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Meaningful Use Workgroup

Meaningful Use Workgroup. Paul Tang, Chair George Hripcsak, Co-Chair. December 20, 2013. Meaningful Use Workgroup Members. J . Marc Overhage , Siemens Healthcare Patricia Sengstack , Bon Secours Health Systems Charlene Underwood, Siemens Michael Zaroukian, Sparrow Health System

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Meaningful Use Workgroup

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  1. Meaningful Use Workgroup Paul Tang, Chair George Hripcsak, Co-Chair December 20, 2013

  2. Meaningful Use Workgroup Members J. Marc Overhage, Siemens Healthcare Patricia Sengstack, Bon Secours Health Systems Charlene Underwood, Siemens Michael Zaroukian, Sparrow Health System Amy Zimmerman, Rhode Island Office of Health & Human Services Federal Ex officios Tim Cromwell, Department of Veterans Affairs Joe Francis , Veterans Administration Greg Pace, Social Security Administration Martin Rice, HRSA Robert Tagalicod, Centers for Medicare & Medicaid Services, HHS Chairs • Paul Tang , Palo Alto Medical Foundation • George Hripcsak, Columbia University Members • David Bates , Brigham and Women’s Hospital • Christine Bechtel , National Partnership for Women & Families • Neil Calman, The Institute for Family Health • Arthur Davidson, Denver Public Health Department • Paul Egerman, Businessman/Entrepreneur • Marty Fattig, Nemaha County Hospital Auburn, Nebraska • Leslie Kelly Hall, Healthwise • David Lansky, Pacific Business Group on Health • Deven McGraw , Center for Democracy & Technology

  3. Workplan 2

  4. Review of Population and Public Health Objectives Stage 3 MU Arthur Davidson, MD, MSPH Meaningful Use Workgroup December 20, 2013

  5. Agenda • Review Stage 1 Public/Population Health Meaningful Use Measures • Review Public Health Efforts Regarding Standards and Interoperability Framework Components • Review of proposed Stage 3 Meaningful Use Measures

  6. Hospital 1st v. 2nd v. 3rd yearPH Menu Objective Performance Source: CMS Presentation – Rob Anthony, December 4, 2013

  7. Update on Current Measures: - Immunization, ELR, SS • Immunization • New guide provides improvements • Progress with providers is better • ONC test criteria are making interoperability better • PH moving toward accepting data coming form certified products • Next version (Feb 2014) of Implementation Guide (IG) will include bi-directional w/ History and forecast back to provider • Electronic Laboratory Reporting (ELR) • New version of IG is available to HL7 members and includes many improvements • Syndromic Surveillance (SS) • Successful centralized infrastructure utilizing BioSense • http://www.hl7.org/dstucomments/showdetail.cfm?dstuid=104

  8. Electronic Laboratory Reporting (ELR) – Pattern of Adherence to Standards • Public Health has consistently made efforts to abide by standards and in turn minimize impact on clinical partners • Proof of PH’s commitment to build on standards and processes used for other use cases,. • ELR Release 1 (HL7 Version 2.5.1: ORU^R01)1was built on the HISTP Lab-to-EHR Implementation Guide • ELR Release 2 is the current profile for Electronic Laboratory Reporting to Public Health (MU Stage 1 and 2). • Public health has demonstrated readiness for standards and will credibly achieve that for Stage 3. http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/opi/infectious%20disease%20surveillance/v251_IG_LB_LABRPTPH_R1_INFORM_2010FEB.ashx

  9. Key Principle for PH Stage 3 MU • Adhere to Standards and Interoperability Framework Components Whenever Feasible

  10. Cancer Reporting • Stage 3 MU Cancer Implementation Guide (IG) should move to consolidated clinical document architecture (c-CDA) because: • EHR vendors are required to use this format for Transition of Care documents in Stage 2 MU • eliminates burden of supporting two different formats for cancer reporting • c-CDA has harmonized and improved templates across multiple sources • cancer program is ready to move to this new standard

  11. Cancer c-CDA: Next Steps • Align Cancer IG sections with c-CDA sections (high level completed) • Add a new document-level template c-CDA R2: "Ambulatory Healthcare Provider Cancer Event Report” • Add Cancer Diagnosis Section to c-CDA • Perform Gap and Overlap analysis of entries, data elements, attributes, and value sets • Put new document through HL7 ballot process Timeline • High level gap analysis performed in November 2013 • Detailed gap/overlap analysis work starting in January 2014 • Ballot in May 2014

  12. Public Health and c-CDA - Progression for some areas 2012 2013 2014+ Pertussis (NY State) EHDI (N. Dakota) Cancer Registry Pertussis (San Diego) EHDI (Oregon) Tuberculosis (Delaware)

  13. Electronic Healthcare Associated Infection (HAI) Detection and Reporting: Supporting Patient Safety CDC Reporting system publishes facility-specific HAI data • Specifications: • eMeasures • Decision rules • Computer code Healthcare Reporting system provides protocol and algorithm Public Health Publicly Reported HAI data Executable expressions of detection and case reporting algorithms Reporting protocol for HAI CMS • CDA transmission: • Manual upload • Automated send NHSN CDC Programs HeD Electronic HAI Report Clinical Document Architecture (CDA) • Electronic • systems: • EHR • Pharmacy • ADT • Lab Additional rules applied to populate full HAI report HAI detection rules applied to patient-specific data Healthcare Facility

  14. Progress : What’s been completed CDA/SDC for Public Health Pilot Projects Public Health Reporting Architecture Continuity of Care Document (CCD) (pre-population data) Public Health Infrastructure Or Health Information Exchange (HIE) CDA-based Case Reports: Tuberculossis Pertussis Newborn Hearing Screening Outcome Report Provider Public Health Electronic Health Record System Information Systems: Surveillance Systems EHDI System Public Health Information Systems Delaware Electronic Reporting Surveillance System (DERSS) New Your State Universal Public Health Node (UPHN) San Diego County (Atlas Public Health) Oregon EHDI System (Filemaker) North Dakota EHDI System (OZ Systems) EHR Vendors Core Solutions Connexin Allscripts (Test Harness) Epic 2012 (Test Harness) Public Health Infrastructure (Orion Rhapsody) HIE (OZ Systems) • Request Form • 2. Provide pre-population data Form Manager Form Manager Form Filler 3. Pre-populated Report Form Form Receiver Form Receiver 4. Populated Report Form Content Creator Content Creator • Send–Receive • CDA Report Content Consumer 15 Sources: Communicable Disease CDA Pilot Project Report. 2012. URL: https://wiki.phdsc.org/index.php/CDA EHDI CDA Pilot Project Report. 2013. URL: https://wiki.phdsc.org/index.php/EHDI-Pilot

  15. Communicable Disease Reporting – CDA/SDC Pilot in NYC and WI Current Progress (as December 2, 2013) – Finalize Testing in Vendor Environment • Key Outcomes • Shift in tradition al public health case report (PHCR) use case • Leverage existing standard (i.e., CCD -> cCDA) • Light-weight service for EMR vendors to connect to various jurisdiction reporting end-points • Minimize development in EMR System • Extensibility/ portability to other EMR vendors • State and LHD can configure forms based on reporting and business needs specific to jurisdiction Electronic Medical Record (EMR) Vendor Test Environ-ment (i.e., EPIC) NYC and WI Public Health Infrastructure Continuity of Care Document (CCD) Reporting Module/Form Manager • Parse • Retrieve Form • Pre-populate web form 4. Send URL with pre-populated web form Electronic Disease Surveillance System 5. Physician/ICP submits addition information directly to system Next Steps – Identify, Recruit, and Implement in Hospital using EPIC EMR System State/Local Surveillance System

  16. Structured Data Capture (SDC) • - Tiger Team and Selected Pilots • Public Health Tiger Team • Community based effort to identify, develop, and implement SDC Public Health Pilots • Proposed Public Health Pilots • EHDI • Cancer Reporting • Case Reporting http://wiki.siframework.org/Public+Health+Tiger+Team+Meeting+Archives 17

  17. Health eDecisions - Use Cases • Use Case 1: standard format for sharing CDS knowledge artifacts • Rules, order sets and documentation templates • Goal: CDS knowledge authored in standard format can be imported and used in any EHR system • Use Case 2: standard interface for accessing CDS Web services • Goal: CDS capability encapsulated using standard interface can be integrated with any EHR system 19

  18. Health eDecisions– Use Case 1 (CDS Artifact Sharing) Use Case 1 Focuses on three artifact types: Event Condition Action Rules Order Sets Documentation Templates 20

  19. Health eDecision - Use Case 1: Pilot Partnerships 21 RCKMS: Reportable Condition Knowledge Management System

  20. RCKMS Long term Scope Reportable Condition Knowledge Management System (RCKMS) Public Health State, Local, Territorial Agencies PH Reports Authoring Framework PH Reporters (Clinicians) Query/View Hospital Labs Database Who, What, When, Where, How Subscription Management Including Notifications LIMS Web Service EHR Other Web Services Ambulatory Care Structured Output Generator (3) Open CDS Local National, Clinical & Public Health Laboratories LIMS EHR DSS Web Service (2) Open CDS HeD HeD Compliant format - Triggering Criteria - Reporting Actions - Links (1) Health eDecision (Hed) • Output file Options • HeD file download • OpenCDS in Cloud • OpenCDS Locally Deployed 22

  21. S&I Data Access Framework Use Cases 23

  22. Data Access Framework- examples

  23. Improving population and public health: Stage 3 Priorities Target Outcome Goals MU Outcome Goals Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives • 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 • 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 • Patient lists • Sharing immunization data • Cancer and specialty registry • Electronic lab reporting • Submission of electronic syndromic surveillance data 25

  24. Improving population and public health: Case Reports Functionality Needed to Achieve Goals 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 • CEHRT uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit. • Recommended as certification criteria only 26

  25. Improving population and public health: Registries Functionality Needed to Achieve Goals 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 • EPs/EHs use CEHRT to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) • EP/EH Registries examples: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. EHs Only: health-care associated infections 27

  26. Improving population and public health: Immunization history Functionality Needed to Achieve Goals Stage 3 Functionality Goals • Eligible Professionals, Hospitals, and CAHs receive a patient’s immunization history supplied by an immunization registry or immunization information system, allowing healthcare professionals to use structured historical immunization information in the clinical workflow • Recommended CEHRT Functionality • Ability to receive and present a standard set of structured, externally-generated immunization history and capture the act and date of review within the EP/EH practice • 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 28

  27. Improving population and public health: Electronic lab reporting Functionality Needed to Achieve Goals 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 No Change from Stage 2 EH Objective: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practiceMeasure: Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period. 29

  28. Improving population and public health: Syndromic Surveillance Functionality Needed to Achieve Goals 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 No Change from Stage 2 EP MENU Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practiceEH Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice EP/EH Measure: Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period 30

  29. Former Objective Details Proposed Merged Registry Objective(404, 405, 407 - EH objective) EH Objective:   Capability to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) from the Certified EHR Technology, except where prohibited, and in accordance with applicable law and practice. This objective is in addition to and does not replace prior requirements for submission to an immunization registry. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of standardized reports from the CEHRT to two registries (either mandated or voluntary)).  Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. Registries include: cancer, health-care associated infections, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community) should maintain the registry Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to an external mandated or voluntary registry, maintain an audit of those reports, and track total number of reports sent.

  30. Former Objective Details Case reports – 402B Certification ONLY

  31. Affordable care:Stage 3 Priorities MU Outcome Goals Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives • CDS support to avoid duplicative care • CDS support to avoid unnecessary or inappropriate care • Eliminate duplicative testing • Use cost-effective diagnostic testing and treatment • Minimize inappropriate care (overuse, underuse, and misuse) • Formulary checks • Generics 33

  32. Affordable care:Clinical Decision Support Examples of Functionality Needed to Achieve Goals Stage 3 Functionality Goals • Demonstrate use of multiple CDS interventions that apply to quality measures in each of the six NQS domains. Recommended interventions include: • Preventive care • Chronic disease management (e.g., diabetes, coronary artery disease) • Appropriateness of lab and radiology orders • Advanced medication-related decision support (e.g., renal drug dosing) • Improving the accuracy/completeness of the problem list • Drug-drug and drug-allergy interaction checks • CEHRT should provide tools that enable the ability to provide these interventions • Related work that can inform: S&I HealtheDecisions, HITSC Clinical Quality WG • CDS support to avoid duplicative care • CDS support to avoid unnecessary or inappropriate care 34

  33. Reducing health disparities:Stage 3 Priorities MU Outcome Goals Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives • Patient conditions are treated appropriately (e.g. age, race, education, LGBT) • Eliminate gaps in quality of health and health care across race, ethnicity, and sexual orientation • Language • Gender • Race • Ethnicity 35

  34. Reducing health disparities:Additional Patient Information Functionality Needed to Achieve Goals Stage 3 Functionality Goals • CEHRT provides the ability to capture • Patient preferred method of communication* • occupation and industry codes • Sexual orientation, gender identity (optional fields) • Disability status • Differentiate between patient reported & medically determined • Communication preferences will be applied to the clinical summary, reminders, and patient education objectives • Providers should have the ability to select options that are technically feasible for them, these could include: Email, text, patient portal, telephone, regular mail • Recommended as certification criteria only • Patient conditions are treated appropriately (e.g. age, race, education, LGBT) 36

  35. Reduction of Disparities – previous deeming recommendations • Reduction of disparities in gap area • Identify areas where attesters should be required to demonstrate they have reduced health care disparities in high-risk populations

  36. Follow-up Items Feedback from HITSC Imaging Sharing and PGHD

  37. Improving quality of care and safety:Imaging Functionality Needed to Achieve Goals Stage 3 Functionality Goals • For both Eligible Professionals and Hospitals imaging results should be assessable through CEHRT. Results consisting of the image itself and any explanation or other accompanying information • Recommended as a Menu Item for EPs and Core for EHs • All relevant data accessible through EHR • CDS supports timely, effective, safe, efficient care and prevention • CDS helps avoid inappropriate care 39

  38. HITSC Clinical Operations WG Charge • How full image sets or designated key images are shared between different facilities and specialists: the high level architecture e.g. role PACS, Archives, and EMRs • How this is deployed with central and distributed reading facilities • What methods and technical standards are used to push, pull, or view images in one place that originated or were interpreted in another place • Issues encountered sharing reports and interpretations, or auditing, with or alongside the images themselves • Inclusion of time series data in scope in addition to radiological images

  39. Recommendations for Image Sharing

  40. Abbreviations/Terminology • Metadata: in this context, patient identifiers, dates, acquisition technique • KIN: IHE Key Image Note • KOS:DICOM Key Object Selection • DIMSE: DICOM Message Service Element (traditional DICOM PS 3.7) • ULP: Upper Layer Protocol (traditional DICOM PS 3.8 TCP/IP protocol) • MLLP: HL7 V2 Minimal Lower Layer Protocol (used by all IHE HL7 V2 stuff) • IID: IHE Invoke Image Display • STOW: DICOM Store Over the Web by RESTful Services (STOW-RS)

  41. Discussion from HITSC • Very difficult to set certification criteria with so much optionality in recommended standards • Need  guidance on specific purposes and use case scenarios for certification • “Our challenge was to provide a parsimonious collection of constrained standards for consumer and professional applications in tightly coupled (modality to PACS), and loosely coupled (web-based, cloud hosted image exchange) architectures.   We all agreed that we need to be very careful when writing certification criteria to avoid optionality such that vendors will be forced to implement many different standards (the "OR" of meaningful use becomes the "AND" of certification)” http://geekdoctor.blogspot.com/2013_12_01_archive.html Office of the National Coordinator for Health Information Technology

  42. Engaging patients and families in their care: Patient Generated Health Data Stage 3 Functionality Goals Functionality Needed to Achieve 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 • Eligible Providers and Hospitals provide the capability for patients to electronically submit patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status), secure messaging or provider-selected devices using CEHRT. (Provider-selected devices pending consideration by HITSC) • Recommended as a Menu item • Low threshold 44

  43. Standards Recommendations • ONC should consider the Direct transport standard for secure messaging and data from devices • ONC should consider the HL7 Care Team Roster standard • ONC should consider the HL7-CCDA for structured and unstructured questionnaires • ONC should consider the Continua standard for data from devices • We encourage standards that support mobile access to patient data and PGHD given the proliferation of mobile devices. However, we do not recommend mandating a specific standard at this time given that might stifle innovation.

  44. Recommendations for Development of Consumer Standards • ONC should consider an S&I Initiative to create needed collaborative care document structure to address versioning, expanded provenance, reconciliation, data governance and curation. • ONC should consider creating a process to align consumer product and provider standards • ONC should consider using BlueButton+ API approach to accommodate PGHD • Trust Framework expanded for consumer/patient adoption in emerging technologies (BB+) • ONC should ask the HITSC to prioritize consumer vocabularies to support wider consumer, patient and family engagement

  45. HITSC Discussion • The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data.  Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices.   • As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases.   • Continua will provide us a list of the named standards so that we can validate the maturity and adoption of Continua's recommendation.   • We will also ensure that the CCDA templates include the appropriate vocabularies that will  enable incorporation of patient generated data into EHRs. • http://geekdoctor.blogspot.com/2013_12_01_archive.html Office of the National Coordinator for Health Information Technology

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