1. HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 2: Care Coordination and Patient and Family Engagement Co-Chairs: Jeff Donnell and Larry Garber Members: Peter DeVault, Jonah Frohlich, Arien Malec

2. Agenda Discuss – Specifying transition content – Exchange of electrocardiography – Query Provider Directory (if time permits) Final Recommendation Language on: – Query for patient record – Collaborative Care Communication (AKA Event notification) – Data portability 2

3. IE Workgroup Timeline DateTopic Tuesday, September 4 th, 2:00-3:00pm ET Goals and Objectives for stage 3 Specifying transition content Exchange of electrocardiography Query Provider Directory (if time permits) Finalize recommendations in all areas IE WG Call - Wednesday, September 5 th, 3:00-4:00pm ET Review Sub WG recommendations IE WG Call – Tuesday, September 11, 3:00-4:30 pm ET Finalize recommendations September 18 th MU WG meeting 3

4. Recommendation Options The Subgroup is tasked with reviewing and developing prioritized recommendation in four key areas. The Subgroup has a number of options for addressing these areas including: – Stage 3 – Certification only – Explore in RFC – Push to Stage 4 – No recommendation 4

5. Specifying Transition Content Existing MU2 recommendation language for a “Transition of care/referral summary” CCD/C32 (for backward compatibility) CCR (for backward compatibility) Consolidated CDA (CCD, Discharge Summary, or Consult Note) Problems: C-CDA has no “Referral” document type Nursing homes and home health agencies receive these but these document types weren’t designed to meet their needs 5

6. Expanded Transfer of Care Dataset Includes Collaborative Care Plan data elements CCD: ~175 Data Elements Transfer of Care Dataset: ~450 Data Elements Next steps: November 2012 Preliminary Implementation Guide completed December 2012Pilot full Transfer of Care Dataset in 16 facilities March 2013Finish Implementation Guide in S&I Framework May 2013 HL7 Balloting of Implementation Guide for inclusion in Consolidated CDA 6

7. Specifying transition content Expand “Summary of Care” to 3 datasets being defined by S&I LCC (which include Care Plan) for C-CDA: 1) Consultation Request (Referral to a consultant or the ED, including referral ID#) 2) Shared Care Encounter Summary (Consultation Summary, Return from the ED to the referring facility, Office Visit, including referral ID#) 3) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency) How does the subgroup want to proceed? – Stage 3 – Certification only – Explore in RFC – Push to Stage 4 – No recommendation 7

8. Exchange of electrocardiography What priorities will the exchange of EKGs support? Is the market ready to support the sharing of EKGs? How does the subgroup want to proceed? – Stage 3 – Certification only – Explore in RFC – Push to Stage 4 – No recommendation 8

9. Query Provider Directory Priorities supported by a provider directory query which facilitates Direct messaging: – Improved care coordination – Reduces readmission, redundant testing – Improves patient safety – Facilitates “hassle-free” health information exchange 9

10. Query Provider Directory Proposed Phase 3 IE WG 1.The EHR must be able to query a separate legal entity’s Provider Directory to obtain DIRECT entity-level addressing information. Are there sufficient standards to support the query of provider directories? How does the subgroup want to proceed? Stage 3 Certification only Explore in RFC Push to Stage 4 No recommendation 10

11. Query for Patient Information (EHR Certification Criteria) Proposed Phase 3 IE WG 1.The EHR must be able to query another entity* for outside records and respond to such queries. This query may consist of three transactions: Patient query based on demographics and other available identifiers Query for a document list based for an identified patient Request a specific set of documents from the returned document list *the outside entity may be another EHR system, a health information exchange, or an entity on the NwHIN, for example. 2.When receiving in inbound patient query, the EHR must be able to tell the querying system whether patient authorization is required to retrieve the patient’s records. (E.g. if authorization is already on file at the record-holding institution it may not be required). 3.The EHR must be able to query an outside entity for the authorization language to be presented to and signed by the patient or her proxy in order to retrieve the patient’s records. Upon the patient signing the form, the EHR must be able to either: Send a copy of the signed form to the entity requesting it Send an electronic notification attesting to the collection of the patient’s signature Note: the authorization text may be located in a directory separate from the record-holding EHR system, and so a query for authorization language would need to be directable to the correct endpoint. 11

12. Collaborative Care Communication (New, Menu) Proposed Phase 3 IE WG MU Objective EH OBJECTIVE: The EH/CAH will send electronic notification of a significant healthcare event in a timely manner to key members of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required. EH MEASURE: The eligible hospital or CAH will send electronic notification within 2 hours of a patient’s arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death, to at least one key member of the patient’s care team, such as the primary care provider, referring provider or care coordinator, with the patient’s consent if required, more than 10 % of the time. Corresponding certification criteria will also include the ability for all (EP and EH) certified EHRs to be able to receive these notifications. Request for Comment for Meaningful Use with these additional questions: Is the mere notification that the event has taken place sufficient, or is more detail needed at a minimum? For instance should the ED Triage note be the minimum ED Arrival Notification? Should the patient discharge instructions with disposition be the minimum Facility Discharge Notification? Is the cause of death required at a minimum for the Death Notification? Are there sufficiently mature standards to define the content and vocabulary for these notifications? Will the Consolidated CDA satisfy these needs? Timeliness of notification must be balanced against the practical ability to produce these notifications, for example, in a busy ED. Is 2 hours a reasonable balance, or should it be shorter or longer? Should notification of more members of the patient’s care team be required? Would a 50% threshold (instead of 10%) be too difficult to achieve? What exemptions from the measure or exclusion from the denominator should be considered? 12

13. Data Portability Between EHR Vendors - RFC Request for Comment for EHR Certification: ONC recognizes the importance of enabling healthcare providers to switch from using one EHR to another vendor’s EHR. It also recognizes that not all data can be migrated from one EHR to another. For instance, it is unreasonable to expect audit trails to be able to be imported from one EHR into another vendor’s EHR because EHR audit trails are so intimately tied to the EHR’s internal data structure and function. In the MU2 Certification Rule, ONC required at a minimum the capability to export C-CDA summaries on all patients which includes their most recent clinical information. It was recognized that this core clinical dataset was merely a first step towards the goal of seamless data portability. ONC also encouraged, although did not require, including historical laboratory test results, immunizations, and procedures. ONC wishes to advance data portability further, and thus seeks comment to help identify reasonable actions that may further facilitate data portability. Should all of the provider’s visit notes, telephone notes, procedure notes, letters, and test results (including lab, radiology, etc…) be included in the exported data? Should this included provider- generated or ordered data that was saved in the EHR as an image or waveform? Should all immunization history and all childhood growth data be exported? Should there be different standards for EP versus EH EHRs with regards to which data elements to export and how far back historically to include? ONC recognizes that some data elements do not need to be transferred into the new EHR but instead need to be archived and made available through some other non-EHR mechanism. What non-EHR mechanisms for storing, retrieving and displaying these archived data are available? Are there standards and services available to accomplish this? What are the risks and harms of requiring EHR vendors to provide data portability beyond C-CDA summaries? What are the risks and harms of not advancing the current state of data portability beyond C-CDA summaries? 13

14. Next Steps Finalize recommendation language for September 5 th IE WG call DateTopic IE WG Call - Wednesday, September 5 th, 3:00-4:00pm ET Review Sub WG recommendations IE WG Call - Week of September 10 th Finalize recommendations September 18 th MU WG meeting 14