structured and codified • Denominator and Numerator Inclusions – Value Sets • Denominator and Numerator Exclusions – Value Sets • Data Capture / Aggregation • Data Reporting to External Agencies

18. IS 06 QualityRequirements (continued) Integrating the Healthcare Enterprise (IHE) Quality, Research & Public Health Domain, Performance Measurement Value Set White Paper, August 2008

19. Hospital-based care IS 06 QualityPerspectives Clinician / Ambulatory-based care

20. Healthcare Information Technology Expert Panel (HITEP) Convened by the National Quality Forum (NQF) Identified 84 Institute of Medicine (IOM) High Priority Measures Common data types Reduce logic to common data types Analyze frequency 88 Data Elements (9 additional subtypes added by HITEP) Facility / clinician demographics Patient demographics Clinical data IS 06 Quality Data Elements / Types

21. Clinical Data Elements Problem Data Diagnosis Data Allergy / Adverse Reaction Vital Signs Procedures and Diagnostic Tests Medication Data Study Findings/Test Results – Laboratory Study Findings/Test Results – Radiology and Other Studies Other (e.g. clinician-clinician communications, provider-patient communications, care classification-”comfort measure only,” clinical trial) IS 06 QualityData Elements / Types / Examples • Base Facility Data Elements • Identifier • Name • Location • Patient Data Elements • Pseudonymized Data Linker • Encounter Date/Time • History • Birth • Gender • Visit Data • Location • Discharge • Death

22. IS 06 Quality Main Business Actors Processing Entity / HIE Document-Based Transmission Hospital Clinician/Ambulatory Provider Quality Measurement Organization Message-Based Transmission Measurement Consumer Other Communities

23. MDO MDO MDO NQF IS 06 Quality Implementation Option #1: EHR does the work Acronym Legend MDO – Measure Development Organization NQF – National Quality Forum measure endorsement, maintenance, syndication, and live broadcast EHR Quality Measure imported Quality Measure Quality report detail exported Quality Report EHR creates patient data summary internally, uses imported measure to calculate quality scores and export quality report Patient Data

24. MDO MDO MDO NQF IS 06 Quality Implementation Option #2:Quality Improvement Organization (QIO) / HIE Acronym Legend HIE – Health Information Exchange MDO – Measure Development Organization NQF – National Quality Forum measure endorsement, maintenance, syndication, and live broadcast Quality Measure imported QIO Message EHR Quality Measure Data transmit Quality report detail exported Patient Data Clinical Data imported Quality Report Document QIO uses imported Quality measures and clinical details to calculate quality scores and export Quality report Quality data assembled internally

25. IS06 QualityTraditional HL7 Messaging

26. IS06 QualityDocument Sharing

27. IS06 QualityAssembly of Patient-Level Quality Data

28. IS 06 Quality New Constructs for IS06 Query for Existing Data (NEW) TP 21 Supports dynamic queries for clinical data to gather patient-level quality data elements Patient Level Quality Data Message (NEW) Patient Level Quality Data Document (NEW) C 34 C 38 Support the process of sending patient-level quality data to an aggregator for analysis and aggregation of quality measures Patient Demographics Query (NEW) T 23 Provide a list of patients and their demographics

29. IS 06 Quality Privacy and Security Secured Communication Channel Collect & Communicate Security Audit Trail T 17 T 15 Ensure the authenticity, integrity, and confidentiality of transactions, and the mutual trust between communicating parties Record audit event in repository Consistent Time Access Control T 16 TP 20 Provides a mechanism to ensure that all the entity systems communicating within the network have synchronized system clocks Ensure that an entity is the person or application that claims the identity provided Nonrepudiation of Origin C 26 Describes the mechanisms to define and identify security relevant events and the data to be collected and communicated as determined by policy, regulation or risk analysis. It also provides the mechanism to determine the record format to support analytical reports that are needed.

30. IS 06 Quality Privacy and Security Entity Identity Assertion Anonymize C 19 C 25 Ensure that an entity is the person or application that claims the identity provided Provides specific instruction for anonymizing data that is ready for repurposing. Anonymization: According to the International Organization for Standardization (ISO), is the process that removes the association between the identifying data set and the data subject. Manage Consent Directives Pseudonymize TP 30 T 24 Defined to support pseudonymization of protected health information. Pseudonymization : The process of supplying an alternative identifier that permits a patient to be referred to by a key that suppresses his/her actual identification information Deals with the capture and communication of patient consent directives and non-patient originated authorizations for disclosure of health information

31. IS 06 Quality Infrastructure Patient ID Cross-Referencing Manage Sharing of Documents TP 22 T 13 Deals with identifying and cross-referencing different patient attributes for the same patient. Facilitates the registration, distribution and access of patient electronic health records across health enterprises Notification of Document Availability Retrieve Form for Data Capture T 29 TP 50 Supports public health authority reportable conditions monitoring and management. Enables capture of supplemental data variables not typically maintained in an electronic health record or laboratory information system Notifies its recipient that a document is available and provides the information needed to retrieve the document Transfer of Documents on Media (NEW) Document Reliable Interchange (NEW) T 33 T 31 Supports media interchange of metadata and documents Supports a point-to-point interchange of metadata and documents

32. IS 06 Quality Future Direction Measurement Criteria Document Measurement Criteria Message TBD TBD Current Activities: Collaborative for Performance Measure Integration with EHR Systems National Committee for Quality Assurance (NCQA) American Medical Association (AMA) Electronic Health Records Association (EHRA, formerly EHRVA) http://www.ama-assn.org/ama/pub/category/18352.html New Constructs Required

33. IS 06 Quality Future Direction(continued) Quality Measurement Message Quality Measurement Document TBD TBD Current Activities: Quality Reporting Document Architecture (QRDA) September 2008 Ballot – HL7, Vancouver, BC New Constructs Required

34. IS 06 Quality Future Direction(continued) Validation, Data Quality Checking Derived Information TBD TBD Quality check of the output for a quality report Describe how to derive information from existing data element, e.g., duration of medication from frequency and # dispensed. Case Review Message Case Review Document TBD TBD Feedback mechanism to the provider to assure patients represented in the quality report are valid; review step New Constructs Required

35. Re-UseApplying an existing construct to more than one IS Re-PurposeUpdating a construct to meet the needs of a new Use Case Can extend or constrain when reusing or re-purposing Specifications contain a common superset Superset can be extended as new requirements are encountered Superset can be constrained with use-specific constraints Units of Information Exchange HITSP IS Constructs - Re-Use and Re-Purpose Constructs (single purposeor reusable) Type 1: Base or Composite Standards

36. Effective interoperability Quality Measurement is based on existing EHR available data Reporting is processed in a standard, machine readable format Current activities that increase data entry for quality measurement are reduced Implementation is flexible for local architecture Data are secure and private Near real-time feedback is available for clinicians Information is available for consumers to make healthcare choices IS 06 Quality Strengths

37. Steve’s story . . . the future Patients can make informed decisions about the ongoing care of themselves and their family members consumers have access to quality and safety reports about individual providers and care facilities Data is collected automatically during routine care and reused for performance measurement Outcome data is available for determining best care protocols, enables standards-based and evidence-based care Reports are standard and comparable enabling true benchmarking and continuous improvement Transparency is the rule Decision support is part of the workflow, with useful safety alerts 

38. Healthcare in an interoperable world . . . The Future is Now HIT data exchange is becoming transparent so that the quality of care delivered by providers and hospitals can be known no matter where the patient is located Consumers are empowered to get the right information at the right time find appropriate, quality and safe care for themselves and their families assume that repeatable information will be safe and secure while also being accessible by those who need it – before, during and after a visit to a care provider Care providers are empowered to provide safe, effective and evidence-based care with information integrated within a clinical care workflow

39. Use or specify HITSP Interoperability Specifications in your HIT efforts and in your Requests for Proposals (RFPs) Ask for CCHIT certification Leverage Health Information Exchanges to promote HITSP specifications to make connections easier in the future Ask . . . Is there a HITSP standard we could be using? Get involved in HITSP . . . Help shape the standards How YOU can become involved

40. How YOU can become involved Learn more about specific HITSP activities in these webinars available for replay:         

41. Webinar Series II Coming soon Stay Tuned – same time Thursdays — 2:00-3:30 pm EDT Send your Webinar ideas to hitsp@ansi.org

42. Join HITSP in developing a safe and secure health information network forthe United States. Visit www.hitsp.orgor contact . . . Michelle Deane, ANSI mmaasdeane@ansi.org Re: HITSP, its Board and Coordinating Committees Jessica Kant, HIMSS Theresa Wisdom, HIMSS jkant@himss.orgtwisdom@himss.org Re: HITSP Technical Committees

43. A Successful Collaboration Interweaving many different standards to address business needs A successful collaboration between HITSP and several HITSP member organizations developing base standards and implementation guides/profiles

44. Sponsor Strategic Partners www.HITSP.org

45. Quality Questions and Answers