HITPC – Information Exchange Workgroup Care Coordination Discussions

1. HITPC – Information Exchange WorkgroupCare Coordination Discussions Stage 3 Planning July 25, 2012

2. Summary of Care (and Care Plan)

3. Reconciliation *Plan of Care goes beyond “Problems” to include Goals and Interventions. Specific elements are being defined via the S&I Framework **Significant Test Results suggests that the results of studies like a brain MRI done during an ED visit will be recorded in the PCPs record. This will reduce the chance that it will be repeated again as an outpatient unnecessarily. Could also include A1C results exchanged between a PCP and an Endocrinologist in order to reduce unnecessary blood tests and the ability to view trends over time through coordinated care. These are limited to the extent that test results are sent in a Care Transition Dataset

4. Collaborative Care Communication (New, Menu)

5. Collaborative Care Communication (New, Menu) - Stretch

6. Request for Information (New, Menu) *Performing directed queries to specific organizations with standard authorization definitions is critical during unplanned visits. One workflow that must be supported by the certified EHR is to first, electronically request authorization template from releasing organization, and then electronically submit the completed authorization form if no authorization already exists. The advantages to this approach are that it: 1) supports interstate requests where release of information laws differ but need to follow the state that is releasing the data, 2) ensures that the releasing organization has the capability to satisfy the request in terms of data segmentation, and 3) could be done with both DIRECT as well as IHE.

7. Update Provider Directory (New, Menu) * This objective is important to facilitate keeping community and regional directories up to date which will rapidly become critical as the use of HIE expands. Need to specify a minimum supported protocol/standard for automatically updating a community/regional provider directory from EHR data, as well as querying that directory to obtain DIRECT addressing information. Need directory of directories to know where the source of truth (DNS?).

8. HITPC – Information Exchange WorkgroupPatient/Family Engagement Discussions Stage 3 Planning July 25, 2012

9. Patient/Family Engagement – Guiding Principles • As part of our work on Stage 3 idea formulation, we: • - Assumed that existing/proposed patient and family engagement requirements would remain and would likely be refined (e.g. increasing percentages for measures) • - Focused on a handful of objectives that not only build on providing patients with easy access to data, but enable those patients to easily supply data (a significant source of patient frustration today) • - Focused on objectives that logically fit with existing or planned requirements • - Embraced general MU criteria (support new models of care, address national health priorities, broad applicability, not already driven by market forces, mature standards)

10. Consume/Reconcile Patient Supplied Data (New, Menu) • *Notes: Patients express significant frustration at inability to easily submit electronic data to healthcare providers. Frustration ranges from necessity to use different patient portals with different providers to difficulty submitting data from portable, patient-managed solutions to provider inability/reluctance to accept patient-supplied data. • Stage 1 and 2 lay groundwork for this objective, with standards for transmission (Direct) and payload (consolidated CDA), and requirements for consumption and reconciliation between providers. • This complements/builds on Stage 2 NPRM around transmit – patient will likely have ability to request transmittal of data from one EHR to designated address(es), which may include other provider EHRs • IE Workgroup suggests that data provenance be included as part of payload, identifying source of data (patient-generated, clinical source, etc.)

11. Consume Patient Supplied Device Data (New, Menu) • *Notes: Patients are increasingly using devices (home monitoring, portable monitoring, mobile applications, etc.) to monitor and manage health information. • This objective fits with new models of care (ACO, PCMH) where patient management monitoring is a critical success factor • Objective should reflect standards committee work around patient ID/Auth/Match • Device data should include provenance and LOINC code (as an example, BP collected at home is viewed differently from BP taken in a clinical setting) • IE Workgroup suggests coordination with Continua Alliance around appropriate standards

12. Provide patients/families with care plans (New, Menu) • *Notes: As Stage 3 objectives are developed regarding transitions in care and care coordination, patients and families, documents that will be exchanged among/between providers should also be shared with patients and family members. • This objective is a logical extension of existing requirements to share clinical summaries • This objective is also a logical extension of Stage 2 NPRM giving patients the ability to view/download/transmit health information

13. Provide patients/families with care plans (New, Menu) • *Notes: Given the emphasis on preventive care and the already embedded quality guideline functionality in certified EHRs, this appears to be a logical extension of Stage 1 and 2 requirements. • Certified EHRs are already building in CDS to support quality measures • Notification can be achieved as an extension of secure messaging, view/download/transmit and other Stage 1 and 2 requirements • This objective could also be tied to Stage 3 work around transitions in care and care coordination, where care plans identify gaps in care, goals/objectives and tasks