Interoperability and Health Information Exchange Workgroup December 1, 2014 Micky Tripathi, chair Chris Lehmann, co-chair

Agenda Complete Review of ONC Roadmap Building Block 4 Supportive Environments Review HITPC Presentation 2

Meeting Schedule 3 MeetingsTask October 9, 2014, 12:00-1:30 PM ET Review charge and workplan Review Governance recommendations October 21, 2014, 2:30-4:00 PM ET Review JASON TF recommendations Feedback from HITPC/HITSC Prepare to inform Interoperability Roadmap October 29, 2014, 2:00-3:30 PM ET Inform Interoperability Roadmap HITPC Meeting November 4, 2014 Draft recommendations to HITPC November 5, 2014, 10:00-11:30 AM ET HITPC feedback integrated into recommendations November 19, 2014, 9:00-10:30 AM ET Refine recommendations December 1, 2014, 1:00-2:30 PM ET Refine recommendations HITPC Meeting December 9 Final recommendations to HITPC December 16, 2014, 10:00 PM-11:30 AM ET Interoperability Measurement

Agreed Upon Scope of IOWG Assessment 4 ONC Roadmap Vision and Building Blocks Oct 29: Vision Oct 29/Nov 5: Rules of engagement and governance Nov 5/Nov 19: Core technical standards and functions (policy dimensions only) Nov 19/Dec 1: Supportive business, cultural, and regulatory environments

Building Block: Clinical, Cultural, Business, & Regulatory Environments 5 From ONC Roadmap

Supportive Regulatory & Business Environment Key Concepts Defines and reinforces incentives and market behavior to improve interoperability across the health IT ecosystem Critical elements: Delivery system reform Other payment policies and contractual arrangements Linkages to voluntary certification and governance Market environment and competition Sustainability of infrastructure* *Not addressed today, as upcoming input from Mitre project will inform proposed milestones and approaches 6 From ONC Roadmap

Supportive Regulatory & Business Environment Draft Milestones Delivery system reform State-led multipayor value- based payment programs are deployed in 18 states Public and private sector payors reinforce payment for quality rather than quantity through value- based payment models Pay for value based on patient-centered longitudinal measures of quality and cost and attributed to providers by algorithm agreed upon across payers TBD Other payment policies and contractual arrangements Federal contracts align requirements with national standards for health IT Require provider adoption and use of interoperable health IT as a condition of participation Provide financial rewards to providers who demonstrate high adoption and use of interoperable health data TBD Market Environment and Competition Health IT users and purchasers demand greater compliance with national standards and better interoperability of health IT products and services Enhanced interoperability increases opportunities for health IT users and purchasers to change products/services when needed TBD 7 From ONC Roadmap

Supportive Regulatory & Business Environment Draft Actions Public and private payors, and employers include requirements for the exchange and use of essential electronic health information in a majority of value- based purchasing arrangements Public and private payors incentivize information sharing and use of interoperable health IT that conforms to national standards (outside value-based purchasing) – Ex: BCBS Kansas and Oklahoma Professional associations, trade associations, RECs, and ONC collaborate to increase awareness and knowledge among providers and other technology purchasers to demand adequate interoperability and data liquidity to change products/modules over time Users and purchasers of health IT build interoperability requirements into contract language ONC and FTC monitor and coordinate activities to advance interoperability by promoting competition and innovation in health IT 8 From ONC Roadmap

Supportive Clinical and Cultural Environment Key concepts Establishes and reinforces knowledge and behavior that advances the use of interoperable health IT Critical elements: Provider knowledge and behavior Individual and caregiver knowledge and behavior 9 From ONC Roadmap

Supportive Clinical and Cultural Environment Draft Milestones Provider knowledge and behavior Increasing numbers of providers proactively offer individuals electronic access to their own health information Providers evolve care processes and information reconciliation to ensure essential health information is sent, found and/or received to support safe transitions in care Providers and other users are able to perform certain key interoperability functions within their system with minimal effort and ease, using clear instructions provided by the technology developers and made publlcly available The majority of providers proactively offer individuals electronic access to their own health information as a standard of care Providers routinely assume information exists about individuals outside their institution and proactively seek it rather than starting with a blank slate as a standard of care Providers routinely use relevant info from a variety of sources, including environmental, occupational, genetic, human service, and cutting edge research evidence to tailor care to the individual Providers routinely use electronic information from remote monitoring tools to care for individuals (telehealth and devices) Individual and caregiver knowledge and behavior Individuals consider having online access to their health information important A growing number of individuals access their online health information and use it to manage their health or that of their loved ones Encounters with the care delivery system are consistently convenient, safe, and high quality for individuals /caregivers Accessing and contributing to electronic health information across the care continuum becomes routine for individuals/caregivers TBD 10 From ONC Roadmap

Supportive Clinical and Cultural Environment Draft Actions The legal community, States, and federal agencies collaborate to clarify the benefits and risks of information sharing across a variety of data trading partners, including clarification of the application of State law to interstate exchange Consumer-oriented and chronic disease advocacy groups collaborate to deploy updated educational programming to increase awareness of consumer benefits and rights to access health information ONC works with the technology community to increase implementation of Blue Button Plus specifications Technology developers deploy innovative aggregation platforms and tools that allow individuals and caregivers to compile health information from multiple sources in one place ONC issues an action plan for laboratories providing individuals access to test results pursuant to CLIA lab regulations Technology developers to make more transparent through public guidance to end users how to perform certain functions and capabilities (example: how a provider or administrator can run batch or registry reports) 11 From ONC Roadmap

HITPC Presentation 12

Interoperability and Health Information Exchange Workgroup December 9, 2014 Micky Tripathi, chair Chris Lehmann, co-chair

Agenda Review Recommendations 14

Current Workgroup Task Review the Jason Task Force and Governance Subgroup materials and recommend how to synthesize and incorporate them into the Interoperability Roadmap. If time allows identify any red flags in the early draft materials presented on the Interoperability Roadmap. 15

Meeting Schedule 16 MeetingsTask October 9, 2014, 12:00-1:30 PM ET Review charge and workplan Review Governance recommendations October 21, 2014, 2:30-4:00 PM ET Review JASON TF recommendations Feedback from HITPC/HITSC Prepare to inform Interoperability Roadmap October 29, 2014, 2:00-3:30 PM ET Inform Interoperability Roadmap HITPC Meeting November 4, 2014 Draft recommendations to HITPC November 5, 2014, 10:00-11:30 AM ET HITPC feedback integrated into recommendations November 19, 2014, 9:00-10:30 AM ET Refine recommendations December 1, 2014, 1:00-2:30 PM ET Refine recommendations HITPC Meeting December 9 Final recommendations to HITPC December 16, 2014, 10:00 PM-11:30 AM ET Interoperability Measurement

Agreed Upon Scope of IOWG Assessment 17 ONC Roadmap Vision and Building Blocks Oct 29: Vision Oct 29/Nov 5: Rules of engagement and governance Nov 5/Nov 19: Core technical standards and functions (policy dimensions only) Nov 19/Dec 1: Supportive business, cultural, and regulatory environments

Summary of Interoperability Roadmap recommendations 1.Explicitly endorse and map to the JASON Task Force Report recommendations – Coordinated Architecture and Public APIs -- FHIR – Market Motivation framework to promote interoperability through escalating set of actions 2.Identify specific market motivating implementation actions that the Federal Government could/should/will take to promote interoperability: – e.g., CMS expose Public API for CQM reporting, MU attestation, and other reporting – e.g., DoD/VA/IHS implement pluggable apps based on Public API 3.Define measures of interoperability status and progress 4.Explicitly set the context for the Roadmap – is it descriptive of all of the activities taking place in the market, or prescriptive in proposing specific approaches and trade-offs? 5.Map actions to actors 6.Other items to consider 18

JASON Task Force Recommendations 1.The Roadmap should explicitly endorse and map to the JASON Task Force Report recommendations – Coordinated Architecture and Public APIs -- FHIR – Market Motivation framework to promote interoperability through escalating set of actions 19

Market Motivators 2.The Roadmap should identify specific market motivating implementation actions that the Federal Government could/should/will take to promote interoperability. The Federal Government should: – e.g., CMS expose Public API for CQM reporting, MU attestation, and other reporting – e.g., DoD/VA/IHS implement pluggable apps based on Public API – Transparency. Aggressive and ongoing public monitoring of the pace of development and use of network mechanisms through collection of API usage data and development of an adoption evaluation framework to facilitate Public API-based exchange – Guidance. Issuing authoritative, ongoing guidance to provide industry-wide direction and benchmarks, and to encourage specific actions for the development of DSNs and the Coordinated Architecture – Organization. Convening existing exchange networks (i.e., prospective DSNs) to catalyze adoption of the Public API and development of industry-based governance mechanisms – Incentive alignment. Aligning incentive programs and existing regulatory processes to stimulate use of the Public APIs, such as ACO contracts, LTPAC regulation, lab regulation, etc – Federal operational alignment. Requiring federal healthcare entities to adopt the Public APIs in their technology procurement activities and day-to-day market interactions, such as Medicare/Medicaid, Department of Defense, Department of Veterans Affairs, Indian Health Services, NASA, etc. 20

Market Motivators, continued The Federal Government could: – Federal government should consider taking the following steps to enable orchestration of Core Services across the DSNs: DSN bridging standards. Developing voluntary standards for vendor-neutral, cross-DSN bridging to fully enable the narrow set of robust transactions required for the loosely coupled architecture (such as patient identity reconciliation, authorization/authentication, key management, etc) Nationwide shared services. Developing standards for, and ensuring deployment of, universally necessary shared services that are highly sought after and thus would facilitate DSN alignment, such as public use licensed vocabularies, and perhaps nationwide healthcare provider and entity directories, etc. – The government may choose to consider direct regulation of DSNs in the event that the market does not develop effective coordination mechanisms Such actions would involve a significant increase in the government's regulatory authority over health information exchange activities, which would have high risk of unintended consequences that could slow market progress. Any such increase in regulatory authority should be carefully considered through evaluation of reasonable and meaningful benchmarks, and specifically calibrated to address any remaining barriers that the market has failed to overcome. 21

Measurement 3.The Roadmap should define meaningful measures of interoperability status and progress – Each milestone should be tied to a measure – The measurement focus should be on outcomes as much as possible with a decreased emphasis on transactional and process measures. 22

Roadmap Context 4.The Roadmap, if it is to be a “Roadmap”, should be a prescriptive document – Need to decide whether the level of detail is directional or specific – If specific, would need to propose narrow approaches and highlight trade- offs The road to interoperability will require hard decisions where uniformity or reduced optionality is required and the ecosystem has taken multiple differing approaches. The outcomes of these decisions will necessitate rework by some stakeholders. Careful consideration should be made around these important and necessary decision points. A glide path should be outlined for stakeholders who will need to make changes to align with the selected direction. – Also need to decide whether the Roadmap is aspirational (i.e., an indication of where the Federal Government would like the industry to go) or directive (i.e., will be promoted and enforced through specific government actions – incentives, regulations, market actions) 23

Linking Actions to Actors 5.Map actions to actors – The Roadmap should explicitly call out the actors who will be expected to implement the various actions/milestones outlined in the Roadmap. This will help coordinate actions across the ecosystem and help reduce duplicate efforts. 24

Other items to consider 6.During the IOWG deliberations a number of items were identified that the group would like to see added to the Roadmap: – Orders is a big gap in vocabularies and needs to be addressed. The Roadmap should outline steps to address this need. – The Roadmap should make clear that legacy approaches will continue to be refined to serve ongoing needs and to fill specfic gaps Registries have a continued important role to play in the ecosystem and should be appropriately represented in the Roadmap Existing approaches (NCPDP, XCA/XDS, etc) will continue to serve specific purposes and be refined by users accordingly 25