1. Interoperability and Health Information Exchange Workgroup April 17, 2015 Micky Tripathi, chair Chris Lehmann, co-chair

2. Agenda Prioritize Review of Objective 7 HIE Start review of “Send”/“Capture” 2

3. Current Interoperability and HIE Schedule MeetingsTask April 17, 2015 2:30-4pm ET Comment on MU3 NPRM April 24, 2015 11:00 am – 12:30 pm ET Comment on MU3 NPRM April 30, 2015 3:30-5pm ET Finalize MU3 NPRM Comments May 12 th – HITPC Meeting MU3 NPRM Comments to the HITPC TBD Looking to schedule a call in case the HITPC requests any revisions or additions to the Workgroups comments May 22 nd – HITPC Meeting Finalize Any Comments the HITPC Requested Changes or Additions to 3

4. Proposed Prioritization Plan Meeting 1: “Send”/“Capture” Meeting 2: Finish “Send”/“Capture” and discuss governance questions Meeting 3: Finish governance and review “reconcile” comments – To allow time to consider all the items in Objective 7 we will solicit Workgroup members comments in writing on the reconcile measure and questions. 4

5. Objective 7: Health Information Exchange Objective: The EP, eligible hospital, or CAH provides a summary of care record when transitioning or referring their patient to another setting of care, retrieves a summary of care record upon the first patient encounter with a new patient, and incorporates summary of care information from other providers into their EHR using the functions of certified EHR technology. (Must successfully attest to 2 out of the 3 measures but report on all three): 5

6. 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. 6

7. 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. 7

8. 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.” 8

9. 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.” 9

10. 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. 10

11. 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. 11

12. 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. 12

13. 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. 13

14. The Common Clinical Data Set includes key health data that should be exchanged using specified vocabulary standards and code sets as applicable 14 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 2015-2017 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

15. Next Steps Next call we will finalize “Send”/“Capture” comments and start review of the governance questions. A comment template for Measure 3 will be sent out to Workgroup members for review. 15