1. Health eDecisions (HeD) All Hands Meeting May 23rd, 2013

2. Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded Another reason to keep your phone on mute when not speaking Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute All Panelists

3. Agenda TopicTime Allotted Announcements5 minutes Work Stream 1 Update: HL7 Meeting Update 5 minutes Work Stream 2 Update: Pilots5 minutes EPIC Discussion : James Doyle and Varghese Mathew 30 minutes Moving Forward….Discussion/Plans/Resources/ Timelines 40minutes Wrap up/Questions5 minutes

4. Announcements Vocabulary and Terminologies sub work will be meeting this week Friday 12:30-1:30 EDT –http://wiki.siframework.org/Health+eDecisions+Homepagehttp://wiki.siframework.org/Health+eDecisions+Homepage We are starting the preparation process for balloting UC 2 through HL7 in September –Stay tuned for updates and ways to participate –We submitted the Project Scope Statement AMIA –We will be presenting June 6 th from 1-2 pm Meeting details will be posted on the wiki homepage when available

5. HL7 Update We have completed a rough draft of the Implementation Guide –http://wiki.siframework.org/HeD+Pilot+Toolshttp://wiki.siframework.org/HeD+Pilot+Tools The Vocabulary and Terminology IG is also complete and will be incorporated into our IG. –To view and comment on the work of the Vocab and Terminology team please see the pilots tool page: http://wiki.siframework.org/HeD+Pilot+Tools http://wiki.siframework.org/HeD+Pilot+Tools We met this week on Tuesdays: NOTE WE HAVE A NEW HL7 MEETING TIME: –Meet every Tuesday from 3-4 pm http://wiki.siframework.org/Health+eDecisions+Homepage )http://wiki.siframework.org/Health+eDecisions+Homepage We will keep the Wednesday time slot in case we need 2 HL7 meetings based on the 2 ballot work streams (UC 1 and UC 2) We are beginning the process of preparing UC 2 for HL7 balloting –Next goal for UC 2 is the Notice for Intent to Ballot – July 7th

6. HeD Pilots Update We met this week Pilots Update –CDC and AllScripts–ECA Rule Allscripts has replaced Practice Fusion and the EHR to consume/implement this rule Transformation of the rule from HQMF to HeD is complete Bryn is working with Manjo (AllScripts) on translating this into AllScripts native format CREF –NewMentor and AllScripts – ECA Rule (COMPLETE) The team has transformed the NQF 0068 (Million Hearts) into HeD and then into the Allscripts native format (CREF) Will be reviewing the IG and updating based on experience –Zynx and DesignClinicals - Order Set (60% complete) Working on simple and complex order sets –VA and Wolters Kluwer - Documentation Template (75% complete) UTI Documentation Template was transformed into HeD schema Wolters Kluwer is checking the rule to ensure it captures what is needed Ken, Robert Lario and Dave Sheilds are working with the VA to prepare for the final rule to be implemented into their system.

7. HeD Pilots Goal Goal The goal of this initiative is to produce, consume and where feasible, execute implementable CDS interventions. 1.Event Condition Action Rules (ECA Rules) 2.Order Sets 3.Documentation Templates Pilot Scope 1.Health eDecisions will apply defined aspects of the Implementation Guide in a real-world setting. 2.Modify the Implementation Guide to ensure it is usable 3.Submission of explicit feedback to sub workgroups such as vMR and Vocabulary and Terminology work group to close gaps 4.The real-world pilots evaluate not only the technology, standards and model (VMR), but also provide a test bed to evaluate the interaction of technology, implementation support, and operational infrastructure required to meet Health eDecisions use case 1 objectives at the stakeholder or organization levels. 5.Demonstrate intent of artifact (specifically structures and semantics) are communicated either by direct execution or by translation to native format 6.Ensure completeness and consumability of artifact New

8. Timeline 10/11/20118 We are Here Goal & Activities EST. Time DatesDeliverables Kickoff /Establish Goals & Partnerships: - Review HeD Initiative Goals - Review Piloting Process & Resources - Define Value Statement - Define HeD Pilot Goals & Success Metrics - Establish & Approve Pilots - Develop Pilot Briefs 4 wks. (reality 5 weeks) 1/07-2/25 (we missed 2 meetings in January pushing our Dates back) -Wiki Capturing Pilot Deliverables -Established Partnerships -Documented Value Statements and Success Metrics -Documented Pilot Briefs Pilot Configuration: - Establish Pilot Test Environment & Resources - Establish Pilot Implementation & Testing Process - Develop & Review Pilot Configuration 2 wks. (reality- 4 weeks) 2/25-3/25 -Use Case is Updated with HL7 Comments (3/4) -Approved Pilot Briefs -Committed Pilot Resources -Documented & Reviewed Pilot Configuration Guide -Weekly Feedback on Use-Cases & IG Alignment Pilot Development : - Setup & Develop Pilot Prototypes - Review prototypes 6 wks. or less depending on Pilot activity 3/25 – 5/6 -Use Case is Updated with HL7 Comments (3/4) -Weekly Pilot Development Status Updates -Weekly Feedback on Use-Cases & IG Alignment -Updates to Pilot Configuration Guides Pilot Testing & Showcase : - Complete Testing - Prepare Solution Showcase 2wks5/6 -5/20-Weekly Pilot Testing Updates & KPIs -Showcase -Prepare for HL7 Pilot Wrap-up : - Develop Lessons Learned an ONC Feedback - Review Initiative Goal Alignment - Establish Next-Steps 2 wks.5/20 – 6/3-Documented ONC Feedback - Next Steps Action Plan

9. Vendor Partners 10/11/20119 EHRArea of InterestPotential or Actual Match Design ClinicalsOrder SetsZynx AllScriptsECA Rules –NQMF Rule (for Ambulatory Setting) – Million Hearts NewMentor (have catalog for rules in ambulatory setting) AllScriptsAnything MU centered CDC (also may need Artifact supplier to help) Wolters Kluwer NewMentor (MU rule as example) VADocumentation Template Wolters Kluwer

10. HeD Use Case 2 Implementation Guide Proposed Solution 5/23/2013

11. Standards Analysis Summary vMR –Pros Designed for computability Compact Wire Format Aligned with HeD Efforts –Cons Limited Vendor Adoption thus far Represents an additional required format for EHRs –If vendors do choose or have the ability to consume HeD artifacts this may not be a con and may actually make it easier to consume the HeD work

12. Standards Analysis Summary (cont.) CDA (C-CDA & QRDA) –Pros Well specified for various use cases Established Vendor Basis Aligned with MU –Cons Difficult for computability Expensive wire format

13. Standards Analysis Conclusion Conclusion –Not likely to be able to recommend a single format –Should provide a solution that allows flexibility in payload formats, but still enables interoperability

14. Proposed IG Outline DSS Guidance with Modular Transport Solution –DSS Profiles Container Profiles Payload Guidance –Foundational Model Data requirements mapped to foundational model Multiple standards mapped to foundational model –Interaction Types Development of guidance as examples

15. Transport Format SOAP and REST guidance both supported –DSS Release 1 currently contains guidance on use with SOAP –REST guidance may or could be added to DSS Release 2 –DSS profiles specified within HeD UC2 IG would be developed to support both (as described in next section) –Do we still want to support this modular approach or do we think it would be better to endorse and support a single format?

16. DSS Profiles This section of the implementation guidance may include four separate DSS profiles: –DSS Profile for CDS Request with SOAP –DSS Profile for CDS Request with REST –DSS Profile for CDS Response with SOAP –DSS Profile for CDS Response with REST

17. Container Profile CDSInput –vMR Container –Extended w/ additional context as specified in UC2 –Could support multiple payload formats CDSOutput –vMR Container –Could support multiple payload formats, if necessary

18. Payload Guidance In order to support multiple payload standards while still promoting interoperability, a solution that leverages a foundational model is being proposed –This solution would also allow for mapping to additional payload formats in the future This section would include a mapping between: –Foundational model and HeD UC2 data requirements –Foundational model and standard(s) Standards to be mapped: vMR, C-CDA, QRDA Initial work may require prioritizing order of standards mapping Foundational Model HeD UC2 Data Requirements vMR Future Standards? QRDAC-CDA

19. Payload Guidance, continued The following elements would be included in the HeD UC2 data requirements that are mapped to the foundational model: –Clinical Concept (Encounter, Problem, Procedure, etc.) –Value Set (A specific value set identifying codes) –Date Range (A date range, relative to the time of the request) This effort would leverage the Value Sets & Terminologies work in order to express each clinical concept in the terminology space

20. Request Service: DSS Request Element Request Items Organizer/Container: vMR Request Item Payload: vMR Clinical Statement Request Service: DSS Request Element Request Items Organizer/Container: vMR Request Item Payload: QRDA Request Service: DSS Request Element Request Items Organizer/Container: vMR Request Item Payload: CCDA C-CDA Payload QRDA Payload vMR Payload This approach would support all payload standards considered as long as each was mapped into foundational model CDS Request Options for Functional Interaction Types

21. Additional Guidance for Foundational Model Additional guidance will be included to explain how to use the foundational model to: If tool(s) for the foundational model are available to support implementation they will be explained within the implementation guidance, as well Obtain an implementable profile based on data requirements vMR Data Profile/ Schema Foundational Model Data Require- ments Develop a transform between standards vMR Data Profile/ Schema Foundational Model C-CDA Data Profile

22. Interaction Types This section will provide example implementations based on selected functional interaction types Each example will include: –Subset of HeD UC2 Data Requirements required for interaction –Data profile created by mapping data requirements to foundational model, and the foundational model to standards

23. Interaction Types (cont.) The proposed approach is to select the most broadly applicable, prevalent and relevant functional interaction types from the following list: –Drug Dosing Calculation –Immunization Forecasting –Disease Management –Quality Measure Evaluation –Transition of Care Support –Prediction Rule Evaluation – APACHE score, AHRQ Pneumonia Severity Index, etc. –Severity of Illness Assessment – Charlson index, etc. Implementation Guidance for the functional interaction types selected will be included based on the top prioritized standard –The additional effort required for other standards (including standards mapping to foundational model and functional interaction-based implementation guidance) will only be included in the initially balloted material as time and resources allow

24. Open Questions for Community Discussion The proposed solution leverages vMR for the container in all cases. Question: Do we anticipate any issues with using vMR as the container for non-vMR payload standards?

25. Open Questions for Community Discussion, continued vMR was used as the basis for HeD UC1 (CDS Knowledge Artifact) and was the recommended payload for the response in HeD UC2. Question: Would mandating the use of vMR for the knowledge artifact and/or the import of clinical guidance from a CDS service be a burden on implementers? Question: Would mandating the use of vMR for the export of clinical guidance to a CDS service be an additional burden on implementers?

26. Open Questions for Community Discussion, continued This proposed solution requires the selection of a foundational model. Question: Which foundational model should be leveraged? –Top Options: vMR Data Model –Used in HeD UC1 Federal Health Information Model (FHIM) –Selected as the information model basis for S&I Framework initiatives –Additional Options: OpenEHR Quality Data Model (QDM) Clinical Element Model (CEM) Fast Healthcare Interoperability Resources (FHIR) HL7 Order Sets

27. Open Questions for Community Discussion, continued CriteriavMRFHIMOpenEHRQDMCEMFHIRHL7OS General Expressivity Model Expressivity (Concept Coverage) (Low, Fair, Good) FairGoodN/AGoodN/ALowFair Model Granularity (Attribute Coverage %) 41%62%N/A33%N/A24%46% Support for model extension by user Limited SupportSupported*N/ANot supportedN/ASupportedNot Supported Support for semantic relationships SupportedPartially SupportedUnsure*Limited SupportSupported Not SupportedUNSURE Composite structure support (e.g., composite orderables) Supported Not supportedSupported Not SupportedNo Clinically Appropriate for CDS (Prospective) concept representation (Yes, No) Yes N/ANoN/ANoYes Implementation Considerations Machine-Processable Constraints? (Yes, No, Not Essential) NoYes* (See Notes)YesN/AYes No Is model stable? (Yes, No) YesNoYesNoYesNo Serializable Patient Record (Yes, No) Yes Yes*NoYes*YesNo Serialization Format XML N/A XMLXML,JSONN/A Existing Tools & Library Support (Yes, No) Yes No Adoption Maturity (None, Low, Medium, High) LowNoneMediumLow None Likely change in adoption UnchangedIncreaseUNSUREIncreaseUNSUREIncreaseUnchanged Licensing HL7FHA/Public Domain OpenEHR/Free & OpenOpen/MU Intermountai n/GEOpenHL7 Interoperability Considerations Harmonization with HL7 and Other Standards (Yes, No, Partial) YesPartial Yes Support for Terminology Bindings (Yes, No) Yes Support for binding model attributes to value sets (Yes, No) NoYes yesUNSURE Model analysis results from UC1 activities:

28. Open Questions for Community Discussion, continued What priority should standards mapping be given, if necessary? –vMR –C-CDA –QRDA

29. Open Questions for Community Discussion, continued Which functional interaction types should be included as examples? –Drug Dosing Calculation –Immunization Forecasting –Disease Management –Quality Measure Evaluation –Transition of Care Support –Prediction Rule Evaluation – APACHE score, AHRQ Pneumonia Severity Index, etc. –Severity of Illness Assessment – Charlson index, etc.

30. Open Questions for Community Discussion, continued Which functional interaction types should be included as examples? –Drug Dosing Calculation –Immunization Forecasting –Disease Management –Quality Measure Evaluation –Transition of Care Support –Prediction Rule Evaluation – APACHE score, AHRQ Pneumonia Severity Index, etc. –Severity of Illness Assessment – Charlson index, etc.

31. Work Stream 1 – HL7: –Tuesday May 28th: http://wiki.siframework.org/Health+eDecisions+Homepagehttp://wiki.siframework.org/Health+eDecisions+Homepage Work Stream 2 – Pilots: –Next Pilots meeting: June 4th, 1-2:30 pm EDT see HeD home page wiki for meeting details: http://wiki.siframework.org/Health+eDecisions+Homepage http://wiki.siframework.org/Health+eDecisions+Homepage –Updates on Pilot Activities, Review of Timelines Work Stream 3 – Use Case 2: –Data Elements and Standards Sub Work Group Next Meeting: May 29th, 2013 Homepage wiki for meetings: http://wiki.siframework.org/Health+eDecisions+Homepage http://wiki.siframework.org/Health+eDecisions+Homepage All Hands Community Meeting –We will reviewing candidate standards –Next meeting May 30th, 2013(see the HeD Homepage wiki for meeting details: http://wiki.siframework.org/Health+eDecisions+Homepage http://wiki.siframework.org/Health+eDecisions+Homepage Next Steps

32. Questions?

33. Contact Information For questions, please contact your support leads –Coordinator: Ken Kawamoto: kensaku.kawamoto@utah.edukensaku.kawamoto@utah.edu –Co-Coordinators: Aziz Boxwala: aziz.boxwala@meliorix.comaziz.boxwala@meliorix.com Bryn Rhodes: bryn@veracitysolutions.combryn@veracitysolutions.com –ONC Leadership: Alicia Morton: alicia.morton@hhs.govalicia.morton@hhs.gov –Project Management: Jamie Parker: jamie.parker@esacinc.comjamie.parker@esacinc.com –Use Case 2: Dave Shevlin: d.s.shevlin@accenturefederal.comd.s.shevlin@accenturefederal.com Virginia Rhiel: virginia.riehl@verizon.netvirginia.riehl@verizon.net –Harmonization: Lynette Elliot: lynette.elliott@esacinc.comlynette.elliott@esacinc.com Anna Langhans: anna.langhans@accenture.comanna.langhans@accenture.com

34. Useful Links Wiki –http://wiki.siframework.org/Health+eDecisions+Homepagehttp://wiki.siframework.org/Health+eDecisions+Homepage Use Case 1& 2 –http://wiki.siframework.org/Health+eDecisions+Use+Casehttp://wiki.siframework.org/Health+eDecisions+Use+Case –UC 2: Use Case 2: http://wiki.siframework.org/UC+2+- +CDS+Guidance+Servicehttp://wiki.siframework.org/UC+2+- +CDS+Guidance+Service Pilots –http://wiki.siframework.org/Health+eDecisions+Pilotshttp://wiki.siframework.org/Health+eDecisions+Pilots HL7 Ballot Submission: –http://wiki.siframework.org/Health+eDecisions+Reference+Materials #Ballothttp://wiki.siframework.org/Health+eDecisions+Reference+Materials #Ballot UC 1 Harmonization and IG: –http://wiki.siframework.org/Health+eDecisions+Harmonization+and+ Standards+%28Implementation%29http://wiki.siframework.org/Health+eDecisions+Harmonization+and+ Standards+%28Implementation%29 HeD Glossary –http://wiki.siframework.org/HeD+Glossaryhttp://wiki.siframework.org/HeD+Glossary