Care Coordination and Interoperable Health IT Systems

1. Care Coordination and Interoperable Health IT Systems Unit 7: Policy and Interoperable Health IT Lecture b – Meaningful Use, ONC Certification, and Interoperability (Part 1) This material (Comp 22 Unit 7) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Policy and Interoperable Health ITLearning Objectives • Objective 1: List and discuss the impact of key health interoperability related topics in health care legislation (Lecture a) • Objective 2: Identify and discuss how the Meaningful Use program and the ONC certification programs have impacted interoperable health IT (Lectures b and c) • Objective 3: Assess and leverage Meaningful Use, ONC certification, and other health IT policy activities to facilitate interoperability (Lecture d)

3. Meaningful Use (MU) and Stage 1 • Mostly in the past • ONC 2011 certification of EHRs • Eligible providers and eligible hospitals attest to meet certain objectives using ONC 2011 certified EHRs. • There are many objectives, so for more information on the full list of Stage 1 Objectives, go to component 1

4. Examples of MU Stage 1 objectives and interoperability • Prescribe medications electronically • Provide patients with an electronic copy of their health information upon request • Provide patients with a clinical summary of their office visit • Maintain an active medication list • Test capability to exchange key clinical information among care providers and patient-authorized entities • Test capability to submit electronic data to immunization registries • Send patient reminders • Collect information in the EHR to calculate quality measures

5. ONC 2011 regulation standards • Terminology • Problem list: ICD-9; SNOMED-CT • Procedures: ICD-9 procedures; CPT4 • Laboratory results: LOINC • Medications: any source vocabulary in RxNorm • Immunizations: HL7 Standard Code Set CVX - Vaccines Administered • Race and ethnicity: Office of Management and Budget Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity • Privacy and security • Encryption and decryption of electronic health information: any encryption algorithm identified by NIST as an approved security function in Annex A of the Federal Information Processing Standards (FIPS) Publication 140-2 • For data exchange: any encrypted and integrity protected link • Verification that electronic health information has not been altered in transit: SHA-1 (Secure Hash Algorithm (SHA-1) or alternative equal in greater in strength

6. ONC 2011 regulations standards: data exchange • Patient Summary Record Standard: HL7 CCD HITSP C32 or ASTM CCR • Electronic Prescribing: NCPDP SCRIPT Version 8.1 or Version 10.6 • Electronic Submission of Lab Results to Public Agencies: HL7 Version 2.5.1 Implementation Guide: Electronic Lab Reporting to Public Health, R1 • Electronic submission to immunization registries: HL7 2.3.1 Implementation Guide for Immunization Data Transactions using or HL7 2.5.1 Implementation Guide for Immunization Messaging Release 1.0 • Quality Reporting: CMS Physician Quality Reporting Initiative (PQRI) 2009 Registry XML Specification and PQRI Measure Specifications Manual for Claims and Registry

7. How did Stage 1 help with interoperability? • Certified EHRs were implemented • Certain data needed for sharing was now regularly collected as structured data • Some public health interfaces were built • Patients were provided with a way to electronically access their data • There was widespread adoption of some standards useful for interoperability

8. Stage 2 objectives related to interoperability and patient-centered care 7.2 Table (Lorenzi, V., 2016)

9. Stage 2 objectives related to interoperability and care coordination 7.3 Table (Lorenzi, V., 2016)

10. Stage 2 objectives related to interoperability and the learning health system 7.4 Table (Lorenzi, V., 2016)

11. Advanced standards named in ONC 2014 certification criteria • Demographics: Language ISO639-2, CDC Race and Ethnicity Value Sets • Problem List and Encounter Diagnoses: SNOMED-CT July 2012 and ICD-10 • Medications and Medication Allergies: RxNorm • Medication Allergy List: RxNorm • Smoking Status: SNOMED-CT • Lab Results: LOINC, UCUM units of measure, SNOMED organisms, HL7 V2 Lab Results Interface Implementation Guide, HL7 V2 Reportable Results Implementation Guide • Transitions of Care and Patient Engagement: All terminology standards, required as well as C-CDA and NHIN Transport standards; No more CCR or CCD (CCD subsumed in CCDA) • CQMs – electronic submission: QRDA Level 2 and 3 and NHIN Transport Standards (no more PQRS layout) • Public Health: HL7 V.5.1 implementation guides for immunization and syndromic surveillance and HL7 V3 Cancer CDA spec • Infobutton: HL7 V3 Context Specific Knowledge Query • Family History: HL7 V3 or SNOMED-CT

12. Stage 2 interoperability efforts / challenges for providers and hospitals • Mapping patient information to data standards • Mapping internal terminologies to standard terminologies • Testing implementation for all types of patient encounters and different data types • Analyzing referral and transition patterns • Identifying data exchange and transition of care partners • Encouraging patients to log into patient portal, view their data, and send secure messages to providers • Educating clinicians • Enhancing clinician workflows • Testing content and send / receipt methods with each partner due to CCDA variances • Resolving privacy / consent issues with sending data to transition of care providers and / or to patient portals • Having a short timeline for implementation • Having multi-site hospital networks and physician organizations at multiple stages • Being audited for Stage 1 while working on Stage 2

13. Interoperability accomplishments from 2011 and 2014 ONC criteria regulations • Vendors were tested and certified to have standards-based interoperability functionality • Even functions that were not directly related to exchange proved to be foundational • ONC included additional interoperability functionality not yet required

14. Unit 7: Policy and Interoperable Health IT, Summary – Lecture b, Meaningful Use, ONC Certification, and Interoperability (Part 1) • Stage 1 of Meaningful Use helped lay the foundation for interoperability by encouraging the implementation of EHRs, which could regularly collect structured data for exchange • It also encouraged adoption of standards that supported interoperability for patient-centered care, public and population health, care coordination and a learning health system • Although there were challenges with Stage 2, interoperability has become increasingly important and incorporated into Meaningful Use

15. Policy and Interoperable Health IT References – Lecture b References Hillestad, R, Bigelow, JH, Fonkych, K, Bower, AG, Fung, C, Wang, J, Taylor, R, Girosi, F, Meili, RC, & Scoville, R. (2006). Health information technology, can HIT lower costs and improve quality? RAND Research Brief. http://www.rand.org/pubs/research_briefs/RB9136.html MedLinePlus. https://www.nlm.nih.gov/medlineplus/connect/overview.html. Charts, Tables, and Images 7.2 Table: Lorenzi, V. (2016). Stage 2 objectives related to interoperability and patient-centered care. 7.3 Table: Lorenzi, V. (2016). Stage 2 objectives related to interoperability and care coordination. 7.4 Table: Lorenzi, V. (2016). Stage 2 objectives related to interoperability and the learning health system.

16. Unit 7: Policy and Interoperable Health IT, Lecture b – Meaningful Use, ONC Certification, and Interoperability This material was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0004.