HIT Policy Committee Certification and Adoption Workgroup Meeting

1. HIT Policy CommitteeCertification and Adoption Workgroup Meeting Dec 2nd, 2013 11:00am Eastern

2. Agenda • Review of Agenda • HITPC Charge: Step Two • Background Regarding LTPAC Providers • Who are LTPAC providers? • What is the clinical utility of EHRs to LTPAC settings? • What is known about EHR adoption by LTPAC providers? • 5 Factor Framework – Considerations related to LTPAC • Presentation and Discussion of Factors 1-5 • Next Steps • Virtual Hearing – ONC EHR Certification for LTPAC, 12/12/13 • Public Comment

3. HIT/EHRs for LTPAC Providers: Considerations for Certification Criteria Identified in the 5 Factor Framework Jennie Harvell, HHS/ASPE Sue Mitchell, Independent Consultant

4. 5 Factor Framework When evaluating whether to establish a new certification program, ONC should consider whether the proposed certification program would:

5. LTPAC Providers A mix of inpatient (including specialty hospitals) and home and community-based providers who provide care for short or long durations, as part of interdisciplinary teams. Team members may be co-located or remote.

6. Clinical Utility of EHRs and Need for HIE in LTPAC • In the Other Provider Study, Clinical Utility was defined as: • Ability of the EHR technology to support interoperability and secure information exchange among health care providers by complying with requirements of a “base EHR."a • Need for HIE in LTPAC:High. • Patients are medically-complex, functionally impaired and require clinicians/other team members with complete knowledge of their medical history.a • Patients are treated by and receive services from multiple healthcare and ancillary providers during single episodes and over-multiple episodes of care. (see details in subsequent slides) • Patients are admitted from and may be transferred to one of several providers/facilities for continuing or emergency care. (see details in subsequent slides) • Close to 40% of Medicare beneficiaries discharged from hospitals go to post-acute care settings (e.g., rehabilitation hospitals and SNFs), but there is little capacity in the system today to support HIE across these settings. b • 20% of Medicare patients are readmitted to the hospital within 30 days. Preventable readmissions waste $26B nationwide annually. C

7. Base EHR Definition (ONC Standards and Certification Criteria (2014 Ed.))

8. HIT/EHR Adoption Rates for LTPAC Providers

9. LTPAC Provider Use of EHRs in Practice

10. Factor #1

11. National Quality Strategy • 3 Aims: Better Care, Healthy People/Healthy Communities, Affordable Care. • 6 Priorities – 3 of which are: • Making care safer by reducing harm caused in the delivery of care. • Promoting effective communication and coordination of care. • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models. • Use of HIT could support these priorities.

12. HIE Needed to Support Care Coordination and Safety • Experts in transitions of care identify “improving information flow and exchange” as the most important tool to improve care transitions. ONC, 2011 • Approximately 50% of all hospital-related medication errors, and 20% of all adverse drug events attributed to poor communication during transitions of care, which can result in hospital readmissions. Barnsteiner, 2005 • When multiple physicians treat patients following a hospital discharge, information is missing 78% of the time. van Walraven, et al., 2008 • Emergency Department physicians lack important/ critical patient information 32% of the time.Stiell, et al., 2003 • Communication failures between providers contribute to nearly 70% of medical errors and adverse events in health care. Gandhi, et al., 2000 • 150,000 preventable Adverse Drug Events ($8 Billion nationwide wasted) per yr due to inadequate medication history at time of hospital admission.MedPAC, 2007

13. HIE Needed to Support Care Coordination and Safety • Shared care is common for persons receiving LTPAC. For example: • In 2005, persons living in NH made approximately 2.2. million ER visits.a • In 2008, 23.8 million Part B claims were allowed for physician visits to NH residents.b • In 2010, a study showed that NH residents average 7-8 medications – which would translate to over 15.8 million prescriptions for new admissions alone. C • Only 25% of hospitals exchanged medication lists and clinical summaries with outside providers and 31% of physicians electronically exchanged clinical summaries with other providers.e

14. Potential Benefits of HIT/HIE in LTPAC “Health IT has the potential to empower individuals and increase transparency; enhance the ability to study care delivery and payment systems; and ultimately achieve improvements in care, efficiency, and population health.” ONC Federal Health IT Strategic Plan 2011-2015 • Health information exchange can benefit persons receiving LTPAC services by “enabling secure, timely electronic information exchange to support proper medication management, seamless transitions of care, and expanded communication between numerous providers.” ONC and ASPE documents

15. Potential Benefits of HIT/HIE in LTPAC Reported benefits in LTPAC include: • Increase efficiencies a, b (e.g., expedited NH and HHA pre-admission decisions/ start of care, reduced time to complete assessments) • Opportunities to re-use data a, b, e (e.g., more complete clinical picture, data re-used from and for assessments) • Improve safety (e.g., reduced med errors) and reduce manual data entry errors e • Re-direct staff from paperwork to caregivinga, b • Data analytics a, b, e (e.g., identify: clinical complexity, resource requirements, safety issues (e.g., medication reconciliation)) • Quality, coordination, and cost improvements a, b, e (e.g., improved transitions and coordination of care, improved medication reconciliation, improved quality measure and reporting, reduced rehospitalizations) • Possible lower malpractice claims and payments c, d • Enhance market position among consumers and health care partners b, d Generally, these benefits were reported as a result of using non-interoperable, non-certified technologies.

16. Potential Benefits of HIT/HIE in LTPAC • Some vendors and LTPAC providers have implemented CDS applications to support service transformation and improve clinical decision making at the point of care to reduce costs and improve outcomes. For example: • CCITI NY assists providers with CDS and quality improvement initiatives including implementation of CDS capabilities that capture electronic patient health data from multiple sources to create real-time alerts designed to help clinicians prevent harmful events and avoid unnecessary transfers. • Univ. of Pitt has implemented CDS applications that use electronic patient level health information from a variety sources (e.g., LTPAC provider, hospital and physician) to create tools that alert clinicians about potential ADEs and prevent medication errors. • SavaSenior Care has implemented data analytic tools that use electronic patient data aggregated across different LTPAC information systems (e.g., assessment data, pharmacy data, supply inventory management data) to create algorithms that identify underlying quality problems and potential solutions. • Some LTPAC EHR vendors have incorporated data analytics and CDS applications into product • The extent to which these LTPAC CDS applications integrate HIT standards and requirements from the ONC 2014 Ed. is unknown.

17. Factor 1 Conclusions • Use of CEHRT by LTPAC providers is expected to improve HIE, improve quality, continuity, and coordination of care, and enhance safety in: LTPAC settings, physician practices, and hospitals, in both the fee-for-service and transformed service delivery environments. • The potential quality, continuity, and coordination of care benefits of establishing a voluntary LTPAC CEHRT program and EHR certification criteria will depend on: • Adopting criteria that supports needed functionality • Aligning these criteria and associated health IT standards with those adopted via the ONC 2014 Ed. requirements • Incorporating these functions and standards in LTPAC vendor EHR products • LTPAC provider acquisition and use of certified products that supports the needed functionality

18. Factor #2

19. Programs Supporting HIT/HIE in LTPAC Service delivery transformation is occurring. CMS and States are implementing service delivery and payment programs that require or support HIE with and by LTPAC providers and other care providers across continuum, and with payers and regulators. Some of these programs are: • ACOs • Bundled payment models • Balancing Incentive Programs (LTSS & HCBS) • TEFT: Testing Experience & Functional Tools • Medicaid Health Home State Plan Option (Patient-Centered Medical Homes (PCMHs) • Dual-eligibles programs • Community-Based Care Transitions Program • State Innovations Models (SIMs) • Hospital Readmission Reduction Program • Medicare Physician Fee Schedule Enhancements for: (i) chronic care management, (ii) services to support transition in care, and (iii) payment for telehealth visits

20. LTPAC – Federally Mandated Assessments • In LTPAC settings, CMS requires the completion and electronic transmission of patient assessment data/instruments (i.e., MDS for NHs, OASIS for HHAs, IRF-PAI for IRFs, and a subset of CARE for LTCHs, IRFs & Hospice) • Assessments support multiple purposes: Patient assessment and care planning, payment, quality monitoring/reporting, and/or survey and certification activities. • Generally, data elements, while similar, are not equivalent across instruments • Assessment instruments/data elements are required by CMS to be electronically transmitted using CMS specified transmission requirements • CMS data submission specifications do not include HIT vocabulary standards identified in ONC 2014 Ed.(e.g., SNOMED for problems, CVX for immunizations) • Data files for MDS and OASIS assessments can be transformed to a: • Clinically relevant document (i.e., the HL7 specified “LTPAC Summary Document”) • LTPAC Summary Document represented as a CCD using the C-CDA standard • The Keystone Beacon Community developed a transform tool for the purpose of enabling HIE between NHs/HHAs and others in the healthcare continuum a,b

21. Quality Monitoring & Reporting in LTPAC • For LTPAC: • CMS calculates QMs using facility-specific and aggregate state/national data from federally-required patient assessments that are electronically submitted by LTPAC providers to CMS. These QMs are not comparable across LTPAC settings. • CMS includes these QMs as part provider performance reports on CMS “compare” websites. • For physicians/hospitals: CMS has established QMs across a variety of programs that are not align with the QMs established for LTPAC. • The ONC 2014 Ed. requires use of certain HIT standards for import, export, and transmission of QMs for use physicians/hospitals. • In contrast to EPs/EHs, LTPAC providers: • Do not calculate and transmit QMs to CMS (they transmit data elements/assessment instruments); and • Do not use the e-CQM standards in the ONC 2014 Ed. (i.e., QRDA is not included in the CMS data submission specifications for LTPAC providers).

22. ONC Certification & Alignment with LTPAC QM Requirements • ONC Certification program will not (on its own) address/resolve: • The lack of policy alignment between CMS and ONC submission/transmission requirements • The proliferation of non-aligned QMs across the care continuum • Critical gap in QMs regarding: Care coordination a

23. LTPAC Quality Monitoring Surveys • LTPAC providers are highly regulated (e.g., statutorily required annual surveys). • The survey process relies resident observation and record review, and uses federally-required assessment data • Surveyors express concerns and questions about their ability to access content of the health record (as required by law) when encountering EHRs during surveys. • The LTPAC survey process uses either automated and/or manual data collection and analytic tools. • LTPAC EHRs are (generally) not aligned with requirements in the ONC 2014 Ed. As a result: • the automated survey process is unable to realize potential efficiencies (e.g., through data re-use); and • the ability to construct templates to facilitate data gathering and analysis is constrained.

24. Factor 2 Conclusions • Identification and inclusion of key EHR certification criteria and functions in a voluntary LTPAC EHR certification program could provide some alignment with and support for existing Federal/State Programs • Implementation of a voluntary EHR certification program in LTPAC could create efficiency gains, permit re-use of data, and enable/support quality improvement and care coordination activities/efforts at Federal, State, and provider levels

25. Factor #3

26. LTPAC Standards & Certification Efforts HL7 LTC EHR-System Functional Profile (LTC EHR-S FP) (2010): • Based on the 2007 HL7 EHR-System Functional Model (EHR-S FM), R1 (a reference list of functions that may be present in an EHR system • HL7 LTC EHR-S FP identifies a subset of functions from the EHR-S FM that reflects the unique aspects and needs for an EHR-S in the LTC setting • Both the LTC EHR-S FP and EHR-S FM are ANSI approved standards

27. LTPAC Standards & Certification Efforts Certification Commission for Healthcare Information Technology EHR Certification 2011 – LTPAC (CCHIT Certified 2011 LTPAC) • Private sector EHR certification program for LTPAC products created in response to request from the LTPAC community • Offered beginning July 2010, the LTPAC certification program was new for the CCHIT 2011 testing cycle • Applied many criteria from the HL7 EHR-S LTC Functional Profile • Contains core LTPAC requirements for functionality, interoperability and security • Offers (i) Skilled Nursing Facility (SNF) and (ii) Home Health (HH) certification options addressing specific EHR needs for providers in those care settings

28. HL7 LTC EHR-S Functional Profile and CCHIT Certified 2011 LTPAC - Issues and Themes • The HL7 LTC EHR-S FP and CCHIT LTPAC program generally do not identify health IT standards in their conformance criteria. • Often when standards are referenced, they are named as examples rather than being specifically required thru conformance criteria. • Key standards identified in the HL7 LTC EHR-S FP and CCHIT LTPAC program are not in sync with requirements in the ONC 2014 Ed. See examples in notes. • These private sector programs have not been updated since publication of the ONC 2014 Ed.

29. HL7 LTC EHR-S Functional Profile and CCHIT Certified 2011 LTPAC - Issues and Themes • Some requirements from the ONC 2014 Ed. are not included in the HL7 LTC EHR-S FP and CCHIT LTPAC program. For example, the: • HL7 LTC EHR-S FP does not include key criteria related to recording the encryption status of end-user devices (e.g., USB flash drive) • CCHIT LTPAC program does not specify criteria to: transmit/send Summary Records/CCDs created per program requirements • HL7 EHR-S LTC FP and the CCHIT LTPAC program do not identify requirements for: • Specific demographic data elements & vocabulary standards for these data elements; and • Vocabulary standards for e-prescribing.

30. LTPAC EHR Products • There are approximately 50 “Fully Functional” LTPAC EHR products available in the market a

31. LTPAC EHR Products ONC-ACB Certified Products for LTPAC a: • A total of 19 products, from 10 vendors, are certified to ONC 2011 or ONC 2014 criteria. • For purposes of the EHR Incentive Programs, Eligible Professionals (EPs)/Eligible Hospitals (EHs) must use EHRs certified to the ONC 2014 Ed. beginning January 2014. • 18 of the 19 products are certified by CCHIT under the ONC HIT certification program (i.e., CCHIT acting as an ONC-ACB). • EHR certification for 10 out 18 of the ONC-ACB, CCHIT-certified products will expire December 2013 (these are ONC 2011 Ed certified products).b

32. LTPAC EHR Products • ONC 2011 certification: • A total of 11 products, from 9 vendors, have been certified to the ONC 2011 criteria • 3 products, from 3 vendors, were certified for the ambulatory practice setting • 8 products, from 8 vendors, were certified for the in-patient practice setting • 3 products, from 2 vendors, have been certified as “Complete EHRs” • 8 products, from 7 vendors, have been certified as “Modular EHRs” • Note: 2 of the 11 products certified to the 2011 criteria were certified in the second half 2013 • Suggesting continuing interest in ONC EHR Certification • However, continuing availability of the 2011 criteria and the use of products certified to these criteria may create confusion in the market, particularly for LTPAC providers and their EP/EH trading partners

33. LTPAC EHR Products • ONC 2014 certification: • A total of 8 products, from 3 vendors, are certified to ONC 2014 criteria • 4 products, from 2 vendors, are certified for the ambulatory practice setting • 4 products, from 2 vendors, are certified for the in-patient practice setting • 2 products, from 1 vendor, are certified as “Complete EHRs” • 6 products, from 3 vendors, are certified as “Modular EHRs” • 1 product is certified on the 2014 ONC Ed. Modules: Authentication/Access Control/Authorization; Automatic log-off; Emergency access; Integrity; and Quality Management System • 1 product is certified on the 2014 ONC Ed. Modules: CPOE; Medication List; Medication Allergy List; Automated Numerator Record; Safety-Enhanced Design; and Quality Management System • 4 other products (offered by 1 vendor) are certified on between 13 – 39 Modules from the 2014 ONC Ed.

34. Certification by Criterion for ONC-ACBCertified Modular EHRs for LTPAC The focus of this analysis is on criteria included in the ONC 2011 Ed. given the limited number of LTPAC EHR products certified to the 2014 ONC Ed.. Number of products reflects the number of products certified to the criterion.

35. New Health IT Standards that Support HIE in and with LTPAC • HL7 C-CDA (July 2012): includes refinements that address the interoperable exchange of functional status, cognitive status, and pressure ulcer content a • HL7 CDA IG for Questionnaire Assessment*: provides guidance on implementing the assessment questionnaires , including the CARE data set used in LTCHs b • HL7 C-CDA IG for LTPAC Summary: provides requirements for the creation of a LTPAC Summary CCD documentbased on content from MDS and OASIS assessments c • HL7 C-CDA (Sept. 2013) *: includes new and enhanced templates to support Transfer Summary, Consult Request and Consult Note document types for use in transitions and referrals in care, as well as support a robust exchange of care plan, including the home health plan of care d * These standards have not yet been implemented. Piloting of some of the new HL7 C-CDA (Sept. 2013) standards is anticipated.

36. New & Emerging Functionality • DIRECT: Provides a low cost means to accelerate to HIE. DIRECT is available in most States and beginning to be used to support HIE with LTPAC providers (e.g., MO, IL) a • KeyHIE Transform: Subscription service that converts MDS and OASIS files from CMS xml format to a CCD that can be exchanged with authorized trading partners (physicians, hospitals, HIEs) b • IMPACT – Surrogate EHR Environment (SEE): Massachusetts initiative enabling non-EHR users to use SEE (software hosted by a trusted authority) to view, edit, and send CCD+ documents via HIE or Direct to next facility c,d • Integration engines: Tools that facilitate exchange of information across disparate provider systems (e.g., across EP, EH, and LTPAC systems)e • Shared care: Electronic tools to support internal communication across team members and transfers in care (e.g., Interact)

37. Other Needed Functionality • The HL7 LTC EHR-S FP and CCHIT LTC EHR criteria include more specificity/ functionality in the areas listed below in comparison to the ONC 2014 Ed. : • Assessments • Care Planning • Three-way communication of medication orders between physicians, NHs, and pharmacies • Medication administration records and Treatment administration records • Lists of medical equipment/prosthetics/orthotic devices • Advance care planning • Patient and family preferences • Additional needed functionality: • Clinical decision support tools to help with certain clinical/ functional areas (e.g., pressure ulcers, falls)a

38. Factor 3 Conclusions • Private sector efforts regarding LTPAC EHR functional requirements and certification have not been updated and are not aligned with requirements in the 2014 ONC Ed. • Private sector efforts typically do not identify specific HIT standards in their conformance criteria • HL7 LTC EHR-S FP and CCHIT LTPAC Program contain requirements tailored to the LTPAC environment that are not found in the ONC 2014 Ed. (e.g., assessments, care planning, advanced care planning, quality measure requirements specified by CMS for LTPAC providers, etc.)

39. Factor 3 Conclusions • There are limited ONC-ACB certified EHRs available for use by LTPAC providers. • Complete EHRs: Approximately 3% of the “Fully Functional” LTPAC EHRs are certified as complete EHRs using criteria in the ONC 2014 Ed.. ONC-ACB certification as a complete EHR: • includes some functionality not needed by LTPAC providers • does not include all functionality needed by LTPAC providers • Modular EHRs: Approximately 9% of the “Fully Functional” LTPAC EHRs have certified modules, certifiedagainst the 2014 criteria: • modules that have been certified do not include certification on critical criteria available in the 2014 Ed. • modular certification is not available for some functionality needed by LTPAC providers

40. Factor #4

41. Stakeholder Support • In response to the HHS/Request for Information (RFI) on Accelerating HIE, multiple stakeholders (i.e., LTPAC providers and associations, physician and hospital providers and associations, vendors, health information associations, standard development organizations, states and state associations, health information exchange organizations, researchers, others) expressed nearly unanimous support for: • Implementing new payment models (e.g., hospital readmission payment reduction, bundled payments, patient centered medical homes) to create incentives to reduce redundancies, improve care coordination, and accelerate e-HIE . • Applying the health IT standards and infrastructure required in the EHR Incentive Programs to LTPAC (and other ineligible providers), including requirements related to interoperable HIE at times of transitions in care. • Efficiencies gains and quality/coordination of care improvements were anticipated by stakeholders though the use of interoperable technology

42. Stakeholder Support (cont’d) • Near unanimous stakeholder support expressed for: • implementing health IT standards needed for widespread, interoperable HIE, including standards emerging through the S&I Longitudinal Coordination of Care Workgroup and use of Direct • supporting interoperable HIE of LTPAC patient assessment: data/ instruments/LTPAC Summary Documents

43. Stakeholder Support (cont’d) • Widespread stakeholder support expressed for: • a voluntary certification program with LTPAC-specific criteria and recommendations to guide the purchase of EHR products that address the clinical processes and information needs of LTPAC providers. • The HIT Policy Committee recommended: • Require (if possible) or facilitate (if not) voluntary certification of technology used by providers ineligible for meaningful use, in alignment with MU requirements • ONC should harmonize the care plan requirements so that MU eligible providers are able to receive care plans from non-MU eligible providers (e.g., NFs) • CMS-required documentation should be harmonized to the C-CDA: MDS, OASIS and Care Tool, HH PoC (CMS 485) and IRF-PAI

44. Stakeholder Support (cont’d) • Stakeholder support expressed for: • Using QRDA for quality reports across providers and between providers and government agencies • Encouraging e-measure definitions that can be easily derived from existing data • Establishing a new e-specified measures of care coordination to encourage e-sharing of summary records following ToC • Providing technical assistance to LTPAC providers to select, implement and meaningfully use CEHRT would improve care coordination across the spectrum

45. Factor 4 Conclusions • Near unanimous support was expressed in response to the RFI for: • Extending the interoperable HIT/HIE infrastructure to LTPAC providers • Aligning the HIT/HIE infrastructure across the care continuum • Extending the HIT/HIE infrastructure to include standards needed in LTPAC • Stakeholder expressed widespread support for a voluntary EHR certification program for LTPAC • Stakeholders indicated that use of standards and certified technology would likely create efficiency gains, enable the re-use of data, and support quality improvements and care coordination activities/efforts at Federal, State, and provider levels

46. Factor #5

47. Implementing a Voluntary EHR Certification Program for LTPAC: Cost/Benefit Considerations • If a voluntary EHR Certification Program for LTPAC products is focused on “key” standards and functions then the: • Number of EHR products that support needed standards and functionality could increase • Number of EHR products available to support interoperable HIE across the continuum could increase • Integrity of the system and privacy and security data could be ensured • Costs of EHR products that include needed standards and functionality could decrease • A voluntary EHR certification program could serve as the foundation for: • LTPAC vendors product enhancements – the standards and functions included in a voluntary certification program could be the base for additional information systems enhancements. • LTPAC provider EHR acquisition decisions – a voluntary certification program could reduce provider uncertainty and confusion regarding EHR acquisition decisions. • Policy decisions by payers/regulators – use of certain/all functions and standards included in certified EHR technology could: (i) support several policy priorities (i.e., improve quality/coordination of care/interoperable HIE and reduce costs) and (ii) be supported through various policy decisions

48. Implementing a Voluntary EHR Certification Program for LTPAC: Considerations Challenges: • Key Standards: Identifying the right “key” standards and functions to include in a voluntary EHR certification program • Accelerating Use of Certified EHR Products: Payment/regulatory policies will be needed to encourage use of certified EHR products to achieve policy priorities. Such policies will need to consider the impact on: • quality/continuity of care beneficiaries receive; • providers; • vendor market; and • other programs and payers NOTE: As noted by ONC during the first SWG call, the focus of a voluntary certification program is on the certification criteria, not of the use of these criteria.

49. “Key” standards and functions in a voluntary LTPAC EHR Certification Program: Considerations • Which of the standards/ functions in the ONC 2014 Ed. of EHR Standards and Certification Criteria are “key” for a voluntary LTPAC EHR certification program?

50. “Key” standards and functions in a voluntary LTPAC EHR Certification Program: Considerations • Which of the standards/ functions in the ONC 2014 Ed. of EHR Standards and Certification Criteria are “key” for a voluntary LTPAC EHR certification program?