Larry Wolf, chair Marc Probst, co-chair Certification / Adoption Workgroup January 17, 2014

Agenda Review of Agenda HITPC Charge: Step Two – Presentation by Michelle Dougherty: Roadmap for Health IT in LTPAC & Alignment with Certification – Continued discussion of proposed LTPAC health IT Certification Criteria Next Steps Public Comment 1

Updated Call Schedule Date Call Schedule 10/25/2013Overview of new charge 11/4/2013, 11/18/2013Develop a framework for certification 12/2/2013, 12/12/2013 1/10/2014, 1/17/2014, 1/21/2014 LTPAC EHR background presentation, virtual hearing, draft recommendations 1/24/2013, 1/28/2014, 2/7/2014, 2/14/2014 BH EHR background presentation, virtual hearing, draft recommendations 2/21/2014, date TBDWorkgroup review and finalization of recommendations 3/11/2014Recommendations to HITPC 3/26/2014Recommendations to HITSC 2 *Dates in red are changes from previous call schedule.

ROADMAP FOR HEALTH IT IN LTPAC & ALIGNMENT WITH CERTIFICATION Roadmap for Health IT in LTPAC & Alignment with Certification 3

LTPAC HIT Michelle Dougherty, MA, RHIA, CHP Senior Director of Research and Development American Health Information Management Association Foundation Presented to: HIT Policy Certification and Adoption Workgroup January 17,

LTPAC HIT Collaborative 5

Publishes an Biennial Road Map

Road Map Priorities over the Years Business Imperative and Emerging Care Delivery & Payment Model s Increase Adoption and Use of EHRs/HIT in LTPAC Advance HIT Standards & Certification Health Information Exchange and Interoperability Transition of Care and Care Coordination E-Prescribing & Medication Management Quality Measurement & Improvement Consumer/Caregiver Engagement & Access to Health Information 7

Strategizing Certification, HIE & Interoperability over the Road Maps Certify EHR and e- prescribing solutions to reduce risk. Advocate, participate in development, & adopt content & messaging standards to promote interoperability across settings Certify EHR and e- prescribing solutions to enhance safe medication prescription and administration Demonstrate interoperability of HIT products through use of emerging standards Establish EHR certification criteria for LTPAC to promote adoption & coordination. Foster inclusion and participation of LTPAC in emerging HIEOs. Promote use of HIT for transition of care and for e- prescribing Achieve enhanced care coordination between hospitals, physicians, & other providers…by facilitating standards, interoperability and certification efforts of LTPAC. 8

Thank You on behalf of the LTPAC HIT Collaborative Michelle Dougherty The LTPAC HIT Road Maps are available at 9

REVIEW & FRAMING FOR CERTIFICATION DISCUSSION Review & Framing for Certification Discussion 10

HITPC Charge to the C/A Workgroup Recommend a process for prioritizing health IT capabilities for EHR certification that would improve interoperability across a greater number of care settings Recommendations shall take into account previously adopted ONC certification criteria and standards and identify the key heath IT capabilities needed in care settings by providers who are ineligible to receive EHR incentive payments under the HITECH Act 11

The Scope of Work for the Charge Step 1: Draft a process that could be used to identify and prioritize certification criteria for health IT that is used by providers outside of the Meaningful Use Program and for which an ONC certification program would be helpful. 12 Began on 12/2/13 Complete Step 2: Recommend a specific application of this process for EHRs used in long-term/post-acute care (LTPAC) and behavioral health (BH) settings. By 3/2014 Step 3: Revise Step 1 recommendations, if needed, based on experience applying them during Step 2.

Focus of Recommendations: Guiding Principles – Health IT privacy and security – Transitions of care – Interoperability – Setting specific health IT (patient assessments; survey and certification) 13 Guiding Principles: Build on and align with existing criteria/standards in the health IT sector (MU, HL7 & CCHIT); address the health IT needs of the LTPAC community, including in the areas of:

Basis for Recommendations HIE RFI LTPAC Hearing Testimony & Submitted Letters Mapped comparison of prior, industry-led certification efforts, including HL7 LTC Functional Profile (FP) and CCHIT (sponsored by ASPE) – Note: these efforts pre-date the MU certification program – However, these efforts demonstrate areas of importance for criteria development (as identified by the industry) – Mapping also linked testimony from the LTPAC EHR hearing Analysis of ONC 2011/2014 certification modules adopted by LTPAC vendors (sponsored by ASPE) New, emerging health IT standards that could support LTPAC HIE (e.g. HL7 TOC and Care plan standards) 14

What does “Interoperability” mean? ONC follows the definition of “interoperability” provided by the IEEE dictionary which defines interoperability to mean: “the ability of two or more systems or components to exchange information and to use the information that has been exchanged.” 15 Source:

Building on existing criteria and standards Proposed Recommendations MUMU 2 BaseMU 2 Interoperability Criteria Privacy and SecurityMU2x Summary Care Record at TOC/Referral MU2, MU3*xx Data Portability MU3* xx View, Download, and Transmit to 3rd Party MU2 x Clinical Summaries MU, M3*x Patient-Specific Educational Resources MU2x Incorporating Laboratory Tests & Values/Results MU2x Clinical Decision Support MU2xx Advance Care Planning MU2, MU3* Patient Demographics MU2x 16

Building on existing criteria and standards Proposed Recommendations MUMU 2 BaseMU 2 Interoperability Criteria Clinical Health Information: Problem list Medication list Medication allergy list MU2x Clinical Information Reconciliation MU2x Electronic Notes MU2 Medication Related: e-MAR Drug-formulary checks MU2 Electronic prescribing x CPOE MU2x Public Health (Immunizations) MU2x LTPAC Setting Specific: Patient Assessment LTPAC Setting Specific: Survey and Certification 17

Review of the Proposed Areas of Certification Consider each proposed area of certification by: – Briefly highlighting LTPAC hearing testimony of relevance to the proposed area of certification – Discuss the proposal (blue box) – Determine whether the proposed area of certification is a “key heath IT capability needed” in the LTPAC care setting 18

Proposed Areas for Certification 19

Clinical Quality Measures “if [EHR]certification requirements for LTPAC… were to include… the ability to exchange…interoperable data elements required for good transitions and …longitudinal coordination of care… this could be a quality metric that could drive some of the adoption of the EHR, [and] fundamentally improve the process of care.” “CMS believes that data uniformity…across settings, is critical to facilitate … transfer of information…and ….implement measures that can be harmonized across settings...” C/A Workgroup requests that HITPC Quality Measures WG discuss clinical quality measures further and provide recommendations to C/A WG on potential LTPAC CQM opportunities for LTPAC EHR certification. Neither the LTC FP nor the CCHIT criteria require the ability to capture the data required by the specified Data Element Catalogs, use the HL7 QRDA standard, or require the ability to calculate quality measures as specified in the ONC 2014 edition. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 20

Privacy and Security “there should be an overarching standard around security and privacy” “.. if my IT department had not evaluated the [EHR]software—I would've implemented a piece of software that, on a daily basis, would have been a HIPAA data breach violation” Authentication, Access Control, and Authorization Auditable Events and Tamper-Resistance Audit Report(s) Amendments Automatic Log-Off Emergency Access End-User Device Encryption Integrity Optional – Accounting of Disclosures Previous certification efforts have supported privacy, security and integrity criteria LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 21

Summary Care Record at TOC/Referral “electronic exchange of standardized, interoperable clinical information between different IT platforms becomes the essential tool for care integration between and among acute and LTPAC providers” “As the patient experiences care transitions, interoperability will lead to efficiencies…” Support the ability to receive, display, incorporate, create and transmit summary care records with a common data set in accordance with the Consolidated Clinical Document Architecture (CCDA) standard and using ONC specified transport specifications Support the inclusion of emerging TOC and care planning standards being reconciled as part of Aug. HL7 CCDA ballot [MUWG- identified MU 3 criteria] Previous certification efforts have supported TOC/referral summaries The LTC FP and CCHIT LTPAC program pre-date the ONC 2014 transport standards. The LTC FP and CCHIT LTPAC program pre-date the HL7 Consolidated CDA standard. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 22

Clinical Summary “…are pressured by receiving EHs for better information and getting pressure from EHs to be part of the system” “The focus of [LTPAC EHR] certification should be to support transitions of care” “standards used in meaningful use, such as CCDA, SNOMED, LOINC, and RxNorm, can be and are supported within the EHR products to help obtain greater parity in the exchange of information regardless of formal certification” Support the ability to create a clinical summary in accordance with the CCDA standard in order to provide it to a patient. [Consistent with MUWG- Support for identified criteria under consideration in MU3; update forthcoming.] Previous certification efforts have supported the Creation of a clinical summary LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 23

Data Portability LTPAC panelists: “..recommended establishment of standards and incentives to help long-term services providers adapt their existing EHR system or purchase a new one that meets requirements for interoperability, transfer of information, and enabling of monitoring for quality.” “The focus of [LTPAC EHR] certification should be to support transitions of care” Support the ability to create a set of export summaries for all patients, formatted in accordance with the CCDA. Support the ability to enable patients who switch providers to have their care continue seamlessly (no repeat tests, missing key clinical information, etc). [MU 3 goal from IE WG] Support the ability to enable providers switching EHR systems to continue providing seamless care to patients (coded data in old system is consumable by the new system so clinical decision support still works). [MU 3 goal from IE WG] Previous certification efforts have supported the creation of a clinical summary LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 24

View, Download, and Transmit to 3 rd Party “As we view, download, and transfer, the provider should protect … information, but the patient should continue…to direct it, so the work being done in Blue Button would have a great application in transitions of care and [LTPAC]” Support the ability to provide secure online access to health information for patients and authorized representatives to electronically view, download their health information in accordance with the CCDA standard Support the ability to transmit such information using ONC specified transport specifications Neither the LTC FP nor the CCHIT LTPAC program include requirements providing patients with an online means to view, download, and transmit specified data to a 3rd party. 12/2 C/A WG call: Patient portals are available across all LTPAC provider types. However, frequency and breadth of use is unknown. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 25

Patient-Specific Educational Resources “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. 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. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 26

Incorporating Laboratory Tests & Values/Results “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.” Support the ability to electronically receive, incorporate, and display clinical laboratory tests and values/results in accordance with the HL7 Version Implementation Guide and with laboratory tests represented in LOINC 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 LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 27

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. 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. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 28

Clinical Health Information “…documents to meet 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.” Support the ability to record, change, and access the: o Problem list o Medication list o Medication Allergy list using ONC specified standards Support clinical information reconciliation. Support Electronic Notes. 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. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 29

Patient Demographics “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 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. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 30

Advance Care Planning “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 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. [MUWG-identified MU3 Criteria under consideration] Future work: Standards for content of the advance directive 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 LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 31

Medication Related Criteria “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 Previous certification efforts have supported the ability to: o 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 LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 32

Computerized Provider Order Entry (CPOE) “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” Support the ability to electronically record, change, and access the following order types: (i) Medications; (ii) Laboratory; and (iii) Radiology/imaging. Previous certification efforts have supported the ability to record, change and access each of the order types (i.e., meds, labs, radiology/imaging) LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 33

Public Health - Transmission to Immunization Registries “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. 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. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 34

LTPAC Setting-Specific Criteria: Federally Required Patient Assessments “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. 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. Support the use of accepted vocabulary standards to enable the reuse of assessment data for: o various clinical purposes; and o administrative purposes. Support the ability of the provider or a designated third party to create and exchange interoperable LTPAC Assessment Summary CDA documents Previous certification efforts have supported the ability to create, maintain, transmit, and reuse assessment content. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 35

LTPAC Setting-Specific Criteria: Federally Required Patient Assessments “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... “ 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. Previous certification efforts have supported the ability to create, maintain, transmit, and reuse assessment content. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 36

LTPAC Setting-Specific Criteria: Survey and Certification “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. 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. Prior certification has supported surveyor access to the complete EHR, consistent with federal requirements. LTPAC Hearing Proposed Areas for Certification Prior LTPAC Certification Efforts (HL7 LTC FP / CCHIT LTPAC) 37

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. 38

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