Larry Wolf Certification / Adoption Workgroup May 28th, 2014

Agenda Review Public Comments from Blog and Listening Session Review Proposed Recommendations for ‘Some’ LTPAC/BH Providers Next Steps: HITPC Virtual Meeting – June 10th 1

Workplan StatusDate Call Schedule 5/1 /2014Review 2015 NPRM Recommendations, Review Voluntary Certification Recommendations, Updates from Privacy and Security TT and Quality Measures WG 5/6/2014HITPC Recommendations Week of 5/12/2014Blog on Voluntary Certification for LTPAC and BH 5/7/2014, 5/8/2014Certification Hearing 5/13/2014Update from May HITPC, Certification Hearing. Refine Proposed Voluntary Certification Recommendation on LTPAC Patient Assessments 5/22/2014Listening Session on Voluntary Certification for LTPAC and BH 5/28/2014Review Voluntary Certification Public Comment, Finalize Voluntary Certification Recommendations. 06/10/2014HITPC Recommendations 2

Listening Session and Written Comment May 22 nd Listening Session 3 Panel 1: Quality Improvement and Health Information Exchange ⁻Marylyn R. Harris, Harrland Healthcare Consulting ⁻Pamela Russell, CORHIO ⁻Nancy Lorey, HealthLINC ⁻Pamela M. Smithson, Davis Medical Center Panel 3: Vendors ⁻Joel Amoussou, FEi Systems ⁻Scott Bressette, Kennebec Behavioral Health ⁻Doron Gutkind, LINTECH ⁻Rossmary Gil, SigmaCare Panel 2: Patient/Caregivers/Care Team ⁻Adrian Gropper, Patient Privacy Rights ⁻Monica Wafford, South Oakland Shelter ⁻Sharon Hamilton, Briggs Healthcare ⁻Rod Baird, Extended Care Physicians 6 Blog Comments Submitted

Workgroup Progress Transitions in Care and Privacy and Security voluntary certification recommendations approved by HITPC in May Privacy and Security Tiger Team considering recommendations for data segmentation/consent management Quality Measure Workgroup considering recommendations for LTPAC and BH Quality Measures LTPAC Patient Assessment recommendations reviewed during May 13 th call, to be presented at June HITPC TODAY: Review recommendations for ‘SOME’ LTPAC and BH Providers 4

Written Comments from Blog General – Vendor effort will be significant but achievable – Significant time and effort needed for workforce training and education related to workflow changes – Starting the admission process from the CCD data will reduce the number of fields that need to be filled, which may result in time savings and reduced errors. – Some existing EMRs are having trouble with consuming outside CCDs, feel very strongly this capability is key – Need for clear directions on which modules are required to support various use cases (e.g. interacting with EHRs for the attending physician or behavioral health staff) – Capability of LTPAC vendors to receive CCDA today is low (e.g., one vendor noted, “only 1 known LTPAC vendor with this capability”). – Challenge of using the Direct protocol to exchange CCDAs across multiple states is overwhelming 5

Written Comments from Blog Care Coordination – Support for certified EHR technology provisions that demonstrate the ability to send and receive transitions of care and referral summaries – Support provisions allowing patients and their caregivers’ access to their medical records in order to be an active partner in the management of their own health and wellness – Support for certification of EHR modules based on care coordination ⁻ Must be able to meet the transitions of care and clinical information reconciliation and incorporation standards. ⁻An EHR module designed to support care coordination must have the ability to transmit and receive data to support this goal. 6

Written Comments from Blog Privacy and Security – Recommendation that educational materials be developed and disseminated that further explain privacy and security criteria – Privacy and Security standards core to any type of electronic record and are not burdensome Clinical Reconciliation – Reconcilable data is key to care collaboration, critical for LTPAC physicians and other ambulatory providers Managing Lab Test Results – Need to support three-way messaging (lab, facility and attending physician). Otherwise, developers will invent their own non-standard solutions. LTPAC eRx – Need to support for the NCPDP 3-way e-Prescribing use case (facility software, certified Physician EHRs, and pharmacy software). Current standard of practice - physicians and extenders initiate patient orders over the telephone. 7

Written Comments from Blog LTPAC Patient Assessments – Support promulgation of standards which are necessary to establish any ‘cross cutting’ quality measures. Standardized data elements are needed to implement ‘shared’ clinical decision support between the facility and attending physicians. Clinical Decision Support – The uncertainty of the pace of CDS and eCQM alignment at ONC/CMS will make developers reluctant to expend significant energy. Patient Engagement – Maintaining Direct connections with many separate locations is beyond one group’s administrative capacity. Currently providers resort to fax messages because they can enter/store a phone # without external support. Advanced Directives – Support documentation of Advanced Directives using ‘standard’ free form text that corresponds to the particular State’s language. Lack of a national standard for Advanced Directives makes it impossible to treat this as a structured data element. Advanced Directives should be an Adult eCQM. 8

Written Comments from Blog Data Portability – No burden on the provider. Basic consumer protection. Immunizations – Complex because there is no fully functional state system in most locations. Passing certification was relatively easy. Past Medical History – Narrative past medical history is reasonable to incorporate in a CCDA. Requiring each provider to create history as structured data would be both intrusive, and of minimal current value. – Recommend including past hospitalizations for patients as a component of Past Medical History. DSM 5 – Recommend harmonization of a diagnostic code system with SNOMED should be changed from the DSM-5 to the ICD-10-CM. DSM-5 codes are truly ICD-10-CM codes. Some codes in the DSM-5 are not used in the ICD- 10-CM, may result in billing errors. 9

Workgroup Discussion 10

Listening Session Comments ⁻Broad issues of parsing CDAs, vendors compatibility issues. ⁻Information often lost in transit from skilled nursing to ED. One HIE attaches PDF summary documents (INTERACT, med list and HIE- generated summary doc) and sends through webDirect. ⁻ EHR order entry, tracking and electronic signature would be valuable, increase efficiencies in the home health setting. ⁻For information sharing, patient data segmentation must be respected across TOC, delegated access via V/D/T and all treatment, payment and operations. ⁻Voluntary Identity Management suggested as interim step until widespread data segmentation adoption achieved. Example: Patient using MyHealtheVet could select check boxes to determine what data goes into the CCD file, link to V/D/T. Allows the patient to decide what data is sent; risk of incomplete data without a flag for receiving provider. 11

Listening Session Comments ⁻LTC physicians and nursing facilities 'share care’ for the patient concurrently. ⁻Orders need to be synchronized with nursing facility EHR systems to be actionable (e.g., clinical documentation such as MD note, history and physical need to be in MD and facility EHR). ⁻RxNorm missing over the counter meds, LTC pharmacies not ready for RxNorm. ⁻Certification process has brought additional structure, beyond narrative notes for certified vendors. Allows for data analytics. ⁻Certification that incorporates more BH data elements would be helpful. ⁻One vendor on the panel is currently certified to ONC 2011 edition, another vendor is considering ONC 2011/2014 edition interoperability certification. 12

Workgroup Discussion 13

Proposed Recommendations for ‘SOME’ LTPAC and BH Providers 14 Voluntary Certification for LTPAC and BH

Organizing Principles for Recommendations 15

Proposed Recommendations for ‘SOME’ LTPAC and BH Providers ⁻Recommendations in this category are based on ONC 2014 edition certification criteria ⁻Modular approach ⁻Functionality may be of value to SOME care settings depending on care delivery needs and scope of practice ⁻May be programmatic reasons for adopting certification functionality, certification may make sense in those instances ⁻Workgroup discussion focused on added value of certification for these functions; no consensus reached 16