1. HIT Standards Committee Clinical Operations Workgroup Report Jamie Ferguson, Chair Kaiser Permanente John Halamka, Co-chair Harvard Medical School 21 July, 2009

2. 2 Clinical Operations Workgroup Members Christopher Chute, Mayo Linda Dillman, Wal-Mart Martin Harris, Cleveland Clinic Stan Huff, Intermountain Healthcare Kevin Hutchinson, Prematics Liz Johnson, Tenet Healthcare John Klimek, National Council of Prescription Drug Plans Wes Rishel, Gartner Nancy Orvis, Department of Defense Don Bechtel, Siemens Joyce Sensmeier, HIMSS John Halamka, Harvard Medical School Jamie Ferguson, Kaiser Permanente

3. 3 Summary The workgroup used a two-phase process first to identify EHR standards, then to assess feasibility for widespread implementation –Almost all of the current 2011 MU measures were addressed Applicable HHS-adopted, recognized or accepted standards are recommended for 2013 and for 2011 –Gaps were identified that may affect 2011 MU measures Unstructured documents, local and proprietary codes generally are recommended as allowable alternatives for 2011 but not for 2013 reporting of MU measures

4. 4 Clinical Operations Workgroup Process Review proposed MU objectives and measures –Initial focus on proposed MU quality measures Identify existing EHR standards for MU measures –Existing HHS adopted, recognized and accepted standards –Other widely accepted and widely deployed standards –Gaps in standards for the measure Identify the feasibility of widespread implementation of the identified national EHR standards by 2011 or 2013 or beyond “Reality check” notes on requirements and next steps

5. 5 Example of Clinical Operations Process Pre-decisional Draft Example For Discussion 2011 Measure HHS Adopted EHR Standards Other Widely Accepted Standards Gaps In Standards Feasible For 2011 Feasible For 2013 Notes / “Reality Check” % patients at high risk for cardiac events on aspirin pro- phylaxis [OP] Standards referenced in HITSP specific- ations for CCD; e- prescribing; medication manage- ment N/AStandards- based definition of high risk patients. Standards for patient self- reporting of medications Measures based on local or proprietary codes and/or ICD-9 – or – 2013 standards Measures based on SNOMED- CT problems, RxNorm and other standards in relevant HITSP specifi- cations Adopted HHS EHR standards are not fully tested nor widely deployed for this use.

6. 6 Workgroup Discussions During Process Concerns were discussed regarding those have not yet implemented, as well as those who have implemented legacy alternatives to HHS adopted standards for MU Main concerns for new implementers included ICD-10 The longer the legacy systems are in place, the more is built up around them and the greater the upgrade cost The workgroup agreed not to let these concerns stand in the way of progress, and found interim solutions to ease the path of implementing or upgrading to the standards

7. 7 Recommendations: Summary Meaningful use based on the standards in recognized and accepted HITSP capabilities is recommended for 2013 and 2011 implementation of the 2011 measures –Includes many uses of CCD, LOINC, RxNorm and other standards referenced in HITSP capabilities Specific additional alternatives are recommended for interim periods such as specified allowable uses of unstructured documents, local/proprietary codes, and current quality measures for meaningful use in 2011 and 2012 –Most alternatives are not recommended for 2013 and beyond See descriptions and details of HITSP Capabilities in the attached documents

8. 8 Recommendations: Detailed Example 2011 Measure Recommended 2011 Standards Recommended 2013 Standards Directional Statement Of Intent % diabetics with A1c under control [EP] Standards in HITSP capabilities 117, 118, 119, 120, 126, 127, 140, and local/proprietary codes, and unstructured documents, and ICD-9 allowed in place of SNOMED CT Standards in HITSP capabilities 117, 118, 119, 126, 127, and ICD-10 allowed in place of SNOMED CT Remote device monitoring to be added in 2013 or 2015 SNOMED CT to be required as applicable in 2015

9. 9 Clinical Operations Recommendations The workgroup requests Committee approval of the attached detailed recommendations for 2011 measures of meaningful use to be forwarded to ONC The workgroup requests Committee approval to proceed and to recommend to ONC if adopted standards may apply to the 2011 MU measures not yet addressed –% encounters where med reconciliation was performed –% reportable lab results submitted electronically –30-day readmission rate The workgroup recommends that ONC determine how to address gaps in standards via HITSP, or direct requests to standards organizations, or other means