S2MU Data Exchange Roundtable

1. S2MU Data Exchange Roundtable An Overview of HIE Requirements in Stage 2 Meaningful Use (S2MU) Trudi Matthews, Keith Hepp & Dr. Robyn Chatman April 26, 2013

2. Overview Background on HealthBridge

3. “Information is the lifeblood of medicine. We are only as powerful as the information we have, whether we are a nurse practitioner, a physician, or a respiratory therapist.” - Dr. David Blumenthal, former National Coordinator for Health Information Technology • If information is the lifeblood of medicine, our communication methods make for a poor circulatory system. Paper, mail and fax still dominant methods for communication • Information can be missing or hard to find in paper charts. • Nearly impossible to manage well a whole population of patients. Current methods for communication not as secure • Encryption not often used in health care communications today Sources: http://www.flickr.com/photos/dougww/922328173/ http://www.flickr.com/photos/greenlagirl/154148230/sizes/o/ http://www.flickr.com/photos/kenjonbro/3418425029/sizes/m/

4. HealthBridge Overview • Network Size = • 30+ hospitals, • 7500 Drs, • 800 practices, • 3+M patients • Data Connections: • Sends 3-4 million messages PER MONTH • Projected 60 million messages for 2012 • Connectivity with 40+ hospital information systems • Interfaces to 30+ different ambulatory EHR systems • One of the nation’s largest, most advanced health information exchange (HIE) organizations • In operation since 1997 as a 501c3 Not for Profit • Provide HIE services for Greater Cincinnati and four other HIEs around the country • Also operates the Tri-State REC and Cincinnati Beacon

5. Summary of Services Three Major HIT & HIE Service Areas: • IT Adoption & Meaningful Use (REC ) • Connection & Exchange (HIE) • Innovation & Improvement Tools (Beacon)

6. Accelerating Practice Transformation “Having an EHR and all the capabilities that it provides has revolutionized our practice. We now run reports that can identify patients who are due for such things as flu shots or mammograms.” - Leah Brunie • Summit Family Physicians was a paper-based practice in mid-2011. • Tri-State REC helped with EHR adoption, EHR live Sept. & attested in December 2011. • Collaborative helped them receive PCMH Level 3 NCQA recognition. • Practice was selected for the CMS • Comprehensive Primary Care • Initiative Dr. Mark Fraser and Leah Brunie, ANP of Summit Family Physicians

7. Overview Stage 2 Meaningful Use Requirements for HIE

8. Meaningful Use Stage 2 (S2MU) • Final released August 23, 2012 • Attestation for Hospitals starts Oct. 31,2013 • Attestation for Professionals starts Jan. 1, 2014 • Builds on stage 1 with increased thresholds • Actual exchange of information required • Electronic access for patients • Updates to quality measures to align with other programs

9. Meaningful Use Stage 2 (S2MU) • S2MUfinal rules consist of two parts: • CMS EHR Incentive Program Rule • ONC Standards and Certification Criteria Rule (S&CC) • Providers will need to pay attention to both in Stage 2. • New Modular EHR certification in gives greater flexibility to providers in meeting S2MU.

10. S2MU – Four Categories of HIE • Lab Exchange • Patient HIE • Transitions of Care • Public Health Exchange

11. S2 Meaningful Use – HIE in Red • EP Menu Requirements (3 of 6) • Imaging Results (20%) • Family History • Syndromic Surveillance (ongoing) • Cancer Case Information (ongoing) • Specialized Registry (ongoing) • Progress Notes • EP Core Requirements (17) • Computerized Provider Order Entry • e-Prescribing • Demographics • Vital Signs • Smoking Status • Clinical Decision Support • Lab Results (55%) • Patient List • Patient Preventative Reminders • Patient Online Access • Visit Summaries to Patient • Secure Messages to Patients (5%) • Rx Reconciliation • Summary of Care (50% - 10%) • Transmission of Immunizations (ongoing) • Security Analysis • EH HIE Requirements • Core (same as EPs) – Lab Results, Summary of Care, Immunizations • Core - Reportable Labs (ongoing) • Core - Syndromic Surveillance (ongoing) • Menu – Lab Results to EPs (20%)

12. Both EP/EH CoreS2 MU HIE Requirements - • Labs: Incorporate lab results for more than 55% • Summary of Care: Provide summary of care document for more than 50% of transitions of care and referrals with 10% sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR • Immunizations: Successful ongoing transmission of immunization data

13. EP – EH Only Core S2MU HIE Requirements • EP only • Secure Messages: More than 5% of patients send secure messages to their EP • EH only • Reportable Labs: Successful ongoing submission of reportable laboratory results • Syndromic Surveillance: Successful ongoing submission of electronic syndromic surveillance data

14. Big Deal: Transitions of Care Summary • Stage 2 requires that a provider send a summary of care record for more than 50% of transitions of care and referrals. • The rule also requires that a provider electronically transmit a summary of care for more than 10% of transitions of care and referrals. • At least one summary of care document sent electronically to recipient with different EHR vendor or to CMS test EHR.

15. New - 3 Options for “Certified EHR Technology (CEHRT)” • • Complete EHR • • EHR Module(s): –Combination of EHR Modules –Single EHR Module • Main Point: It is now possible to choose and use multiple technologies or applications to meet the CEHRT definition. • Need Base EHR + MU Core + MU Menu + CQM

16. HB HIE Architecture & Applications An Overview

17. hbDirect – New Secure Email Service Using Direct

18. Public Health Connectivity • Dr. Crankshaw’s practice -– Family Physicians of Urbana -- was one of two primary care practices in southern Ohio that have successfully tested sending immunization records from their practice’s EHRs to the Ohio ImpactSIIS Immunization registry. “As a primary care practice, we are committed to providing the best quality of care in a cost effective way,” stated Dr. John Crankshaw, a physician with Family Physicians of Urbana. “We want our patients to receive the right vaccinations at the right time, and have a clear record of their immunizations over time.”

22. Links to more information • Tri-State REC S2MU Central: www.tristaterec.org/s2mu • Stage 2 MU Overview: http://www.nationalehealth.org/how-play-final-rules-overview-meaningful-use-stage-2-and-standards-and-certification-criteria-final-8 • S2MU HIE Matrix – from HIMSS: http://www.himss.org/files/HIMSSorg/content/files/MU2_HIE_Matrix_FINAL.pdf • ONC Interoperability Basics: http://www.healthit.gov/Interoperability_Basics_Course_Web_Package_20130206/M/wrap_menupage.htm • Requirement Specific Spec Sheets from CMS on S2MU – • Hospitals: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EligibleHospitals_CAHs.pdf • EPs - http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2_MeaningfulUseSpecSheet_TableContents_EPs.pdf • S&I Companion Guide to S2MU Consolidated CDA http://wiki.siframework.org/Companion+Guide+to+ Consolidated+CDA+for+MU2

23. RoundtableDiscussion We want to hear from you. • What was hard about the HIE requirements in Stage 1? • What are you most concerned about HIE in Stage 2? • How can we help?

24. S2MU Standards and Certification Criteria Background Slides

25. Base EHR Requirements

26. Clinical Document Architecture (CDA) and Templates Clinical Document Architecture (CDA) is the base standard for building electronic clinical documents for exchange Templates apply CDA for a specific concept, such as a diagnosis or hospital discharge summary Templates are reusable and interchangeable “building blocks” that can build a variety of clinical documents To help simplify implementations, commonly used templates were harmonized into a single implementation guide – Consolidated CDA

27. How does C-CDA meet 2014 Ed. CEHRT requirements? Sets of CDA templates are arranged to create a purpose-specific clinical document CDA standardizes the expression of clinical concepts which can be used/re-used Templates are used to specify the ‘packaging’ for those clinical concepts 2014 Ed. CEHRT data requirements can be captured through C-CDA templates MU2

28. 2014 Ed. CEHRT Data Requirements Transition of Care Criterion Criterion Description Summary Type Electronically create a transition of care/referral summary Transition of Care/ Referral Summary Transition of Care 170.314(b)(1)&(2) Objective-Specific Data Requirements Common MU2 Data Set • Patient name • Sex • Date of birth • Race ** • Ethnicity ** • Preferred language • Care team member(s) • Allergies ** • Medications ** • Care plan • Problems ** • Laboratory test(s) ** • Laboratory value(s)/result(s) ** • Procedures ** • Smoking status ** • Vital signs • Provider Name & Office Contact Information (Ambulatory Only) • Reason for Referral (Ambulatory Only) • Encounter Diagnoses ** • Cognitive Status • Functional Status • Discharge Instructions (Inpatient Only) • Immunizations ** NOTE:Data requirements marked with a double asterisk (**) also have a defined vocabulary which must be used

29. Stage 2 Meaningful Use Standards – 5 Categories Services (N/A in S2MU) Vocabulary Content Transport Security

30. 1. S2MU Vocabulary & Code Sets • Standardized terms to describe clinical problems, procedures and other clinical information coded for easy comprehension. • The following Vocabulary and Code Sets have been added to Meaningful Use Stage 2: • Preferred Language (ISO 639-2), • Smoking Status (SNOMED CT – value set), • Medication Allergies (RxNorm), • Encounter Diagnosis (ICDEE-10-CM or SNOMED CT). • LOINC also continues from Stage 1

31. 2. S2MU Content Structure • For MU Stage 2, the Content Structure has been updated to include formatting for: • Lab Exchange: HL7 Version 2.5.1 Implementation Guide (S&I Framework Lab Results Interface) • Summary Record: HL7 Implementation Guide for Clinical Document Architecture (CDA®) Release 2: IHE Health Story Consolidation (Consolidated CDA) (Note: the use of the “unstructured document” document level template is prohibited.) • Lab Reporting to Public Health: HL7 Version 2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 1 (US Realm) • Cancer Registry Reporting:CDA R2 + IG

32. 3. S2MU Transport • Transport was not specified during MU Stage 1 • Stage 2 consists of the following: • Applicability Statement for Secure Health Transport specification • Applicability Statement for Secure Health Transport specification and the XDR and XDM for Direct Messaging specification (Optional) • Simple Object Access Protocol (SOAP)-Based Secure Transport Requirements Traceability Matrix (RTM) version 1.0 standard and the XDR and XDM for Direct Messaging specification (Optional).

33. CEHRT Criterion 170.314(b)(2) – Transition of Care (Send) • In order for a certification criterion to be met, all specific capabilities expressed as part of it need to be demonstrated. • For example, in 45 CFR 170.314(b)(2) there are two: • Create CCDA with requisite data specified for MU • Enable a user to electronically transmit CCDA in accordance with: • Direct (required) • Direct +XDR/XDM (optional, not alternative) • SOAP + XDR/XDM (optional, not alternative) • Thus, whatever EHR technology is presented for certification must demonstrate compliance with both (i) and (ii) under (b)(2) to meet the certification criterion. • This also means that there’s no certification for ‘transport only’ as part of MUS2 / CEHRT 2014 Edition

34. Valid Certification Scenarios for EHR Technology (Sending with Direct) • 45 CFR 170.314(b)(2) • Create CCDA with requisite data specified for MU • Enable a user to electronically transmit ToC in accordance with Direct (or Direct +XDR/XDM; or SOAP + XDR/XDM) Whatever EHR technology is presented for certification must demonstrate compliance with both (i) and (ii) under (b)(2) to meet the certification criterion. Provider A Provider B Direct (SMTP + S/MIME) HISP Provider A Provider B Any Edge Protocol Direct (SMTP + S/MIME) EHR Affiliated HISP Provider A Provider B Any Edge Protocol Direct (SMTP + S/MIME) What gets presented for certification

35. MU Transition of Care • Measure #2: The eligible provider, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either: • (a) electronically transmitted using CEHRT to a recipient, or • (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network.

36. Approach #1 -- Send with CEHRT Required Transport: Using Direct Provider A Provider B Direct (SMTP + S/MIME) HISP Provider A Provider B Any Edge Protocol Direct (SMTP + S/MIME) EHR Affiliated HISP Provider A Provider B Any Edge Protocol Direct (SMTP + S/MIME) CEHRT

37. Approach #2 -- Send with CEHRT Optional Transport: SOAP + XD (Example) Provider A Provider B SOAP + XDR/XDM CEHRT Note:This is one example of how a provider may use EHR technology that has been certified to include optional transport standards. The CEHRT could support a different optional transmission mechanism (e.g., Direct + XDR/XDM). Also, as with the required Direct transport, the CEHRT has architectural flexibility to use relied upon software in their solution, seek modular certification, etc.

38. Approach #2 -- Send with CEHRT Optional Transport: SOAP + XD via Intermediary (Example) HISP Provider A Provider B Direct (SMTP + S/MIME) SOAP + XDR/XDM Because Provider A is sending to Provider B using their CEHRT’s SOAP + XDR/XDM transport option, the fact there’s a “HISP in the middle” is irrelevant with respect to Provider A meeting MU requirements. This allows any EHR vendor supporting the SOAP + XDR/XDM option to interoperate with any HISP that also offers SOAP + XDR/XDM support. Under this approach, HISPs do not have to be certified If EHRs implement SOAP/XD support and then partner with a HISP (i.e., use the HISP as relied upon software for certification), they can also fulfill their Direct requirement under Scenario #3 with minimal (or no) additional development/technical work on their part. CEHRT

39. Approach #3 – Send via NwHIN Exchange Participant Provider A NwHIN Exchange Participant (now eHealth Exchange) Provider B CEHRT CEHRT Note:the regulation also permits an EP, eligible hospital, or CAH to count in their numerator instances where a summary care record for transitions of care or referrals was received via electronic exchange facilitated in a manner consistent with the governance mechanism ONC establishes for the nationwide health information network. ONC has not yet established a governance mechanism for the nationwide health information network. Until ONC establishes such a governance mechanism, this specific option will not be available.