Meaningful Use Workgroup Improving Care Coordination – Subgroup 3

1. Meaningful Use Workgroup Improving Care Coordination – Subgroup 3 Charlene Underwood, Chair September 2012

2. Guiding Principles • 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 • Reasonableness/feasibility of products or organizational capacity • Prefer to have standards available if not widely adopted • Don’t want standards to be an excuse for not moving forward MU Workgroup Stage 2 Final Rule

3. Key to reviewing items • Red items are changes from Stage 1 to Stage 2 • Blue items are changes from Stage 2 to Stage 3 recommendations MU Workgroup Stage 2 Final Rule

4. Improve Care Coordination Improve Care Coordination SGRP302 HITSC Questions: Are there value sets that exist related to the nature of reaction for allergies (i.e. severity)? We are considering including medication allergies for Stage 4. Clinical Operations WG/ Vocabulary Task Force response: Substantial work would have to be done to adapt and further develop existing standards for this purpose but we feel the development of standard value sets could be done within 2 years. MU Workgroup Stage 2 Final Rule

5. Improve Care Coordination Improve Care Coordination 5 MU Workgroup Stage 2 Final Rule

6. Improve Care Coordination Improve Care Coordination • HITSC Questions: • What counts as a transition? Definition of a transition? • We need a definitional statement about what the care plan refers to. • What standards exist for structured data elements to include in summary of care? • Clinical Quality response (primary): Typically care plan is free text-- there are places in a consolidated CDA that accommodate text but little is encoded data. • There is no standard around defining goals and related interventions for the care plan, but many other elements can be pulled from the EHR. • The care plan should be present regardless of transition but should certainly be transmitted at transfers of care. • Transitions of greatest concern are separate encounters—hospital to other facility would probably be first step and therefore moving from one encounter to another is a possible definition, although this does not capture the full intent and might still be difficult to define for the denominator. • Clinical Operations WG/ Vocabulary Task Force response (secondary): Consolidated CDA currently enables templates for problems, medications, allergies, notes, labs, and care plans. There are no standards to support the structured recording of a number of items listed in the suggested criterion. Much more specific policy requirements for the criterion must be documented quickly to have any hope of using sufficiently mature standards in time for MU3. MU Workgroup Stage 2 Final Rule

7. Improve Care Coordination Improve Care Coordination HITSC Questions: Are there mature standards available to “close the loop” for this process? What format/infrastructure would you recommend? Clinical Operations WG/ Vocabulary Task Force response :There are no mature standards available to close the loop for this process. Standards for provenance on CDA could be developed but work would have to be done. ONC update: A project our team is leading, 360x, is working to create implementation guidance for closed looped referrals.  MU Workgroup Stage 2 Final Rule

8. Objectives Not Included - Improve Care Coordination Objectives not included Okay to remove these? MU Workgroup Stage 2 Final Rule

9. IE workgroup MU Workgroup Stage 2 Final Rule

10. Prior Authorization (EHR Certification Criteria) Add notification to 3 and 4? 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?

11. 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?

12. 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) Don’t want to be too prescriptive, too early, too much.