Certification / Adoption Workgroup

1. Certification / Adoption Workgroup Larry Wolf, chair Marc Probst, co-chair January 21, 2014

2. Agenda • Review of Agenda • HITPC Charge: Step Two • Continued discussion of proposed LTPAC health IT Certification Criteria • Next Steps • Public Comment

3. Patient-Specific Educational Resources Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Previous certification efforts have supported the process for patient educational resources • 12/2 C/A WG call: Patient portals are available across all LTPAC provider types. However, frequency and breadth of use is unknown. • “75 percent of [long term care]provided by families in the home, and by non-licensed personnel and agencies going into the home.” • “we need to figure out the presentation layer that appeals to patients and families, … have one record that all parties can tap into, upload to, download from, right through to the end of the person’s life…” • Support the ability to use ONC specified standards to electronically retrieve patient-specific education from content/knowledge resources. [MU 2 certification criteria]

4. Incorporating Laboratory Tests & Values/Results Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Support the ability to electronically receive, incorporate, and display clinical laboratory tests and values/results in accordance with the HL7 Version 2.5.1 Implementation Guide and with laboratory tests represented in LOINC [MU 2 certification criteria] • Previous certification efforts have supported receiving and incorporating, displaying lab results • Neither the LTC FP nor the CCHIT LTPAC criteria explicitly identify the ONC specified lab data components, for a test report “The [CDS] systems that we've developed use signals that require the presence of admission, discharge, transfer, lab, and medication data…there are existing standards for lab, including LOINC and medications, NCPDP, and are widely available to support [AD detection and management].” “Due to our recent certification process, we've built in some key capabilities. We can now import lab results…” “Indeed, we find that sharing…lab results and just the exchange of demographics … have been the primary interest.”

5. Clinical Decision Support Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Prior certification efforts have supported CDS interventions based on problems, medications, medication allergies, demographics & labs • No match on reference information, source attribution, and electronic triggering for clinical decision support. • “CDS can greatly improve the detection and management of [adverse consequences] and improve [regulatory compliance] and inclusion of medication specific CDS should provide alignment with and support existing federal and state programs...” • “the level of opportunity for using [CDS] at the time of prescribing can be quite significant. For example, …clear opportunity to optimize the way antibiotics are being used and other antimicrobials” • “we should try and link [CDS rules] to those harm related events to try and reduce that ” Support the ability to have: • Evidence-based decision support interventions. • Linked referential clinical decision support. • Clinical decision support configuration. • Automatically and electronically interact • Source attributes • Drug-drug, drug-allergy interaction checks. [MU 2 certification criteria]

6. Clinical Health Information Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Prior certification efforts have supported the ability to electronically record, change, and access problem list, medication list , medication history, active medication allergy list and medication allergy history. • Support the ability to record, change, and access the: • Problem list • Medication list • Medication Allergy list using ONC specified standards [MU 2 certification criteria] • Support clinicalinformation reconciliation. [MU 2 certification criteria] • Support Electronic Notes. [MU 2 certification criteria] • “CMS documentation requirements of an annual comprehensive med review. This structured document contains the pharmacist provided reconciled active med list, allergy list, indications for each active medication, and special instructions for the patient…can be used by pharmacists and other health care providers in all practice settings including LTPAC and behavioral health.” • “…We could require some interoperability of at least a small set of data, the medications, diagnoses, care plans, function, mental status, likely course”

7. Patient Demographics Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Neither LTC FP nor CCHIT criteria identify explicit demographic data elements to be captured and maintained. • Neither LTC FP nor CCHIT include criteria addressing the ability to record, change, and access preliminary cause of death in the event of a mortality. “exchange of demographics and using some of the older ADT standards have been the primary interest…” • Support the ability to record, change, and access patient demographic data using ONC specified standards [MU 2 certification criteria]

8. Advance Care Planning Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification Prior certification has indicated: • the type of advance directives completed • when last reviewed, time stamp entry of information • name and relationship of party completing the advance directive • location and or source of legal documentation *More info in supplemental mapping materials • “We need advanced plans in all records, we need to know who the surrogate is, and not just a yes/no. We need to be able to code the major decisions…We need to make the core elements available to the patient, family, and caregiver. “ “…it is becoming actually harmful and dangerous to have in the electronic record only a yes/no on an advanced directive. Now, a majority of states accept the POLST—we could readily digitize most of the POLST entries, and we could readily scan and attach to the record a real document” • Support the ability to record whether an advance directive exists for the patient [MU 2 certification criteria] • Support the ability to store an advance directive document in the record or provide a link to the advance directive in a repository or other location. [MUWG-identified MU3 Criteria under consideration] • Support the ability to retain versions of the advance directive document in the record or enable links to earlier versions of the advance directive document. • Future work: Standards for content of the advance directive

9. Medication Related Criteria Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Previous certification efforts have supported the ability to: • record, change and access each of the order types (i.e., meds, labs, radiology /imaging) • Verify right patient • NCPDP SCRIPT v10.6 • Automatically and electronically check whether a drug formulary exists for patient or drug • “the practice of prescribers entering orders electronically into the EHR will decrease the chance for errors in the interpretation of prescriber orders.” • “a significant number of orders are changed today verbally or via telephone, …..keystroke errors are frequently identified in our business as contributors to adverse events that result in patient harm.” • “Pharmacists electronically accessing and exchanging clinical information in these settings are vital to meeting institutional quality and safety medication management processes.” Support for: • e-MAR • Electronic prescribing • Drug-formulary checks [MU 2 certification criteria]

10. Computerized Provider Order Entry (CPOE) Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • “A subset of the criteria rules, such as e-prescribing, labs and other diagnostic data, and activities of daily living [from the ONC 2014 certification criteria would support TOC], could apply” • Previous certification efforts have supported the ability to record, change and access each of the order types (i.e., meds, labs, radiology/imaging) • Support the ability to electronically record, change, and access the following order types: (i) Medications; (ii) Laboratory; and (iii) Radiology/imaging. [MU 2 certification criteria]

11. Public Health - Transmission to Immunization Registries Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Previous certification efforts have supported the ability to record, change, and access immunization information. • Neither the LTC FP nor the CCHIT LTPAC criteria address creating immunization information for transmission using the HL7 v2.51 Immunization Messaging standard or HL7 Standard Code Set CVX – Vaccines Administered. • “defining a health IT standard for… influenza vaccine administration… would enable…information… exchanged between… providers as well as … state vaccination registries. This could reduce duplication of immunization …among different…providers caring for the same person, reduce… individual’s risk of receiving multiple vaccinations…, and provide [PH] with reliable information and vaccine coverage within communities” • Support the ability to electronically generate immunization information for electronic transmission using ONC specified standards. [MU 2 certification criteria]

12. LTPAC Setting-Specific Criteria: Federally Required Patient Assessments Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • “The handling of the MDS, … census data, care planning, quality assurance activities, by and large …are primarily used for internal operations of the SNF. There are a number of SNFs that would like to be able to transmit data… but the interoperability structure in the state is not terribly well developed for communicating between hospitals and SNFs, SNFs and home health or home care, assisted living. • Previous certification efforts have supported the ability to create, maintain, transmit, and reuse assessment content. • Support the ability to create, maintain, and transmit (in accordance with CMS requirements) assessment instruments and data sets for LTPAC: MDS 3.0, OASIC-C , IRF-PAI, CARE subset for LTCH, and a Hospice Item Set. [Criteria not in MU] • Support the use of accepted vocabulary standards to enable the reuse of assessment data for: • various clinical purposes; and • administrative purposes. [Criteria not in MU] • Support the ability of the provider or a designated third party to create and exchange interoperable LTPAC Assessment Summary CDA documents [Criteria not in MU]

13. LTPAC Setting-Specific Criteria: Federally Required Patient Assessments Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • “LTPAC reporting requirements should be harmonized with clinical data required for patient care.” • CMS believes that data uniformity…across settings, is critical to facilitate … transfer of information. It’s also what’s needed…to develop and implement measures that can be harmonized across settings... “ • Previous certification efforts have supported the ability to create, maintain, transmit, and reuse assessment content. Future work: • Harmonization of federal content and format for patient assessments with ONC specified EHR standards (e.g. consistent standards on demographics). • Make the data element library publically available and link content to nationally accepted standards.

14. LTPAC Setting-Specific Criteria: Survey and Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) LTPAC Hearing Proposed Areas for Certification • Prior certification has supported surveyor access to the complete EHR, consistent with federal requirements. • “Surveyors need prompt and complete access to the EHR to complete surveys as required.” • “It would be interesting to consider if an EMR certification program could also include certain interoperability with this QIS [Quality Indicator Survey] software.” • “it [is] imperative for the surveyors …to look across modules of the EMR to understand the timeline of how the different care components fit together.” • Support the ability to promptly provide surveyors with access to the complete EHR, consistent with federal requirements. [Criteria not in MU] Future work: • Support  surveyor navigation of the EHR. (e.g.  Implementation guide  describing the functions in the EHR that surveyors need). More work is needed in this area. • Support the QIS process. More work is needed in this area.

15. Tracking LTPAC EHR Adoption and Use Trends Additional Proposals: • As ONC advances LTPAC certification, ONC should track national trends in LTPAC health IT adoption. Such efforts should include tracking use by functionality and criteria. • National survey data on LTPAC EHR adoption and use should utilize definitions that are consistent with those in the MU program.

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