ONC Site Visit Technical Update September 12, 2011

1. ONC Site Visit Technical UpdateSeptember 12, 2011

2. Agenda • Technical Overview • Health Information Exchange (HIE) • Continuity of Care Documents (CCD) • Meaningful Use (MU) • Clinical Data Repository ( CDR) • Asthma Action Plan (AAP) • Diabetes : Quality of Life Tool(QOL) • Portal/Patient Engagement

3. Project Timelines Site System Knowledge Transfer Vendor Demos Metrics Collection Data Flow Models Metrics Collection Implement Installation Technical Training HL7 feeds Implement Test Design Implement Develop

4. HIE/CCD

5. Opportunity This project has the opportunity to leverage Health Information Exchange technology at a national level in order to effect measurable improvements in the care and treatment of patients afflicted with asthma and diabetes.

6. Objectives • Share continuity of care (CCD) documents within the SE MN BEACON region, between provider organizations and with the 11 County Healthcare Communities & a subset of the schools (school nurses). • Share asthma action plans between providers and with the 11 County Healthcare Communities, & a subset of schools (school nurses) • Collect assessments and measures on asthmatic children enrolled in the BEACON program to validate improvements and determine appropriate interventions within the region. • Share diabetic care plans between providers and with the 11 County Healthcare Communities. • Collect assessments of measures on adults with diabetes who are enrolled in the BEACON program to validate improvements and determine appropriate interventions within the region. • Implement any additional interventions deemed appropriate by the practice community and approved by the BEACON Governance Committee.

7. Participant Requirements Varying collaborative partner capacity requires multi-dimensional exchange approach Significant Capacity NHIN CONNECT standards based document exchange. Intermediate Capacity Standards based Single Point to Single HIO document exchange Minimal Capacity Web portal with ability to provide feedback

8. Health Information Exchangeexcluding repository services

9. MN-HIE Hub & spoke strategy using mixture of NwHIN CONNECT and MN-HIE adapter solution. Utilizing MN-HIE: Sites use CONNECT or load their patient demographics into Secure Patient Directory. Sites use CONNECT or provide feeds of resources or documents to the Record Locator Service. Supporting XDS.b, w/ adapters for CORE II, REST, or proprietary interfaces CONNECT Peer to peer connectivity strategy using NwHIN CONNECT solution. Utilizing NwHIN CONNECT: Each site maintains a patient correlations via CONNECT. Utilizing direct communication between BEACON partners, each site maintains their set of documents to share. Reference implementation for NwHIN which Interoperates with State HIE initiatives nationally. Alternative Strategies Explored

10. Big Picture KP GH IMH Consortium G MN HIE NHIN FL Mayo AZ Public Health MHS MCR OMC WHS Cerner small providers (schools, home care, etc.) SE MN Beacon

11. CONNECT & MPI The concept of an MPI is an integral to the operation of NwHIN CONNECT. It is utilized to facilitate "correlating" patients among organizations / gateways. • It is envisioned that in a production environment, CONNECT will support the use of adapters to access local implementations of Registration or enterprise level MPI solutions. • For those groups wanting to localize the cross walks between their identifiers and other external identifiers, MIRTH provides an add-on; MIRTH Match, to manage the cross walks. As CONNECT is based on point to point correlations, the full cross reference of patients identifiers will be in Regenstrief ‘s repository.

12. Project 1 - 2011

13. Overview Mayo’s Health Information Exchange solution is moving forward on two fronts. • Regionally - SE MN BEACON • Nationally - Care Connectivity Consortium Both implementations are based on the same infrastructure NwHIN Protocols using Aurion 4.0 / Mirth Connect. The following diagram represents the various communities that are working together to share documents.

14. Highlights • Continuity of Care Document (CCD) Generation and Receipt • Specialty Document Conversion (Asthma Action Plans) from Mayo forms solution (CDM) to HIE. • Establish a Document Registry and Repository • Utilize NwHIN protocols to support secure transfers • Supports local site EMR integrated viewing and / or transfer as needed. • Health Information Management Services (HIMS) Functions at All Sites • Processes to Capture and Audit Authorizations and Revocations

15. Health Information Exchange

16. Current Status • Mayo has just installed the MIRTH / Aurion 4.0 server and is wiring up the interfaces. • The Asthma Action Plan queue has been established and conversion software is under development. • Initial connectivity test is planned the last two weeks of Sept, with more testing in Oct.

17. HIE : Status of Sites • OMC • EHR Software Generates CCD • NwHIN Exchange will be used • Anticipated production HIE by 12/31/11 • Winona • Producing CCD’s in production EHR. • Plan to exchange with area tertiary facilities as soon as they are ready • Public Health

18. Public Health • MIRTH Appliance is installed and running at two sites:   physical appliance at ACS (developer site) and virtual appliance at Olmsted County (user site) • Gateway is installed at both sites • ACS is holding on gateway development until after MIRTH WEBEX training • This week, Dan Jensen arranged for 80 hours of additional training on the gateway for ACS ( to be held AFTER #3 training)

19. Meaningful Use

20. MU : Status of Sites • OMC • Eligible Providers to Attest 10/1/11 • Winona stage one attestation periods • Hospital – July – September 2011 • Eligible Provider – October – December 2011

21. HIE Demo Following this presentation will be an HIE demonstration of CCD generated at Winona health system which is accessed, consumed, displayed and parsed by PH-Doc

22. Clinical Data Repository

23. Background This project will establish via a combination of historical loads and interfaces from provider organizations EMR Systems a community based clinical data repository. Assessment documents and other relevant clinical information gathered by County Healthcare and School Nurses will be incorporated in the repository as approved by the BEACON Governance Committee. The repository will be used to generate summary reports on the effectiveness of the community based BEACON program and used to complement the existing Population Health Management solutions in production today.

24. Objectives • Establishment and utilization of the community based clinical repository for the Beacon program. • Establishment of complementary clinical data interface flows between providers who have patients in common.

25. Drivers for CDR • Two driving factors for the repository: • Population Management • Infrastructures/environment & project beyond the grant • Provider EMR Systems -> Provider PM Systems • Population management in support of meaningful use

26. Concept: build a system that will allow us to scale incrementally after we demonstrate the value of the repository data A D B E C F A B G C D E F G

27. Repository Requirements Correlate patients, students, and PH cases Identified & anatomized patient access Merge & unmerge patient EMR data to accurately identify patient’s for clinical care. Support complex access authorization matrix to protected patient information Easy access to various authorized data sets for reporting and analytics requirements Secure, audited, scalable, cost efficient …

28. In Scope • Aggregation of the following patient health information • Patient Demographics (including ZIP code and age • Vital Signs (including blood pressure measurement • Laboratory Findings • Tobacco use documentation • ED Visit information from CPT coding or Visit codes • Any additional metrics deemed in scope by Beacon Governance • Patient cross correlations provided by Regenstrief • Submission of patient clinical information to provider population health solutions from Regenstrief based repository

29. Options Explored • Regenstrief Hosted – agreed to work with BEACON and SHARP • Covisint Hosting – more of a secure network to move information back and forth • Regenstrief Code (OpenSource) • Amalga Code • Mirth Results Code (OpenSource) – co-develop with them with SHARP Data Normalization Pipeline

30. CDR- Current Status • Hosted at Regenstrief Institute Indiana • Connectivity established and test data feeds are being sent • Next steps: • Completion of legal documentation • Production feeds • Timeline December 2011

32. CDR : Status of Sites • Mayo/MCHS • ADT and Lab Data testing • OMC • VPN Connectivity established • ADT and Lab data testing underway • Backload to commence upon execution of Data Agreement • Winona • HL7 connectivity has been established • Test data feeds to start • Public Health

33. Public Health is focused on sending ADT and QOL data to the CDR. • ADT programming and testing is completed • ADT backload by end of October 2011 • Installing QOL tool in PH-Doc

34. SHARPn in a real-world healthcare setting The Beacon Communities are looking for ways to use their HIT infrastructure to provide better, more efficient care. The Southeastern Minnesota Beacon will trial the SHARPn middleware to identify high-risk diabetes patients in its population to target resources where they will have the greatest impact. The SE Minnesota Beacon needs to identify high-risk diabetes patients in its population. The Beacon Community consists of multiple sites, with multiple EHR systems How will it look at data across the entire population?

35. SHARPn Pilot in the SEMN Beacon The SHARPn pilot will utilize… • Natural language processing • High-Throughput Phenotyping using a diabetes algorithm, and • Deep Question Answering on the UIMA platform …to identify high-risk patients in the Beacon population and effectively target resources.

36. Use Case Analysis • Two sets of use cases were documented for the SE MN Beacon project. They were: • Asthma care focused • Diabetic care focused

37. Provider Portal for Patients QoL & Decision Aids School Portal & NwHIN Gateway SE MN Beacon Use Cases Provider NwHIN Gateway Public Health NwHIN Gateway High-Level Summary

38. Asthma Action Plan

39. Asthma Care • Establish a school based portal, that is used by School Nurses to receive Asthma Action Plans and submit incident reports back to primary care providers. • Manages authorizations by parents to allow exchanges between Primary Care Providers and School Nurses. • Supports creation of incident reports and forwards those it is authorized to send to primary care physicians.

40. Asthma Care Overview Asthma Action Plan Incident Report School Nurse Visit Authorizes: School to follow Care Plan and communicate w/ Physician Communicates via: • School Visits • School Calls • School Notes • Provider Visits • Provider Portal Primary Care Physician Visit Parental Involvement

41. Asthma Action Plan Mayo Clinical Forms CDM Mayo Health Information Exchange BEACON Partners XML PDF XML NwHIN Request PDF PDF XML XML

42. AAP Current workflow • Physician visits with patient and creates an Asthma Action Plan. • The plan is stored in Mayo’s Clinical Forms solution (CDM) and forwarded on to the Health Information Exchange (HIE) Server. • The HIE Server, converts the Mayo XML document into a PDF so all providers can handle the content. • Later, School Nurses, Public Health or other providers can access the Asthma Action Plan from the Mayo HIE server.

43. Diabetes

44. Diabetic Care Overview • Diabetic Care contained a number of use cases. • Public Health – Diabetic Care Scenarios • Supporting notifications of admission and discharges from provider organizations of clients under their oversight. • Quality of Life Assessment • Enabling providers and patients to work together to seek care plans and strategies that improve the patients quality of life. • Decision Aids • Supporting joint decision making processes, between providers and patients in determining appropriate care strategies.

45. Public Health Use Cases Continuity of Care Admission & Discharge PH Reports Vital Signs Primary Care Physician Visit Public Health Visits

46. Quality of Life • Supports both self-administered assessment and provider / patient discussion. • Needs to support trends over time of discrete data. • Supports additional summarizations over time and identification of clinical pathway recommendations. • Called for the sharing of QoL across the HIE network. • Each site needs to consider how to best incorporate the QoL measures into their practice flow.

47. Diabetes QOL Tool • Final template is approved and ‘development ready’ • Development will commence in the respective EMR systems • Timeline is December 2011 • PH will be installing the QOL assessment form in the Beacon counties by end of 2011

48. 8 Decision Aids Extract 23 items from the EMR to support decision aid processing. EMR System Age, Sex. Ethnicity, Smoking, Height, Weight, Tx for HTN, SBP,DBP, Total Chol. HDL, BMI, Diabetes (Y/N), A1c, Diabetes (Duration), a. fib., CPR, Family Hx, PR Int., HF, LVH, Murmur, Stroke Provider and Patient Interaction

49. Decision Aids • Risk Calculator Tools: • Currently defined : UKPDS, Reynolds, A. Fib. CVD30, CVD10, CVD10 D, HTN, Stroke post a fib. • Uses patient EMR data to access risks and options in care and treatment. • Mayo supports copy / paste of summary into clinical notes from decision aids. • Each site needs to consider how to best incorporate the decision aids into their practice flow.

50. Portal/Patient Engagement