HITPC – Information Exchange Workgroup Care Coordination Discussions Stage 3 Planning July 25, 2012

Summary of Care (and Care Plan) Phase 1Phase 2Phase 3 MU WGProposed Phase 3 IE WG Paper “Summary of Care” 50% Paper “Summary of Care” 65% HIE “Summary of Care” 10% Paper “Summary of Care” 65% PHR “Summary of Care” 30% Some increased detail including Care Plan (mostly free text) to a single “Summary of Care” Paper “Summary of Care” 65% HIE “Summary of Care” 10% (PHR in Consumer Engagement) Expand “Summary of Care” to 3 datasets being defined by S&I (which include Care Plan): 1) Consultation Request (Referral to a consultant or the ED) 2) Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility, including referral ID#) 3) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency)

MU WG’s SGRP 303 Stage 3 Care Coordination Objective (Revised Summary of Care) EP/ EH / CAH Objective: EP/EH/CAH who transitions their patient to another setting of care or refers their patient to another provider of care Provide a summary care record for each transition of care or referral when transition or referral occurs, at the time transition or referral occurs Measure: The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care (including home) or provider of care provides a summary of care record* for 65% of transitions of care and referrals. At least 30% of all patients need to receive a summary of care record electronically. *Must include the following information: Concise narrative in support of care transitions (free text, to include key points from summary of care, including setting-specific goals and instructions for care during transition and for 48 hours afterwards) Setting-specific goals* Instructions for care during transition and for 48 hours afterwards* Care team members, including primary care provider and caregiver name, role and contact info (using DECAF)*

MU WG’s SGRP 304 Stage 3 Care Coordination Objective (New, CORE – Care Plan) EP/ EH / CAH Objective: EP/ EH/CAH who transitions their patient to another setting or care or refers their patient to another provider of care For each transition of care, provide a care plan with the following elements as applicable: -Medical diagnoses and stages -Functional status, including ADLs* -Relevant social and financial information (free text) -Relevant environmental factors impacting patient’s health (free text) -Most likely course of illness or condition, in broad terms (free text) -Cross-setting care team member list, including the primary contact from each active provider setting, including primary care, relevant specialists, and caregiver -The patient’s long-term goal(s) for care, including time frame (not specific to setting) and initial steps toward meeting these goals -Specific advance care plan (POLST) and the care setting in which it was executed For each referral, provide a care plan if one exists Measure: The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides the electronic care plan information for 10% of transitions of care to receiving provider and patient/caregiver. * = aligned with PE View/Download/Transmit and Report objective

Reconciliation Phase 1Phase 2Phase 3 MU WGProposed Phase 3 IE WG Transitions: Med Rec 50% Transitions: Med Rec 65% Transitions: Med Rec 50% Allergies 10% Problems 10% Transitions: Med Rec 50% Allergies 10% Problems 10% Plan of Care* 10% Immunizations 10% Significant Test Results** 10% *Plan of Care goes beyond “Problems” to include Goals and Interventions. Specific elements are being defined via the S&I Framework **Significant Test Results suggests that the results of studies like a brain MRI done during an ED visit will be recorded in the PCPs record. This will reduce the chance that it will be repeated again as an outpatient unnecessarily. Could also include A1C results exchanged between a PCP and an Endocrinologist in order to reduce unnecessary blood tests and the ability to view trends over time through coordinated care. These are limited to the extent that test results are sent in a Care Transition Dataset

MU WG’s SGRP 302 Stage 3 Care Coordination Objective (Revised – Med Rec) EP / EH / CAH Objective: The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform reconciliation for: medications contraindications* and medication allergies problems EP / EH / CAH Measure: The EP, eligible hospital or CAH performs reconciliation for medications for more than 50% of transitions of care, and it performs reconciliation for contraindications, medication allergies, and problems for more than 10% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital’s or CAH’s inpatient or emergency department (POS 21 or 23). *A contraindication is defined as any medical reason for not performing a particular therapy; any condition, clinical symptom or circumstance indicating that the use of an otherwise advisable intervention in some particular line of treatment is improper, undesirable, or inappropriate. This must include specification of the particular contraindicated therapy, reason for contraindication, and severity of contraindication.

Collaborative Care Communication (New, Menu) Phase 3 MU WGProposed Phase 3 IE WG Referrals 10% Consult Reports 10% Care Summary 10% Lab results after transition (Already in proposed “Summary of Care”) Key “Clinical Activity Points” for messaging (10% of time): Test results finalized after transition (to receiver of patient) Placing order/referral (to performing and authorizing entities) Approval of order/referral (to referring provider and performer) Scheduling of test/procedure/visit (to ordering provider) Arrival for test/procedure/visit (includes arrival at ED) (to ordering provider or PCP if unplanned and permitted by pt.) Discharge instructions/disposition at completion of test/procedure/visit/stay (includes admission to hospital from ED, or discharge from a hospital) (to ordering/referring provider or next provider of care, and PCP with patient’s permission) Change of Primary Care Physician (PCP) – to all known members of care team including old and new PCP Health Care Proxy Activation – to all known members of care team including PCP Death notification – to all known members of care team including PCP

Collaborative Care Communication (New, Menu) - Stretch Phase 3 MU WGProposed Phase 3 IE WG Key “Clinical Activity Points” for messaging (10% of time): 1. Handoff of responsibility – this involves the assignment or transfer of a task, intervention, or responsibility for a health concern to another member of the care team. This includes tasks ranging from performing a home blood-draw to problems such as being responsible for following an abnormality (e.g. a pulmonary nodule) 2. Acknowledging acceptance of responsibility (to the sender of the “Handoff of responsibility”) 3. Change in Plan of Care– this includes changes not covered by the above messages, including changes to Goals, Patient/family preferences/wishes, patient instructions, other non-ordered interventions, etc… (to all relevant members of the care team, including PCP)

MU WG’s SGRP 305 Stage 3 Care Coordination Objective (New, Menu – Collaborative Care) EP / EH / CAH Objective (new): Acknowledgment of sending and receipt of external care management information. Must include (but not limited to): Referral Orders and Consult reports Lab results received after transition/referral Summary of care Measure: 2 Part measure: Provider acknowledges sending consult reports, lab results received after transition/referral and summary of care for 10% of patients referred or transitioned during the reporting period. (automation is OK; to be sent to origin of referral and patient/caregiver) [potential to remove]: Provider acknowledges receipt of consult reports, lab results and summary of care received after transition/referral for 10% of patients referred or transitioned during the reporting period. (automation not OK)

Request for Information (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: The EP/EH that receives a patient that is typically cared for by another provider of care but has not received a relevant care transition dataset from that provider should perform an electronic query* for patient information from that provider with the patient's consent. EP/EH MEASURE: The EP, eligible hospital, or CAH that receives a patient that is typically cared for by another provider of care but has not received a relevant care transition dataset from that provider, performs an electronic query for patient information from that provider with the patient's consent using certified EHR technology or documents the patient's refusal to authorize the query more than 10 % of the time. *Performing directed queries to specific organizations with standard authorization definitions is critical during unplanned visits. One workflow that must be supported by the certified EHR is to first, electronically request authorization template from releasing organization, and then electronically submit the completed authorization form if no authorization already exists. The advantages to this approach are that it: 1) supports interstate requests where release of information laws differ but need to follow the state that is releasing the data, 2) ensures that the releasing organization has the capability to satisfy the request in terms of data segmentation, and 3) could be done with both DIRECT as well as IHE.

Update Provider Directory (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: The EP/EH will update a community or regional Provider Directory with changes in provider name, credentials, contact information, or affiliation. EP/EH MEASURE: The EP, eligible hospital, or CAH will update a community or regional Provider Directory with changes in provider name, credentials, contact information, or affiliation using certified EHR technology more than 10% of the time that changes take place. * This objective is important to facilitate keeping community and regional directories up to date which will rapidly become critical as the use of HIE expands. Need to specify a minimum supported protocol/standard for automatically updating a community/regional provider directory from EHR data, as well as querying that directory to obtain DIRECT addressing information. Need directory of directories to know where the source of truth (DNS?).

HITPC – Information Exchange Workgroup Patient/Family Engagement Discussions Stage 3 Planning July 25, 2012

Patient/Family Engagement – Guiding Principles As part of our work on Stage 3 idea formulation, we: - Assumed that existing/proposed patient and family engagement requirements would remain and would likely be refined (e.g. increasing percentages for measures) - Focused on a handful of objectives that not only build on providing patients with easy access to data, but enable those patients to easily supply data (a significant source of patient frustration today) - Focused on objectives that logically fit with existing or planned requirements - Embraced general MU criteria (support new models of care, address national health priorities, broad applicability, not already driven by market forces, mature standards)

Consume/Reconcile Patient Supplied Data (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: Use certified EHR technology to consume and reconcile patient- submitted data EP/EH MEASURE: The EP, eligible hospital, or CAH that receives patient-generated and/or patient-aggregated data in a standard electronic format (consolidated CDA) from a patient PHR, portal or other patient managed solution must be able to consume, compare and reconcile that data in a certified EHR for 25% of the patients who submit data *Notes: Patients express significant frustration at inability to easily submit electronic data to healthcare providers. Frustration ranges from necessity to use different patient portals with different providers to difficulty submitting data from portable, patient-managed solutions to provider inability/reluctance to accept patient-supplied data. -Stage 1 and 2 lay groundwork for this objective, with standards for transmission (Direct) and payload (consolidated CDA), and requirements for consumption and reconciliation between providers. -This complements/builds on Stage 2 NPRM around transmit – patient will likely have ability to request transmittal of data from one EHR to designated address(es), which may include other provider EHRs -IE Workgroup suggests that data provenance be included as part of payload, identifying source of data (patient-generated, clinical source, etc.)

Consume Patient Supplied Device Data (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: Use certified EHR technology to consume patient-submitted home- monitoring device data EP/EH MEASURE: The EP, eligible hospital, or CAH that receives device data from an authorized patient must be able to consume data from at least one device in a certified EHR for 10% of the patients who submit data *Notes: Patients are increasingly using devices (home monitoring, portable monitoring, mobile applications, etc.) to monitor and manage health information. -This objective fits with new models of care (ACO, PCMH) where patient management monitoring is a critical success factor -Objective should reflect standards committee work around patient ID/Auth/Match -Device data should include provenance and LOINC code (as an example, BP collected at home is viewed differently from BP taken in a clinical setting) -IE Workgroup suggests coordination with Continua Alliance around appropriate standards

Provide patients/families with care plans (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: Provide care plans to patients/families with each transition of care or referral EP/EH MEASURE: As the EP, eligible hospital, or CAH transitions their patient to another setting of care and/or refers their patient to another provider of care, care plans or updated care summaries should be made available within 24 hours for 25% of patients *Notes: As Stage 3 objectives are developed regarding transitions in care and care coordination, patients and families, documents that will be exchanged among/between providers should also be shared with patients and family members. -This objective is a logical extension of existing requirements to share clinical summaries -This objective is also a logical extension of Stage 2 NPRM giving patients the ability to view/download/transmit health information

Provide patients/families with care plans (New, Menu) Proposed Phase 3 IE WG EP/EH OBJECTIVE: Notify patients when they are due for preventive services, screenings, vaccinations or are out of compliance with quality of care guidelines EP/EH MEASURE: The EP, eligible hospital, or CAH will use certified EHR technology to notify 10% of their patients when they are due for preventive services, screenings, vaccinations or are out of compliance with quality of care guidelines *Notes: Given the emphasis on preventive care and the already embedded quality guideline functionality in certified EHRs, this appears to be a logical extension of Stage 1 and 2 requirements. -Certified EHRs are already building in CDS to support quality measures -Notification can be achieved as an extension of secure messaging, view/download/transmit and other Stage 1 and 2 requirements -This objective could also be tied to Stage 3 work around transitions in care and care coordination, where care plans identify gaps in care, goals/objectives and tasks