HIT Policy Committee: Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Debrief

1. HIT Policy Committee: Meaningful Use Workgroup Stage 3 – Preliminary RecommendationsDebrief Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair August 1, 2012 Washington Marriott, 1221 22nd Street, NW, DC 20037

2. Workgroup Membership Co-Chairs: Paul Tang Palo Alto Medical Foundation George Hripcsak Columbia University Members: • David Bates Brigham & Women’s Hospital • Michael Barr American College of Physicians • Christine Bechtel National Partnership/Women & Families • Neil Calman Institute for Family Health • Tim Cromwell Department of Veterans Affairs • Art Davidson Denver Public Health • Marty Fattig Nemaha County Hospital • James Figge NY State Dept. of Health • Joe Francis Veterans Administration • Leslie Kelly Hall Healthwise • Yael Harris HRSA • David Lansky Pacific Business Group/Health • Deven McGraw Center/Democracy & Technology • Latanya SweeneyCarnegie Mellon University • Greg Pace Social Security Administration • Robert Tagalicod CMS/HHS • Karen Trudel CMS • Charlene Underwood Siemens • Amy Zimmerman Rhode Island Department of Health and Human Services HITPC: MU Workgroup Stage 3 Recommendations

3. HITPC Stage 3 MU Timeline • Aug, 2012 – present draft preliminary stage 3 recs • Oct, 2012 – present pre-RFC preliminary stage 3 recs • Nov, 2012 – RFC distributed • Dec 21, 2012 – RFC deadline • Jan, 2013 – ONC synthesizes RFC comments for WGs review • Feb, 2013 – WGs reconcile RFC comments • Mar, 2013 – present revised draft stage 3 recs • Apr, 2013 – approve final stage 3 recs • May, 2013 – transmit final stage 3 recommendations to HHS HITPC: MU Workgroup Stage 3 Recommendations

4. Guiding PrinciplesMU Objectives • 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 • Add guideline about reasonableness (feasibility) • Reapply principles to get to the next stage of objectives HITPC: MU Workgroup Stage 3 Recommendations

5. Subgroup 1:Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

6. General Comment: Subgroup 1 & Overall • Which objectives address health disparities? • Answer: Demographic collection & patient dashboard (with near real time results) provide the capability to record better demographic data and thus better reporting tools to help us focus our attention to populations that need it • Is there more that can be done? • Have you explored objectives that would be helpful to organizations that are specifically addressing health disparities and similar populations? • Answer: We have not focused on any specific organizations. We are interested in demographic conditions and bettering our reporting • Has patient safety been explored within the institution setting? • Will there ever be 100% adherence to an objective? • Answer: Setting the bar at 80% allows providers to maintain exclusions for why they do not have data on 100% of patients. There are legitimate reasons for omitted information and we do not want to penalize providers for those reasons. 80% is the highest we want to push as a policy initiative. We do not want to force providers to explain why they are missing some data for a few patients. We consider measures that are at 80% ‘topped out’ because if you are achieving 80% you have the capability to achieve 100%. • Many items are not "e" ready. Are there ways to accelerate this work to share with the industry in an open source fashion. • Need to take advantage of HHS resources. • Concern about timing, already behind for stage 2. • The stages should be driving each other, but we haven't had the time to learn from stage 1 which is concerning. There are 4/5 things that could be identified that would dramatically improve things. • P&S as well interoperability and functions HITPC: MU Workgroup Stage 3 Recommendations

7. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

8. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

9. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

10. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

11. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

12. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

13. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

14. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

15. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

16. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

17. Objective Not Included in Stage 2 NPRM - Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations

18. Improve Quality Safety, Efficiency and Reducing Health Disparities HITPC: MU Workgroup Stage 3 Recommendations 18

19. Subgroup 2: Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

20. Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

21. Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

22. Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

23. Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

24. Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

25. Objective not included - Engage Patients and Families HITPC: MU Workgroup Stage 3 Recommendations

26. Subgroup 3: Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

27. General Comments: Subgroup 3 • True care coordination depends upon exchanging data - long way from making it happen. • Want a public hearing from people having trouble with this. • What are the issues? • Remove percentages the are distracting and takes away from the policy that we are trying to accomplish. • We need to figure out where the market is and where it will be in 2 years in order to understand the best infrastructure to transmit the data. HITPC: MU Workgroup Stage 3 Recommendations

28. Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

29. Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

30. Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

31. Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

32. Objectives Not Included - Improve Care Coordination HITPC: MU Workgroup Stage 3 Recommendations

33. Subgroup 4: Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

34. General comments: Subgroup 4 • (Judy F) – Does this objective keep in mind those who move from immunization system to another (I.e. moved from North Dakota to Utah). There is no national standard established – each state has different standards for how the data is stored, how it is formatted, how it is viewed/transferred There is an assumption that we are driving the market to come up with standards? HL7? • But how do we drive the public health area (HIE in particular)? And how do we decide when to drive and when to follow the market? • (Terry) – Again, it comes back to what is the state of readiness in the states? We don’t want to have unintended adverse consequence by putting out all this different stuff out there as objectives. Can we relook at this issue to drive capacity? • Have to consider the receiver of this information and the sender of this information in these objectives. • Goal may be to drive states to adopt common standards. HITPC: MU Workgroup Stage 3 Recommendations

35. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

36. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

37. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

38. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

39. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

40. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

41. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

42. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

43. Improve Population and Public Health HITPC: MU Workgroup Stage 3 Recommendations

44. HITPC Final Comments • HITPC policy recommendations • Immunizations & other objectives that do not have the most mature standards: • HITPC considering making a policy statement regarding national standards for immunization data (so states can transmit immunization data) • The recommendation would join in with CDC (who has the authority to do this) • Hearings • HIE • Area in HIT riddled with problems • Need to hear problems and proposed/implemented solutions • Include P& S • Consider state-perspective (Gayle) • Consider specialists? (their records need interoperability as well) • Setting Direction CDS • Essential to a learning health care system • Fear of CDS that tries to look at how providers respond to it [filter alerts CDS example] • Start directing decisions and limiting them, becomes a difficult path. Concern that payers and others are making decisions about how to limit care. • . • General • Requirements creep. Need core capabilities and an architecture that establishes it. • Concern about time, money, will power, and consensus to do all of this? • Are we in danger of diluting what we are trying to do with too many objectives. • Stage 3 time to drive truly different care delivery. • Broad things that we need to focus on. • MU has laid a tremendous foundation. We are seeing systems deployed by those who probably would not before MU. • There is a lack of evidence that we are achieving goals of MU & EHR. • We need to lay down clear tracks to lower costs and save lives. • Concerns about number of requirements • Prioritizing: 56 objectives is too many HITPC: MU Workgroup Stage 3 Recommendations

45. Public Comment Larry Wolf Need to look carefully at the minimum necessary to achieve policy goals. Darryl Roberts - P&S Tiger Team [nursing]LOA3 doesn't do what is intended - just by association. Interferes with patient care, takes away time and takes away from relationship with the patient. Committee did not discuss the use of biometrics. Thumb print reduces helpdesk calls too.Julie Cantor-Weinberg [pathologist] A lot of pressure on labs. Pathologists are not included in objectives for stage 1 and 2, as they don't fit in. Urge the committee to revisit, as they are considered eligible providers. Move slowly on items related to lab data, need to make sure that the data can move in the appropriate format and can cause problems with patient safety. Tom Larry - HIMSSGood dialogue around P&S. National HIT week September 14th.Seth Foldy- wants the group to know that considerable work has been done with the lessons from stage 1 to find ways to tighten implementation and certification. Each of the implementation guides used in stage 1 have conformance statements. Working on harmonizing data elements across PH reports - stage 3 will have ramifications for future PH reporting. HITPC: MU Workgroup Stage 3 Recommendations