Recommendation to the Meaningful Use Workgroup on Meaningful Use Stage 3

1. Recommendation to the Meaningful Use Workgroup on Meaningful Use Stage 3 September 18, 2012 Information Exchange Workgroup Micky Tripathi, Larry Garber, Dave Goetz

2. Workgroup Membership • Micky Tripathi (Chair) Massachusetts eHealth Collaborative • Hunt Blair Vermont Medicaid • Tim Cromwell Department of Veterans Affairs • Jeff Donnell No More Clipboards • Judy Faulkner Epic • Seth Foldy Centers for Disease Control and Prevention • Jonah Frohlich Manatt • Lawrence Garber Reliant Medical Group • Dave Goetz OptumInsight • James Golden Minnesota Department of Health • Jessica Kahn Centers for Medicare & Medicaid Services • Charles Kennedy Aetna • Ted Kremer Rochester RHIO • Arien Malec RelayHealth • Deven McGraw Center for Democracy & Technology • Stephanie Reel John Hopkins University • Cris Ross Mayo Clinic • Steven Stack AMA • Christopher Tashjian River Falls Medical Clinics • Jon Teichrow Mirth Corporation • Amy Zimmerman Rhode Island Office of Health & Human Services

3. Approach to Recommendation Development General MU Criteria • Supports new model of care (e.g., team-based, outcomes-oriented, population management) • Addresses national health priorities (e.g., NQS, Million Hearts) • Broad applicability (since MU is a floor) • Provider specialties (e.g., primary care, specialty care) • Patient health needs • Areas of the country • Promotes advancement -- Not "topped out" or not already driven by market forces • Achievable-- mature standards widely adopted or could be widely adopted by 2016 IE WG-specific criteria • What overall health information exchange objective do we want to accomplish in Stage 3? • Current IE WG policy objective criteria: • Consolidate our gains • Make HIEeasy • Advance queryfor continuity of care and administrative simplification

4. Stage 3 Recommendations • The IE WG was asked to provide input to the MU Workgroup in nine key areas for Meaningful Use Stage 3. The areas were broken up among two subgroups: • Subgroup 1 – Quality and Efficiency • Electronic prescribing of controlled substances • Lab orders • Prior authorization • Medication history • Subgroup 2 – Care Coordination and Patient and Family Engagement • Query for patient record • Notification of utilization event • Data portability • Specifying transition content • Exchange of electrocardiography

5. Subgroup Membership • Care Coordination and Patient and Family Engagement • Chairs: Larry Garber and Jeff Donnell • Members: Peter DeVault, Jonah Frohlich, Arien Malec • Quality and Efficiency • Chair: Dave Goetz • Members: Cris Ross, Chris Tashjian, Steve Stack

6. Recommendations

7. Lab Orders (EHR Certification Criteria) • Certification Only for EPs: The EHR must have the ability to issue an electronic order of laboratory test within a providers workflow. The capability should be compatible with the Lab Order Interface and Lab Results Interface guidelines produced by the S&I Framework Initiative. • Request for Comment for Meaningful Use with these additional questions: • Are the existing standards for laboratory orders adequate to support including this certification criterion?

8. Medication History MU WG recommendation The IE WG concurs with this recommendation 8

9. Prior Authorization Background Language 1. The first order is to look to what might be required of EHRs that would facilitate prior authorizations, and then to look to providers to use where available. The certification requirements should build upon and hopefully reuse functionality that already exists or is being developed.2. The goal is to reduce unwanted variation in quality and cost and to remove complexity and friction in the interaction between providers and payers in working towards that goal. The strategy is to identify the use cases where this interaction improvement could most readily take place.3. The current interactions occur by fax, phone, web portal and EDI. It is generally acknowledged by both providers and payers that fax exchanges are the least efficient method of interaction, and a focus on reduction of faxes could reduce the level of frustration on both sides. The highest number of interactions currently would be phone calls, which are often time consuming and labor intensive for both payers and providers. Uses of electronic exchange could reduce the number of calls, but phone calls will always be necessary for interaction over the more complex procedures with the most variation around efficacy and appropriateness. Next would be payer portals where providers may both inquire as to eligibility and coverage issues and also submit clinical and other information necessary for the most efficient determination, receipt of approvals, filing appeals of adverse decisions. Last in current utilization is the transaction sets around EDI. Some payers currently use these X12 transactions, mostly with hospital systems. There are serious efforts underway, led by the AMA, to consider how to use this existing set of interactions between payers and providers to improve these interactions.

10. Prior Authorization Background Language 4. Sub group 1 discussed these issues, and suggests that use cases for EHR certification can go from interaction with existing authorization systems through the transmission of clinical information for more complex decisions.  We recommend that: a.Where available, EHRs should be able to automatically check and make available to Meaningful Users as part of the clinical workflow those methods of interacting with payers that are already in widespread usage.  For example, for electronic prescribing, EHRs should be able to import formularies and medication histories, where available.  Where payers have secure portals for the purpose of receiving prior authorization requests, EHRs should be able to allow Meaningful Users to sign into those portals as part of the clinical workflow without having to leave their EHR.  Some payers currently have clinical questions on these portals, and clinicians can answer those to receive an automated approval.  This functionality should be encouraged for those approvals where the clinical pathways are clear.  b.Where this functionality exists in both EHRs and payer systems, providers should use this functionality in order to qualify as Meaningful Users, and payors should accept. c.As payers and providers work together to simplify and improve interactions around prior authorizations, they should be aware of how existing functionality in EHRs could be repurposed.  For example, CCDA could provide the clinical information that payers would need in order to be able to more efficiently reach decisions with a minimum of repetitive or lengthy interactions.  As noted above, there is work underway to see if other transaction sets can be repurposed or expanded to help automate routine transactions.

11. Prior Authorization (EHR Certification Criteria) Proposed Use Cases: 1. Medication formulary compliance v.1: prescriber electronically prescribes, EMR reconciles against relevant formulary, if formulary-compliant, prescription transmitted to pharmacy2. Medication formulary compliance v.2: prescriber electronically prescribes, EMR reconciles against relevant formulary, if NOT formulary-compliant, prescription rejected, prescriber alerted to non-compliance, opportunity given via structured data prior-auth form to document medical necessity for non-formulary med, prior auth electronically and automatically granted in real-time if required prior auth requirements are fulfilled; this entire transaction could be done with structured data3. Procedure/Surgery/lab/radiology/test prior authorization v.A: for those procedures/surgeries/lab/radiology /test with clear and objective prior authorization requirements and a structured data prior authorization form is available, clinician fill out the prior authorization form using structured data fields and prior authorization can be granted electronically and in real-time by the payor.4. Procedure/Surgery/lab/radiology /test prior authorization v.B: for those procedures/surgeries/lab/radiology/test, for which prior authorization is non-standardized and is highly individualized, a standardized form is created that collects from the clinician text fields answering an agreed upon set of medical necessity questions, standardized form is sent electronically to insurer for review, insurer responds with Approval/Denial (with rationale if denied) using a standardized format text document back to clinician with either approval and/or denial with rationale.A CCD (or comparable) could be appended to any of the above for added context if/when desired by either party. Request for Comment for Meaningful Use with these additional questions: Are there sufficiently mature standards in place to support this criterion?  What implementation of these standards are in place and what has the experience been? Would the inclusion of this criterion provide sufficient incentive for payors to participate and develop the required infrastructure? What infrastructure would payors need to establish or update to support providers achievement of this criterion?

12. E-Rx of Controlled Substances (modify existing objective) • MU objective: Controlled substance prescriptions should count towards the e-prescribing numerator, but not the denominator. • Certification criterion: The EHR system must be able to support the e-prescribing of controlled substances. • This approach provides an extra credit incentive for providers to e-prescribing controlled substances by counting towards their achievement of the e-prescribing numerator but not towards the denominator. This approach also obviates the need to include exemptions around state law restrictions and the capabilities of trading partners.

13. Query for Patient Information (EHR Certification Criteria) • Certification Criterion: • The EHR must be able to query another entity* for outside records and respond to such queries. This query may consist of three transactions: •  Patient query based on demographics and other available identifiers •  Query for a document list based for an identified patient •  Request a specific set of documents from the returned document list *the outside entity may be another EHR system, a health information exchange, or an entity on the NwHIN, for example. • When receiving in inbound patient query, the EHR must be able to tell the querying system whether patient authorization is required to retrieve the patient’s records. (E.g. if authorization is already on file at the record-holding institution it may not be required). • The EHR initiating the query must be able to query an outside entity* for the authorization language to be presented to and signed by the patient or her proxy in order to retrieve the patient’s records. Upon the patient signing the form, the EHR must be able to either: •  Send a copy of the signed form to the entity requesting it •  Send an electronic notification attesting to the collection of the patient’s signature *Note: The authorization text may come from the record-holding EHR system, or could be located in a directory separate from the record-holding EHR system, and so a query for authorization language would need to be directable to the correct endpoint.

14. Query Provider Directory (EHR Certification Criteria) Certification criterion: The EHR must be able to query a Provider Directory external to the EHR to obtain entity-level addressing information (e.g. push or pull addresses). Request for Comment for Meaningful Use with these additional questions: • Are there sufficiently mature standards in place to support this criteria?  What implementation of these standards are in place and what has the experience been? Priorities supported by a provider directory query which facilitates Direct messaging and queries: • Improved care coordination • Reduces readmission, redundant testing • Improves patient safety • Facilitates “hassle-free” health information exchange

15. Collaborative Care Communication (New, Menu) EH OBJECTIVE: The EH/CAH will send electronic notification of a significant healthcare event in a timely manner to key members of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required. EH MEASURE: The eligible hospital or CAH will send electronic notification within 2 hours of a patient’s arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death, to at least one key member of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required, more than 10 % of the time. • Corresponding certification criteria will also include the ability for all (EP and EH) certified EHRs to be able to receive these notifications. • Request for Comment for Meaningful Use with these additional questions: • Is the mere notification that the event has taken place sufficient, or is more detail needed at a minimum? For instance should the ED Triage note be the minimum ED Arrival Notification? Should the patient discharge instructions with disposition be the minimum Facility Discharge Notification? Is the cause of death required at a minimum for the Death Notification? • Are there sufficiently mature standards to define the content and vocabulary for these notifications? Will the Consolidated CDA satisfy these needs? • Timeliness of notification must be balanced against the practical ability to produce these notifications, for example, in a busy ED. Is 2 hours a reasonable balance, or should it be shorter or longer? • Should notification of more members of the patient’s care team be required? • Would a 50% threshold (instead of 10%) be too difficult to achieve? • What exemptions from the measure or exclusion from the denominator should be considered?

16. Specifying transition content (EHR Certification Criteria) Support “Summary of Care Record” as defined in the MU WG’s MU3 Objective SGRP303, by providers optionally using 3 datasets (which include the Care Plan) being defined by S&I Longitudinal Coordination of Care WG and are expected to complete HL7 balloting for inclusion in the C-CDA by Summer 2013: 1) Consultation Request (Referral to a consultant or the ED) 2) Shared Care Encounter Summary (Consultation Summary, Return from the ED to the referring facility, Office Visit) 3) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency)

17. Data Portability Between EHR Vendors (RFC) • Request for Comment for EHR Certification: • ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to switch from using one EHR to another vendor’s EHR. It also recognizes that not all data can be migrated from one EHR to another. For instance, it is unreasonable to expect audit trails to be able to be imported from one EHR into another vendor’s EHR because EHR audit trails are so intimately tied to the EHR’s internal data structure and function. In the MU2 Certification Rule, ONC required at a minimum the capability to export C-CDA summaries on all patients which includes their most recent clinical information. It was recognized that this core clinical dataset was merely a first step towards the goal of seamless data portability. ONC also encouraged, although did not require, including historical laboratory test results, immunizations, and procedures. • ONC’s HIT Policy Committee wishes to advance data portability further, and thus seeks comment to help identify reasonable actions that may further facilitate data portability. • What are the most important current and historical data elements that should be included in the exported data? Should this included data that was saved in the EHR as an image or waveform? • What associated metadata should be exported to provide context to these historical data elements? • Should there be different standards for EP versus EH EHRs with regards to which data elements to export and how far back historically to include? • ONC’s HIT Policy Committee recognizes that some data elements do not need to be transferred into the new EHRbut instead need to be archived and made available through some other non-EHR mechanism. What non-EHR mechanisms for storing, retrieving and displaying these archived data are available? Are there standards and services available to accomplish this? • What are the risks and harms of requiring EHR vendors to provide data portability beyond C-CDA summaries? • What are the risks and harms of not advancing the current state of data portability beyond C-CDA summaries?

18. Exchange of electrocardiograms (RFC) • Request for Comment for EHR Certification: • ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to exchange electrocardiograms (EKGs). It also recognizes that there is limited experience with exchange of EKGs between healthcare providers. • ONC’s HIT Policy Committee wishes to advance the exchange of EKGs between healthcare providers, and thus seeks comment to help identify reasonable actions that may promote this exchange. • How useful is the exchange of electrocardiograms (EKGs). What is the incremental value of exchanging the actual image or waveform instead of just the textual EKG reading? • What technologies and standards are available for exchange of EKGs, and how mature are they? What vendors support these standards and to what extent are they supported? Should EKGs be exchanged as waveforms or images and why? • Are current EKG systems designed for sending and receiving EKGs? If yes, by what means and using which standards? • Are current EHR systems designed for sending and receiving EKGs? If yes, by what means and using which standards? • What examples of successful and unsuccessful exchange of EKGs are available? • What are the barriers to the exchange of EKGs? Are these barriers universal or unique to certain EKG vendors?