1. FDASIA Taxonomy Subgroup HIT Policy Committee FDASIA Workgroup On Site Meeting 30 May 2013

2. Subgroup Co-Chairs Patti Brennan Meghan Dierks

3. Charge 1 Charge, Anticipated Output of Subgroup 1

4. To identify the scope of Health IT that should be considered or included in deliberation by the full workgroup … as the full workgroup develops strategy and recommendations on an appropriate, risk-based regulatory framework for health IT that promotes innovation, protects patient safety, and avoids unnecessary and duplicative regulation. Taxonomy Subgroup Charge – Anticipated Output

5. To identify the scope of Health IT that should be considered or included in deliberation by the full workgroup Taxonomy subgroup scope not to be interpreted as being the final recommendation for what is to be regulation Taxonomy Subgroup Charge – Anticipated Output

6. Charge 2 Statutory Definitions 2

7. The term “health information” means any information, whether oral or recorded in any form or medium, that— (A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual. Statutory Definitions Health Information [ SSA § 1171(4); 42 U.S.C. 1320d ]

8. “The term ‘health information technology’ means hardware, software, integrated technologies or related licenses, intellectual property, upgrades, or packaged solutions sold as services that are designed for or support the use by health care entities or patients for the electronic creation, maintenance, access, or exchange of health information.” Statutory Definitions Health Information Technology [ HITECH Act (2009) ]

9. ” … an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is: — recognized in the official National Formulary, or the United States Pharmacopoeia, or any supplement to them, — intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or — intended to affect the structure or any function of the body of man or other animals, and which does not achieve its primary intended purposes through chemical action within or on the body of man or other animals and which is not dependent upon being metabolized for the achievement of any of its primary intended purposes." Statutory Definitions Medical Device [ Federal Food, Drug and Cosmetic Act 21 CFR 800 -1299 ]

10. Scope Options 3

11. Scope Options Considered EXISTING TECHNOLOGY FOCUS: Explicitly limit scope to existing, named types or categories of Health IT EXCLUSIONARY FOCUS: Explicitly exclude named types of Health IT as Not-in-Scope; assume all else is In-Scope PRESCIPTIVE/INCLUSIONARY FOCUS: Explicitly include named types of Health IT as In-Scope, assume all else is Out-of- Scope

12. Scope Options Considered STATUTORY DEFINITION FOCUS: Explicitly state the scope as any software useable by patients or providers to create, maintain, access, or exchange health information Explicitly exclude from scope products that meet definition of medical device, hence fall under existing regulatory framework

13. Scope Options Considered USER TYPE FOCUS: Create a scope based on user type FUNCTIONALITY/INTENDED USE FOCUS: Create a scope where scope driven by Health IT’s functionality and intended use RISK-HARM FOCUS: Create a scope based on potential for injury or harm with failures, malfunctions, foreseeable misuse

14. Organizing Principles 4

15. Platform agnostic — e.g., Scope is not defined by ‘Wireless’/wired Mobile/fixed Installed versus Software as a Service (SaaS) Avoid creating list of specific examples — Attempt to define generically — For product categories – focus on functions/intended use

16. Organizing Principles Part-Whole: — If ‘component’ or part is in-scope, the whole is in scope

17. Scope Dimensions Considered Product Categories ﹣ … User Type ﹣ … Phases of product lifecycle ﹣ … Developer/ ‘Manufacturer’ Type ﹣ … Distribution Model ﹣ … Conditions of use ﹣ …

18. Scoping 5

19. User Types Health Care Providers – institutional and individual Clinical Researchers using on human subjects Patients under care by a provider General public user/consumer under own use/health management In ScopePotentially Out of Scope

20. Product Lifecycle Design phase: use of risk-mitigating design controls, standards, requirements, documentation, labeling Implementation- Installation: Configuration mgmt, interfacing with other systems, interoperability as systems-of-systems In ScopePotentially Out of Scope

21. Product Lifecycle Design phase Implementation- Installation Maintenance: Routine updates/upgrades, performance tuning, defect and safety-related corrective, enhancements and Δ to base functionality In ScopePotentially Out of Scope

22. Product Lifecycle Design phase Implementation- Installation Maintenance Recall: Managing entire install base (vs. index customer), maintaining configuration log In ScopePotentially Out of Scope

23. Product Lifecycle Design phase Implementation- Installation Maintenance Recall End-of-Life Support: De-installation of out-dated or non-conforming product (vis-à-vis contemporary standards) In ScopePotentially Out of Scope

24. Product Lifecycle Design phase Implementation- Installation Maintenance Recall End-of-Life Support Cybersecurity: Control of PHI, assuring protection against malware-based risks In ScopePotentially Out of Scope

25. Product Lifecycle Design phase Implementation- Installation Maintenance Recall End-of-Life Support Cybersecurity Methods and modes of end-user training In ScopePotentially Out of Scope

26. Developer/ ‘Manufacturer’ Types Entity who develops/markets/licenses/d istributes products with commercial interest Healthcare provider* who develops products de novo for use on patients, even if no direct or indirect commercial interest Healthcare provider* who modifies functionality of previously licensed, ‘finished’ products In ScopePotentially Out of Scope *institutional or individual provider

27. Developer/ ‘Manufacturer’ Types Independent entity who develops/ advertises/distributes via public channel products intended for general public users, even if no commercial interest In ScopePotentially Out of Scope

28. Developer/ ‘Manufacturer’ Types Entity who develops/markets/licenses/distrib utes products with commercial interest Healthcare provider* who develops products de novo for use on patients, even if no direct or indirect commercial interest Healthcare provider* who modifies functionality of previously licensed, ‘finished’ products Independent entity who develops/ advertises/distributes via public channel products intended for general public users, even if no commercial interest Individuals who develop for personal private use Individual who develops/distributes via private channel to limited individuals without commercial interest Independent non- commercial developers who advertise/distribute via public channel products intended for general public users In ScopePotentially Out of Scope *institutional or individual provider

29. Distribution Model Marketed-licensed- distributed-sold in a restricted manner, with credentialing requirements Marketed-licensed- distributed-sold in a restricted manner, without credentialing requirements Made available for download via an unrestricted public channel, with or without credentialing requirements Available under a SaaS model In ScopePotentially Out of Scope

30. General Conditions of Use Intended use Foreseeable misuse Non-foreseeable, willful misuse Use clearly beyond labeled intended use In ScopePotentially Out of Scope

31. General Conditions of Use By prescription, recommendation or under direction of licensed/credentialed healthcare provider Independently by general public consumer/user For management of defined illness or chronic condition ? For health maintenance or fitness In ScopePotentially Out of Scope

32. Specific Product Types - Categories In ScopePotentially Out of Scope

33. Decision Tree Approach Functionality – Intended Use – Potential for Harm

34. Diagram Does product currently meet FDA (Act 21 CFR) definition of Medical Device (including MDDS) ? Does product currently meet FDA (Act 21 CFR) definition of Medical Device (including MDDS) ? NO YES Out-of-scope … defer to existing regulatory framework Potentially in-scope

35. Diagram 2 Does malfunction, foreseeable misuse have potential to cause patient injury, via: Delay or failure to present clinical data/ information at time of need Presentation of outdated information Patient-data mismatch ? YES NO Potentially in-scope Potentially out-of-scope

36. Diagram 3 Is the data/information that is managed by system the sole or 1 o source of data at point of care (i.e., no alternate sources of data /info that can be used for confirmation) ? YES NO Potentially in-scope Potentially out-of-scope

37. Diagram 4 Through design and intended use, is patient or provider reliant on data/information to initiate or modify prescribed intervention or tx ? YES NO Potentially in-scope Potentially out-of-scope

38. Diagram 5 Through design and intended use, is patient or provider reliant on alerting or function about a change in clinical status and/or a need to initiate or modify tx ? YES NO Potentially out-of-scope Potentially in-scope

39. Products Types - Categories Claims processing Health benefit eligibility Practice management / Scheduling / Inventory management Healthcare provider communication tools (e.g., email, paging) Population management tools Software using historical claims data to predict future utilization/cost of care Cost effectiveness analytic software In ScopeOut of Scope

40. Products Types - Categories Diseases severity scoring algorithms Electronic guideline distribution Disease registries In ScopeOut of Scope

41. Products Types - Categories EHRs (installed, SaaS) Hospital Information Systems-of-systems Decision support algorithms Visualization tools for anatomic, tissue images, medical imaging and waveforms ? Health Information Exchanges Electronic/robotic patient care assistants Claims processing Health benefit eligibility Practice management / Scheduling / Inventory management Healthcare provider communication tools (e.g., email, paging) Population management tools Software using historical claims data to predict future utilization/cost of care Cost effectiveness analytic software Diseases severity scoring algorithms Electronic guideline distribution Disease registries In ScopeOut of Scope

42. Strive to: — develop a framework that is able to meet future undefined needs — avoid a discrete, static and specific defined list of named products Favor the decision tree approach that emphasizes functionality as a primary scoping criterion Words of Caution

43. Questions and Discussion