PDMP & HITI Solution Planning Workgroup Session May 29, 2014

HIE/ Pharmacy Intermediary In-State PDMP Out of State PDMP Hub EHR or Pharmacy System 1 2 3 4 6 5 7 8 PMP/HITI User Stories with Alternate Workflows EHR or Ph. to In-State PMP: 1a: EHR to In-state PMP 1b: Ph. to In-state PMP 2a: EHR to In-state PMP via HIE 2b: Ph. to In-State PMP via HIE 3a: EHR to In-state PMP via Hub 3b: Ph. Intermediary to In-State PMP via Hub EHR or Ph. to Out-of-State PMP: 1a+4: EHR to out-of-state PMP via In-state PMP 1b+4: Ph.to out-of-state PMP via In-state PMP 2a+4: EHR to out-of-state PMP via HIE & In-state PMP 2b+4: Ph. to out-of-state PMP via Ph. Int & In-state PMP 2a+5: EHR to out-of-state PMP via HIE 2b+5: Ph. to out-of-state PMP via HIE 3a+4: EHR to out-of-state PMP via Hub & In-State PMP 3b+4: Ph. to out-of-state PMP via Hub & In-State PMP 1a+8: EHR to out-of-state PMP via In-State PMP & Hub 1b+8: Ph. to out-of-state PMP via In-State PMP & Hub 3a+6: EHR to out-of-state PMP via Hub 3b+6: Ph. To out-of-state PMP via Hub Transactions Scope From Via To 1a1b  EHR Pharmacy - In-State PDMP 2a 2b HIE Ph. Int 3a 3b Hub 4  In-State PDMP Out of State PDMP 5a 5b Ph. Intermediary Out-of-State PDMP 6 7a 7b 8

Summary of Transactions Data Flow Transactions Reviewed on 5/15 & 5/22 SPWG Transaction System - Outbound System Intermediary 1 System Intermediary 2 System Inbound 1a EHR -- PDMP 1b Pharmacy IT 2a HIE 2b Pharm. Int. / Switch 3a PDMP Hub PDMPs 2a+7a+6 Have not yet performed necessary analysis on EHRs capabilities to handle certain standards and implications to existing vendor solutions. Data Flow Transactions To Be Reviewed on 5/29 SPWG Transaction System - Outbound System Intermediary 1 System Intermediary 2 System Inbound 3b Pharmacy IT PDMP Hub PDMPs 2a + 2b + 7a + 7b + 6 Pharm. Int. / Switch or HIE

Items Required for Further Clarification Transaction Summary from SPWG 5/15 Items Required for Further Clarification 1a: EHR System to PDMP (Direct) EHRs don’t generally query PDMPs directly Ohio connectivity model is a direct connection to OARRS via PMIX Kansas leverages HIEs and PMPi data hub for all of their connections Illinois and Ohio use a direct connection – need further clarification on standards used Jinhee Lee to gather information on transactions occurring in Illinois, Kansas, Indiana – In progress Jean Hall to confirm Ohio connectivity model – Complete 2a: EHR System to PDMP via HIE HL7 messaging relatively uncommon in EHRs for PDMP connections Kentucky using QRY^T12 as request and DOC^T12 as acknowledgment and response message – CCD structure Some states that cannot make interstate connections might have no other option but to use this model Washington, Maryland, Maine, Oklahoma use this model Washington response – PMIX-NIEM is mapped to NCPDP SCRIPT and responding with NCPDP SCRIPT message ADT used as trigger in Ohio, Indiana, Illinois, Kansas Jean Hall to further clarify what the query/message pairing used to engage EHR system to HIE – Complete 1b: Pharmacy IT System to PDMP (Direct) Transaction 1b is not currently in use ASAP Web Services standard was developed specifically with this transaction in mind NCPDP Medication History might be suitable for this purpose but is not used currently Jean Hall to further clarify standards currently in use – Complete

Items Required for Further Clarification Transaction Summary from SPWG 5/15 Items Required for Further Clarification 2b: Pharmacy IT System to PDMP via Pharmacy Intermediary/ Switch NCPDP SCRIPT Medication History is being used today but not for the purposes of querying PDMP data Real-time query for claim to be dispensed through switch via Telecommunication standard Not yet in use but is possible via claim submission SureScripts to enable this transaction (Intermediary to PDMP) in the future Lynne Gilbertson to verify if standards are currently being used (Nebraska) – Complete Summary from SPWG 5/22 3a: EHR System to PDMP via Hub Ohio, Kansas use PMIX to connect to PMPi data hub PMP Gateway will be used in the future to centralize translations, where endpoints can communicate with gateway EHR provides translation from HL7 (V2/ADT?) to PMIX in Kansas pilots Hub functions as aggregator, depending on arrangements Clay Rogers and Jeff McGonigal to verify translation/EHR generating PMIX request 2a + 7a + 6: EHR System to HIE to Hub to PDMP Indiana and North Dakota provides translation to PMIX from the HIE to the Hub HIE translates using NCPDP SCRIPT with PMIX wrapper for Hub SureScripts: SCRIPT (predominantly) and HL7 (Emdeon does not support) used to connect to SureScripts for medication history (EHR  Intermediary), Does not connect to a PDMP Ohio EHR systems  (NARxCheck used as interface, does not “go through” hub)  PDMP (does not use HIE or PMPi) ADT used as trigger to send query to PDMP through NARxCheck PMIX used from NARxCheck to PDMP Jinhee Lee to verify how Indiana performs translation from HIE to Hub Danna Droz and Chad Garner to confirm third party software functionality of NARxCheck via NABP – NARxCheck uses ADT feed and directly connects to OARRs system, which uses PMIX NARxCheck does not act as a hub but may get information from PMPi (does not go through interconnect directly) What type of message is being sent from NARxCheck

Summary of Current Standards Landscape What we know: Several states utilize the EHR  HIE  PDMP transaction Some states that cannot make interstate connections might have no other option but to use this model PMIX-NIEM is the standard used for the Hub to PDMP transaction Translation from HL7 messaging to PMIX must occur prior to Hub to PDMP transaction Thus, translations can occur from the EHR system to the HIE, the HIE to the Hub, the EHR system to the Hub, or the HIE to the PDMP HL7 ADT is used as a trigger in several states Currently, EHR systems and Pharmacy IT systems do not generally query the PDMP directly ASAP Web Services standard was developed specifically for this purpose

Current In-State HIT Integrated System Workflows

Current In-State Pharmacy Workflow (Hub) Transaction 3b – Not Effective Workflow? Currently Active? Translation? Pharmacy System Translation? In-State PDMP PDMP Hub PMIX ? PMIX Notes: Hub to PDMP available for use but is not currently in production Pharmacy system to hub not currently in use May be used in the future; under development AI: Alex/Divya to follow up with more information What standards these transactions are based on? Ohio to possibly pilot for pharm chain to go through hub (one of 16 states that is a part of SAHMSA grant) Request Response Legend

Current Interstate HIT System Workflow

Current Interstate Pharmacy Workflow Transaction 2a + 2b + 7a + 7b + 6 HIE In-State PDMP Pharmacy System Third Party Software PMIX Wrappers NCPDP SCRIPT PMIX-NIEM XML PMIX-NIEM XML PMIX-NIEM Pharmacy Int. / Switch NCPDP SCRIPT PDMP Hub Out-of-State PDMP PMIX-NIEM ? Request Response Legend Notes: Not currently in use but Pharmacy IT System may be able to go through intermediary in the future Pharmacy workflow using medication history could be a future use case – PDMP checking on a claim vs. query of history ?

Questions to be answered: Differences in pharmacy and clinician workflows / data systems and expectations in PDMP data transmitted? How do we define intermediaries and their relationships to Health IT systems? What components of PDMP report are extracted for decision support? Can EHR and Pharmacy IT systems handle the proposed standards (in the context of PDMP systems)? What standard(s) fit into message and workflow configuration per transaction type? Are transactions collapsible in terms of capability of leveraging same standard? Are all transactions necessary? What is the relative cost associated with the proposed solutions? How do we define an aggregator? (collection of response from different PDMPs back to recipient) Parking lot item: Differences in care settings - Ambulatory vs. Acute; In-hospital pharmacies vs. retail pharmacies. Are different standards needed for different EHR systems?

Controlled Substance History Report, Integration Architecture Drivers FROM: Pervasive challenges to access data within clinical workflows TO: Easy, timely, consistent access to reliable PDMP data Vision As-Is Architecture Segmented conceptual framework for data exchange Varying solution practices Varying state requirements and source ownership (e.g., authorization, authentication protocols) Flexible interstate data sharing and intermediaries facilitating open data exchange for authorized users Constraints on cost for Δ in source data architecture Constraints on ease of implementation of foreign standards in established functional models/frameworks To-Be Design Principles Congruent data / message formats across integration sites Compatible with established PMIX-NIEM architecture Ability to support various front-end capabilities Ability to integrate within existing technical systems and evolve to support regulatory/technology changes Architecture Health Information Exchanges Interstate Data sharing Hubs Data harmonization and structuring of a data integration layer Continuous improvement of real time reporting Drivers Controlled Substance History Information Needs

PDMP Med History Architecture Recommendation/Notes Integrated PDMP Data Exchange Architecture Solution Plan - Multi -Level Standards PDMP Med History Architecture Recommendation/Notes Out of scope - however… User access modes important to consider in standards selection. Modules within ambulatory and enterprise in-patient EHRs vary. Where would the interface be most effective? CDS Med History/ Reconciliation ePrescribing Internal Med Orders PMS Functions User Interface (Presentation) HL7 SCRIPT EHR EMR Pharmacy IT Define a comprehensive query-response strategy aligned to both EHRs and Pharmacy IT systems compatible with state PDMP architecture/regulations and intermediary capabilities/infrastructure. Health IT / Clinical Databases Translation / Transformation SCRIPT ASAP PMIX Metadata transformations, routing Pharm. Int / HIEs Hubs Data Harmonization Establish standard data models and an approach for data harmonization; achieve standard and consistent data in this layer for query-response while addressing the source system layer in parallel. Translations are essential for compatible standards to interoperate. Data Extraction / Transformation State PDMPs PMIX Source Systems HIE/PDMPs (Nebraska) Defined standards architecture based on source data framework: PMIX-NIEM. Other Medication History Sources (eg. PBMs)

Review Proposed Solutions Solution Plan Review Review Proposed Solutions

Appendix

HIE/ Pharmacy Intermediary Context Diagram HIE/ Pharmacy Intermediary 2 5 2 7 4 EHR or Pharmacy System In-State PDMP Out of State PDMP Hub 1 8 8 3 3 7 Hub 6 = In Scope

System Transaction-Relationship Flow Known To Confirm Legend

Current In-State EHR Workflow (Direct) Transaction 1a EHR System In-State PDMP PMIX? Request Response Legend

Current In-State EHR Workflow (HIE) Transaction 2a HL7 A04 NCPDP SCRIPT with PMIX Wrappers Third Party Software HL7 ADT feeds NCPDP SCRIPT EHR System HIE In-State PDMP HL7 OBX XML Report NCPDP SCRIPT XML Response NCPDP SCRIPT with PMIX Wrapper Request Response Legend

Current In-State Pharmacy Workflow (Direct) Transaction 1b Pharmacy IT System In-State PDMP Request Response Legend

Current In-State Pharmacy Workflow (Pharmacy Int. / Switch) Transaction 2b NCPDP SCRIPT (Medication History) Pharmacy System Pharmacy Intermediary/ Switch ? In-State PDMP NCPDP SCRIPT (Medication History) ? Request Response Legend

Current In-State EHR Workflow (Hub) Transaction 3a – Not Effective Workflow? Currently Active? EHR System In-State PDMP PMIX PDMP Hub ? ? ? Request Response Legend

Current Interstate EHR Workflow Transaction 2a + 7a + 6 EHR System HIE In-State PDMP NCPDP SCRIPT (Medication History) Third Party Software PMIX-NIEM PMIX-NIEM XML PMIX-NIEM XML PMIX-NIEM Out-of-State PDMP Request Response Legend PDMP Hub PMIX-NIEM