Beacon Community Program Build and Strengthen – Improve – Test innovation

1. Beacon Community ProgramBuild and Strengthen – Improve – Test innovation Beacon-EHR Vendor Full Affinity Group August 30, 2013

2. Today’s Goals • Roll call – Lynda Rowe • Welcome to Participants (Adele, Chuck) • Review of Affinity Group Goals, and Progress (Adele, Chuck) • Orientation to the Problem (Lynda Rowe) • Goals and Outcomes of the Meeting(s) (Lynda Rowe) • Timeline • Outcomes • Deep Dive Numerator/Denominator Calculations (All) • Next Steps • Future meeting to complete work • Output deliverable and distribution

3. Affinity Group Goals • The ONC Beacon EHR Vendor Affinity Group convened and collaborated to advance mutually agreed to EHR adoption and interoperability goals between November 2011 and September 2012 • Original charter available on the ONC Beacon EHR Vendor AG HITRC portal http://wiki.statehieresources.org/Beacon+EHR+Affinity+Group • On February 1st, 2013, all members confirmed an interest to align the activities of the group to support achievement of MU Stage 2 in the following manner: • Explore the transport standards associated with Transitions of Care (TOC) • Explore how to achieve the View online, Download, and Transmit(VDT) measures • Act as a venue to pilot and test the implementation of the transport standards outlined in the ONC Standards and Certification Criteria Final Rule for TOC and optionally VDT objectives • Act as a means to extend the knowledge gained and deliverables created by collaboration to vendors and communities outside of this affinity group

4. Orientation to the Problem & Goals • Problem • MU Stage 2 TOC provides ways for HIEs/HIOs to support measure 2 • HIE/HIO participating in TOC need to provide evidence of message receipt – contribute to overall numerator • Counting methods not yet defined • Goals • Establish a proposed set of specifications for N/D calculations for EHRs and HIOs participating in MU2 TOC • Establish a process and timeline for completing the work • Determine appropriate processes for getting broader buy-in and dissemination

5. Meaningful Use & Certification Relationship “Transitions of Care” (ToC) Objective Meaningful Use 2014 Edition Certification • For Meaningful Use Stage 2, the ToC objective includes 3 measures: • Measure #1: requires that a provider send a summary care record for more than 50% of transitions of care and referrals. • Measure #2 requires that a provider electronically transmit a summary care record for more than 10% of transitions of care and referrals using CEHRT or eHealth Exchange participant • Measure #3 requires at least one summary care record electronically transmitted to recipient with different EHR vendor or to CMS test EHR • Two 2014 Edition EHR certification criteria • 170.314(b)(1) : Transitions of care—receive, display, and incorporate transition of care/referral summaries. • 170.314(b)(2) : Transitions of care—create and transmit transition of care/referral summaries.

6. Feature Focus: ToCMeasure #2 & 170.314(b)(2) ToC Measure #2 170.314(b)(2) • Transitions of care—create and transmit transition of care/referral summaries. • (i) Enable a user to electronically create a transition of care/referral summary formatted according to the Consolidated CDA with, at a minimum, the data specified by CMS for meaningful use. • (ii) Enable a user to electronically transmit CCDA in accordance with: • “Direct” (required) • “Direct” + XDR/XDM (optional, not alternative) • SOAP + XDR/XDM (optional, not alternative) • The eligible provider, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either: • (a) electronically transmitted using CEHRT to a recipient; or • (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. eHealth

7. Transmit Summary Care Record Using eHealth Exchange Participant Provider A eHealth Exchange Participant (formerly NwHIN Exchange) Provider B Example 1 CEHRT An eHealthExchange Participant does not have to be certified in order for Provider A’s transmissions to count for MU. However, Provider A must still use CEHRT to generate a standard summary record in accordance with the CCDA.

8. Transmit Summary Care Record Using “Pull” or “Query” Infrastructure Provider 1 Provider 2 Provider 3 Provider 4 • Providers #1-4 (1) have CEHRT, and (2) use the CEHRT’s transport capability (Direct or SOAP) to send a CCDA to a HISP/HIE that enables the CCDA they’ve sent the HISP/HIE to be subsequently pulled by Provider #5. HISP/HIE In this scenario, the HIE does not have to be certified. Provider 5

9. Transmit Summary Care Record Using “Pull” or “Query” Infrastructure Provider 1 Provider 2 Provider 3 Provider 4 • If Providers #1-4 do not have CEHRT, their EHR technology will either • Need to be certified as a pair with HISP/HIE to be able to create the CCDA and transmit it to Provider 5 (per the prior slides). • Need to use an HIE that has been certified to support this criteria (per the prior slides). HISP/HIE Provider 5

10. Transmit Summary Care Record Using “Pull” or “Query” Infrastructure • Regardless of certification path, Provider #5 needs to “pull” the summary care record in order for Provider #1-4 to potentially count the pull in their numerator. • For all Providers where the patient meets the denominator requirements, when Provider #5 pulls they can then count that pull in their numerator as a transmission to Provider #5 (e.g., Providers #1-3 saw the patient during the reporting period but #4 did not; thus only Providers #1-3 could count the pull). Provider 1 Provider 2 Provider 3 Provider 4 HISP/HIE Provider 5 In the “pull” scenario, accurately counting transactions for the providers’ numerators and denominators represents a non-trivial challenge.

11. Options for HIOs to participate in MU2 TOC • There are a number of options for an HIE/HIO to participate in TOC MU2 exchange • Become certified for TOC (transport, content) • Partner with an EHR and become relied upon software • Become an eHealth Exchange (N/D) • Push content delivered by CEHRT (receipt confirmation) – repackaged and deliver with any transport • Pull/Query – messages must be delivered using CEHRT (N/D) • Focus today is on those options requiring tracking of numerator and denominator values to calculate the measure and meet audit requirements

12. Possible Pilot Scenarios 1 - 5

13. Possible Pilot Scenarios 6 - 10

14. Numerator/Denominator for TOC measure #2 • Measure 1: The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals. • Measure 2: The EP, EH or CAH that transitions or refers its patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transition and referrals either: • Electronically transmitted using CEHRT to a recipient; or • Where the recipient receives the summary of care record via exchange facilitated by an organization that is an eHealth Exchange participant • Denominator: Number of transitions of care and referrals during the CEHRT reporting period for which the EP or eligible hospital’s or CAH’s inpatient or emergency department (Place or Service 21 or 23) was the transferring or referring provider • Numerator: Number of transitions of care and referrals in the denominator where a summary of care record was a) electronically transmitted using CEHRT to a recipient or b) where the recipient receives the summary of care record via exchange facilitated by an organization that is an eHealth Exchange participant. The organization can be a third-party or the senders own organization. • Of note: • EP/EHs may only count transmissions in the measures numerator if the are accessed by the provider to whom the sending provider is referring or transferring the patient • An EP or EH may only count in the numerator transitions of care that first count in the denominator • Receipt by the provider occurs when either the clinician receives/queries or the practice/facility at which the clinician works receives/queries the summary of care

15. Numerator/Denominator Calculations • Key Points • EPs/EHs must use one of two methods to calculate their denominator: • Minimal denominators provided by CMS in the Stage 2 Final Rule • http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_15_SummaryCare.pdf • Minimal denominators PLUS criteria defined and consistently documented by the EP/EH such as all self referrals not just self referrals reported by the HIO

16. Numerator/Denominator Calculations • Counting Concepts • Unit of measure for ToC measure 1 and 2 is transition/referral and not individual patient • 1:1 relationship between transitions/referrals in the EP/EH’s denominator and numerator. An EP/EH cannot count more than one pull/query in the numerator for just on TOC in the denominator • All EPs/EHs contributing data to a patient’s CCDA may receive credit when that document is exchanged/pulled only if the transfer is in the EP/EHs denominator • It is likely that an HIO will not have easy access to a particular EP or EH’s denominator unless the HIO is also the EHR vendor, and EHR vendor provides a list of denominator transitions or referrals to the HIO, or the EP or EH provides a list of denominator transitions or referrals to the HIO • Approach to calculating the denominator for ToC measure 1 and 2 must be the same • The HIO must account for multiple “query/views” of a patient’s record and which provider or organization viewed the record

17. ToC Measure 2 Query Pull Method for EPs, EHs, and CAHs

18. Numerator Denominator Deep Dive • Deep Dive Numerator/Denominator Calculations • Technical Scenarios and Permutations of eHealth Exchange/Query Retrieve • Push from sender to receiver through eHE/HIE/HISP (no N/D issue) • Push to eHE/HIE/HISP from single provider, only content contributor • Push to eHE/HIE/HISP from single provider – multiple contributors to C-CDA • Push to eHE/HIE/HISP – stored as single document • Push to eHE/HIE/HISP – stored as longitudinal record (multiple providers contribute) • Query by recipient – no electronic notification • Query by recipient – electronic notification from HIE • Requirements from CEHRT for denominator – Measure 1, Measure 2 • Requirements from HIE to be able to calculate eHE/HIE/HISP numerator contribution • Exchange of information between CEHRT and HIE/HIO required for Numerator and Denominator Calculation

19. MU 2 Numerator Denominator Discussion - Questions • How will a CEHRT distinguish a CCD that is tied to the ONC definition of a TOC. For CEHRTs that trigger a CCD to the local exchange based on some trigger event, how will the system determine that a CCD is part of the TOC denominator vs. other reasons (lab data, update registry, immunization, ED discharge without follow-up, etc.) • How will the CEHRT “count” the denominator based on the TOC definition as well as the time frame for reporting the measure • Option 1 – HIE will calculate numerator and denominator (CEHRT passing the denominator) • How will the CEHRT export to an HIE/HIO the patient, sending provider, intended recipient, and date stamp for referral, transition or discharge (or DOS) to an HIE? • What format would be used to provide that to the HIE? • How might the CEHRT time bound denominator information to be sent based on the providers preference for their 90 day reporting period? • The assumption is that if the CEHRT provides this information to the HIE, the HIE could then match to “receipt/view/query” of TOC which would count as the numerator • Option 2 – HIE will send CEHRT the numerator. CEHRT will calculate the measure and will already have documented patient transitions in the denominator • If an HIE/HIO sends to the CEHRT a numerator file, what will be needed at a minimum to count the numerator – how will patient and provider matching happen? • If more than one provider views the TOC as a recipient is there a mechanism to account for that? • What does the CEHRT need for date/time stamp to match to the denominator reporting window? • How will the CEHRT system determine if an EP/EH TOC denominator counts toward more than one sending provider (i.e. in a multi specialty practice both the PCP and a specialist contributed to the CCD that will be sent to the receiver)

20. Wrap Up/Next Steps • Final comments • All attendees • Co-Chairs: Chuck Tryon and Adele Allison • Next steps • Conclusion