Interoperability and Health Information Exchange Workgroup April 24, 2015 Micky Tripathi, chair Chris Lehmann, co-chair

Agenda Finish review of “Send”/“Capture” Start review of governance questions 2

Current Interoperability and HIE Schedule MeetingsTask April 17, :30-4 pm ET Comment on MU3 NPRM April 24, :00 am – 12:30 pm ET Comment on MU3 NPRM April 30, :30-5 pm ET Finalize MU3 NPRM Comments May 12 th – HITPC Meeting MU3 NPRM Comments to the HITPC May 14, :30-5 pm ET Address any changes or questions from the HITPC May 22 nd – HITPC Meeting Finalize Any Comments the HITPC Requested Changes or Additions to 3

Summary of Discussion From Last Call 4

Measure 1 (Send) (1 of 3) Will the ecosystem across the country be ready to support a 50% threshold?: – Some felt the current threshold for sending may generate unforeseen and unintended side effects by modifying referral patterns to those providers and hospitals able to receive summary of care records. Others felt a high threshold was important to drive increased exchange of information by MU providers during transitions and to support increased exchange participation by providers and entities not directly touched by MU (labs, pharmacies, LTPAC etc). 5

Critical Access Hospitals reported sending an electronic summary of care to a higher proportion of transitions than other hospital types Based on CMS EHR Incentive Program data through January 31, The electronic summary of care measure applies only to stage 2 hospitals, and requires that more than 10% of care transitions have a summary of care record provided electronically using certified technology.

Measure 1 (Send) (2 of 3) Providers who are willing and able to send care summaries to meet the measure should not be penalized if there are not enough recipients ready to catch care summaries. Potential approaches to operationalize this goal could include: – A EP and EH/CAH should be able to exclude a referral or transitions from the denominator if the organization they are intending to send to does not have the capability to receive it electronically. The sender would attest to the accuracy of the inability of the other organization to receive it electronically. The sender could maintain documentation from the receive demonstrating that they lack the capability to receive electronically. – Other suggestions? 7

Measure 1 (Send) (3 of 3) The quality and relevance of the summary of care document is not great – Discussion centered on the length and the hidden information in pages of insignificant content. There was a discussion on the need to improve the document quality first. – A few folks seemed to be pushing for allowing more choice in how to meet the content requirements through means besides the C-CDA (the interest was focused on allowing discrete data approaches to be able to meet the requirements as well) Remove the exclusion for EP and EH/CAH that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a county) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures. 8

Definition of Referral/Transition The rule is proposing that for a transition or referral to occur, it must take place between providers which have, at a minimum, different billing identities within the EHR Incentive Programs, such as a different National Provider Identifiers (NPI) or hospital CMS Certification Numbers (CCN) to count towards this objective. CMS is proposing revising this objective for Stage 3 to allow inclusion of transitions of care and referrals in which the recipient provider may already have access to the medical record maintained in the referring provider’s CEHRT, as long as the providers have different billing identities within the EHR Incentive Program. Our discussion indicated that we did not feel this change is necessary and would advantage large players. The Workgroup recommends not revising the HIE objectives for Stage 3 to allow inclusion of transitions of care and referrals in which the recipient provider already has access to the medical record maintained in the referring provider’s CEHRT. 9

Patient Self Referrals Patient self-referrals should not be counted in numerator or denominator for the send measure. The intent of the proposal to include patient self-referrals is a good one however the level of effort for developers and providers to address this edge case significantly outweighs the benefit. 10

Measure 2 (Capture) (1 of 2) The 40% threshold was considered too high. – What threshold would the Workgroup like to propose? “Never before encountered” should be removed from the measure. Workgroup members feel that even if the patient had been seen two days before and was seen in the meantime in another ED, capturing that data could be helpful but would be excluded under the current proposal. – Is their a time horizon or other modifier the Workgroup would like to include for measure 2 to replace “never before encountered”? (Perhaps two weeks since last encounter?) Additional specificity is needed on the definition of “unavailable” to determine if it strike an appropriate balance. The Workgroup had a number of questions: – What does HIE functionality mean? Could any entity provide these services? – What does it mean to have access to HIE functionality? Does this mean if there is HIE functionality available in your region you would have to join or not be able to meet the definition of unavailable? What if the functionality is cost prohibitive or if you have signed up but haven’t been onboarded yet? Remove the exclusion for EP and EH/CAH that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a county) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures. 11

Measure 2 (Capture) (2 of 2) To address concerns about bloat and duplication of information in patient records providers should be able to determine what information from the received clinical summary is clinically relevant for incorporation into their EHR. The concept of clinical relevance should mirror the approach used for sending clinical summaries as outlined in the NPRM. – “We believe that while there may be a benefit and efficiency to be gained in the potential to limit laboratory test results or clinical notes to those most relevant for a patient's care; a single definition of clinical relevance may not be appropriate for all providers, all settings, or all individual patient diagnosis. Furthermore, we note that should a reasonable limitation around a concept of "clinical relevance" be added; a provider must still have the CEHRT functionality to include and send all labs or clinical notes. Therefore, we defer to provider discretion on the circumstances and cases wherein a limitation around clinical relevance may be beneficial and note that such a limitation would be incumbent on the provider to define and develop in partnership with their health IT developer as best fits their organizational needs and patient population. We specify that while the provider has the discretion to define the relevant clinical notes or relevant laboratory results to send as part of the summary of care record, providers must be able to provide all clinical notes or laboratory results through an electronic transmission of a summary of care document if that level of detail is subsequently requested by a provider receiving a transition of care or referral or the patient is transitioning to another setting of care. We note that this proposal would apply for lab results, clinical notes, problem lists, and the care plan within the summary of care document.” 12

Finish Review of Capture 13

Measure 2 (Capture) Measure: For more than 40 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital or CAH incorporates into the patient's EHR an electronic summary of care document from a source other than the provider's EHR system. – Note that capture is required, unless the summary of care record is “unavailable.” Unavailable means that a provider: Requested an electronic summary of care record to be sent and did not receive an electronic summary of care document; and Queried at least one external source via HIE functionality and did not locate a summary of care for the patient, or the provider does not have access to HIE functionality to support such a query. 14

Measure 2 (Capture) continued Denominator: Number of patient encounters during the EHR reporting period for which an EP, eligible hospital, or CAH was the receiving party of a transition or referral or has never before encountered the patient and for which an electronic summary of care record is available. Numerator: Number of patient encounters in the denominator where an electronic summary of care record received is incorporated by the provider into the certified EHR technology. Threshold: The percentage must be more than 40 percent in order for an EP, eligible hospital, or CAH to meet this measure. Exclusion: – EP and EH/CAH: Any EP, eligible hospital or CAH for whom the total of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, is fewer than 100 during the EHR reporting period is excluded from this measure. – EP and EH/CAH: Any EP that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a county) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures. 15

Measure 2 (Capture) Questions We seek comment on whether electronic alerts received by EPs from hospitals when a patient is admitted, seen in the emergency room or discharged from the hospital-- so called "utilization alerts"--should be included in measure two, or as a separate measure. Use of this form of health information exchange is increasingly rapidly, driven by hospital and EP efforts to improve care transitions and reduce readmissions. We also seek comment on which information from a utilization alert would typically be incorporated into a patient's record and how this is done today. 16

Common Clinical Data Set The Stage 3 NPRM proposes requiring summary of care documents used to meet Objective 7 measures must include the requirements and specifications included in the Common Clinical Data Set (CCDS), as specified in the 2015 Edition. In circumstances where there is no information available to populate one or more of the fields included in the CCDS, either because the EP, eligible hospital, or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital, or CAH may leave the field blank and still meet the requirements for the measure. However, all summary of care documents used to meet this objective must be populated with the following information using the CCDS certification standards for those fields (can record there are no problems, no medications or no medication allergies recorded): – Current problem list (Providers may also include historical problems at their discretion). – A current medication list, – A current medication allergy list. 17

The Common Clinical Data Set includes key health data that should be exchanged using specified vocabulary standards and code sets as applicable 18 Patient nameLab values/results SexVital signs Date of birthProcedures RaceCare team members EthnicityImmunizations Preferred languageUnique device identifiers for implantable devices ProblemsAssessment and plan of treatment MedicationsGoals Medication allergiesHealth concerns Lab tests Send, receive, find and use a common clinical data set to improve health and health care quality. ONC Interoperability Roadmap Goal CCDS Elements Required in 2015 Edition

Governance Questions 19

Governance In the Stage 2 proposed rule, we noted the benefits of requiring standards for the transport mechanism for health information exchange consistently nationwide (77 FR 13723). We requested public comment in that proposed rule on the Nationwide Health Information Network specifications and a governance mechanism for health information exchange to be established by ONC. In the final rule, a governance mechanism option was included in the second measure for the Stage 2 summary of care objective at 77 FR In this Stage 3 proposed rule, we again seek comment on a health information exchange governance mechanism. Specifically we seek comment on whether providers who create a summary of care record using CEHRT for purposes of Measure 1 should be permitted to send the created summary of care record either-- (1) through any electronic means; or (2) in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. We additionally seek comment on whether providers who are receiving a summary of care record using CEHRT for the purposes of Measure 2 should have a similar requirement for the transport of summary of care documents requested from a transitioning provider. Finally, we seek comment on how a governance mechanism established by ONC at a later date could be incorporated into the EHR Incentive Programs for purposes of encouraging interoperable exchange that benefits patients and providers, including how the governance mechanism should be captured in the numerator, denominator, and thresholds for both the first (send) and second (receive) measures of this Health Information exchange objective. 20

Next Steps Next call we will finalize the governance questions response and review comments on Measure 3. Please send in your comment templates by COB April 27 th. 21

Appendix 22

Measure 1 (Send) Measure: For more than 50 percent of transitions of care and referrals, the EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care: (1) creates a summary of care record using CEHRT; and (2) electronically exchanges the summary of care record. 23

Measure 1 (Send) continued Denominator: Number of transitions of care and referrals during the EHR reporting period for which the EP or eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) was the transferring or referring provider. Numerator: The number of transitions of care and referrals in the denominator where a summary of care record was created using certified EHR technology and exchanged electronically. Threshold: The percentage must be more than 50 percent in order for an EP, eligible hospital, or CAH to meet this measure. Exclusions: – EP: An EP neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period. – EP and EH/CAH: Any EP that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a county) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures. 24

Definition of Referral/Transition Based on questions and public comment on the Stage 2 Final Rule the definition of referral/transition of care is proposed to change in the Stage 3 NPRM to address when a setting of care can be considered distinct from another setting of care: – “Therefore, for the purposes of distinguishing settings of care in determining the movement of a patient, we explain that for a transition or referral, it must take place between providers which have, at the minimum, different billing identities within the EHR Incentive Programs, such as a different National Provider Identifiers (NPI) or hospital CMS Certification Numbers (CCN) to count toward this objective.” 25

Patient Self Referrals “In this rule, we also recognize there may be circumstances when a patient refers himself or herself to a setting of care without a provider's prior knowledge or intervention. These referrals may be included as a subset of the existing referral framework and they are an important part of the care coordination loop for which summary of care record exchange is integral.” “Therefore, a provider should include these instances in their denominator for the measures if the patient subsequently identifies the provider from whom they received care. In addition, the provider may count such a referral in the numerator for each measure if they undertake the action required to meet the measure upon disclosure and identification of the provider from whom the patient received care.” 26