1. DRAFT Paul Tang, Chair George Hripcsak, Co-Chair Meaningful Use Workgroup October 24, 2013

2. DRAFT Workplan 1 DateMeeting Tasks 10/24/2013 10:00-11:30 ET Continue review of objectives (Finish subgroup 3, review subgroup 2, follow-up with subgroup 4) 10/28/2013 10:00-12:00 ET Care Planning: virtual hearing 9/23/10 Timing 11/21/2013 9:00-11:00 ET Review draft deeming recommendations from QM WG at 11/6/13 HITPC PGHD: recommendations from Consumer WG at 11/13/13 HITSC Imaging: recommendations from 11/13/13 HITSC Begin final review of recommendations 11/26/2013 10:00-12:00 Final review of recommendations 12/4/2013 Present recommendations to HITPC TBD Deeming – functional measures to be deemed TBD Deeming – functional measures to be deemed

3. DRAFT Improving care coordination: Stage 3 Priorities 2 Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Goals, care plans, and interventions are shared and tracked MU Outcome Goals All members of a patient’s care team (including professional healthcare team, patient, and caregivers), as authorized, participate in implementing coordinated care plan Summary of care Medication reconciliation Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives

4. DRAFT Improving care coordination: Notifications 3 Functionality Needed to Achieve Goals Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to key members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required Significant events include: – Arrival at an Emergency Department (ED) – Admission to a hospital – Discharge from an ED or hospital – Death Recommended as a Menu item Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Goals, care plans, and interventions are shared and tracked Former Objective MENU 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. Significant events include: Arrival at an Emergency Department (ED) Admission to a hospital Discharge from an ED or hospital Death EH Measure: For 25 patients with a significant healthcare event (arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death), EH/CAH will send an electronic notification 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, within 24 hours of when the event occurs. Certification Criteria: Ability to send/receive notification of a significant healthcare event EHRA EHRA estimate: Jumbo Estimate depends on approach and the availability of standards. Would have both development and implementation impact. Identification of appropriate triggers; Sending notification; Capture who the patient wants to send notifications to; Capturing patient consent for sending the notifications ; Tracking/auditing of notifications; Directory of recipients of notifications; Reporting for new measure

5. DRAFT Former Objective Details Notifications – 308 4 Stage 2 Final RuleStage 3 Recommendations Proposed for Future Stage Questions / Comments NewMENU 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. Significant events include: Arrival at an Emergency Department (ED) Admission to a hospital Discharge from an ED or hospital Death EH Measure: For 25 patients with a significant healthcare event (arrival at an Emergency Department (ED), admission to a hospital, discharge from an ED or hospital, or death), EH/CAH will send an electronic notification 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, within 24 hours of when the event occurs. Certification Criteria: Ability to send/receive notification of a significant healthcare event Consider making this a modular certification criteria because HIEs offer this functionality.

6. DRAFT Engaging patients and families in their care: Stage 3 Priorities 5 Provide patient and caregivers online access to health information Provide ability to contribute information in the record, including PRO Patient preferences recorded and used Target Outcome Goals MU Outcome Goals Patients understand their disease and treatments Patients participate in shared decision making Patient preferences honored across care teams View, download, transmit Clinical summary Patient-specific educational resources Patient reminders Secure messaging Advance directives Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives

7. DRAFT Engaging patients and families in their care: View, Download, Transmit (VDT) 6 Functionality Needed to Achieve Goals Eligible Professionals provide patients the ability to view online, download, and transmit (VDT) their health information within 24 hours if generated during the course of a visit Labs or other types of information not generated within the course of the visit should be made available to patients within four (4) business days of information becoming available It is recommended that CEHRT provide the ability for patients to designate to whom and when a summary of care document is sent to a patient- designated recipient, building upon Blue Button Stage 3 Functionality Goals Provide patient and caregivers online access to health information Provide ability to contribute information in the record, including PRO Patient preferences recorded and used Former Objective EPs should make information available within 24 hours if generated during the course of a visit For labs or other types of information not generated within the course of the visit, it is made available to patients within 4 day of becoming available Potential to increase both thresholds (% offer and % use) based upon experience in Stage 2 Add optional item: family history Certification Criteria: CEHRT should provide the ability for patients to designate to whom and when a summary of care document is sent to a patient- designated recipient, building upon Blue Button. EHRA Overall estimate: Large Small: False precision around measuring 24 hour ranges of visits Small: Addin g family history to portal Auto mated transmit, small. Small: updated reporting for revised measure, small

8. DRAFT Former Objective Details VDT - 204 A EPs should make information available within 24 hours if generated during the course of a visit For labs or other types of information not generated within the course of the visit, it is made available to patients within four (4) business days of information becoming available to EPs Potential to increase both thresholds (% offer and % use) based upon experience in Stage 2 Add optional item: family history Note: Depending on experience in Stage 2, CMS may want to give credit to some providers (e.g. specialists) for view/download/transmit where the patient has requested that they prefer info to be sent to a location they specify (such as another provider portal or PHR), rather than only making available information on the provider’s portal. Certification Criteria: CEHRT should provide the ability for patients to designate to whom and when a summary of care document is sent to a patient-designated recipient, building upon Blue Button. 7

9. DRAFT Engaging patients and families in their care: Amendments 8 Functionality Needed to Achieve Goals CEHRT includes the functionality to provide patients with an easy way to request an amendment to their record online (e.g., offer corrections, additions, or updates to the record) Recommended as certification criteria only Stage 3 Functionality Goals Provide patient and caregivers online access to health information Provide ability to contribute information in the record, including PRO Patient preferences recorded and used Former Objective Provide patients with an easy way to request an amendment to their record online (e.g., offer corrections, additions, or updates to the record) Stage 3 or future?

10. DRAFT Former Objective Details Amendments - 204 D 9 Stage 2 Final RuleStage 3 Recommendations NewProvide patients with an easy way to request an amendment to their record online (e.g., offer corrections, additions, or updates to the record)

11. DRAFT Engaging patients and families in their care: Patient Generated Health Data 10 Stage 3 Functionality Goals Provide patient and caregivers online access to health information Provide ability to contribute information in the record, including PRO Patient preferences recorded and used Functionality Needed to Achieve Goals Eligible Providers and Hospitals provide the capability for patients to electronically submit patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status) using CEHRT Recommended as a Menu item Former Objective EP/EH MENU Objective: Patients have the ability to electronically submit PGH information EP/EH MENU Measure: Provide the ability to electronically submit PGH information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status) for more than 10 % of all unique patients seen by the EP during the EHR reporting period. Standards work needed: Certification criteria for devices, continue to work with HITSC. Placeholder: Awaiting feedback from Consumer Engagement and Consumer Technology Workgroups

12. DRAFT Former Objective Details PGHD – 204B Stage 3 Recommendations EP/EH MENU Objective: Patients have the ability to electronically submit patient- generated health information. EP/EH MENU Measure: Provide the ability to electronically submit patient- generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status) for more than 10 percent of all unique patients seen by the EP during the EHR reporting period. Standards work needed to incorporate and acknowledge PGHD – feedback from HITSC needed. Certification criteria for devices, continue to work with the standards committee. Consumer technology will have information by the end of the August. 11

13. DRAFT Engaging patients and families in their care: Clinical Summary 12 Functionality Needed to Achieve Goals Eligible Professionals and Hospitals provide office-visit summaries to patients or patient-authorized representatives with relevant, actionable information, and instructions pertaining to the visit in the format indicated by the patient – Summaries should be shared in the format of the patient’s preference (e.g., telephone, email), if the provider has the technical capability Recommend that CEHRT draw from existing specified information enabling providers to include and exclude data based upon patient needs Stage 3 Functionality Goals Provide patient and caregivers online access to health informati on Provide ability to contribut e informati on in the record, including PRO Patient preferenc es recorded and used Former Objective The clinical summary should be pertinent to the office visit, not just an abstract from the medical record. EP Objective: An office-visit summary is provided to a patient or patient-authorized representative with relevant and actionable information and instructions pertaining to the visit in the format indicated by the patient. EP Measure: An office visit summary is provided to a patient or patient-authorized representative with relevant and actionable information and instructions pertaining to the visit in the format requested as indicated by the patient (e.g., available online, via email, print out of summary, etc.),if the provider has the technical capability within 1 business day for more than 50 percent of office visits. Certification criteria #1: Intent is to make sure the EHR can draw from the range of existing specified information and enable providers to include and exclude data based upon patient needs. Certification criteria #2: HITSC to identify what the communication preferences options should be. Providers should have the ability to select options that are technically feasible, these could include: Email, patient portal, regular mail. EHRA Overall estimate: Large to Jumbo Small: Tracking format requested by patient and provision, small Large: Including/ excluding data in multiple media formats. Small: updated reporting for revised measure.

14. DRAFT Stage 2 Final RuleStage 3 Recommendations EP Objective: Provide clinical summaries for patients for each office visit EP Measure: Clinical summaries provided to patients or patient- authorized representatives within 1 business day for more than 50 percent of office visits. The clinical summary should be pertinent to the office visit, not just an abstract from the medical record. EP Objective: An office-visit summary is provided to a patient or patient- authorized representative with relevant and actionable information and instructions pertaining to the visit in the format indicated by the patient. EP Measure: An office visit summary is provided to a patient or patient- authorized representative with relevant and actionable information and instructions pertaining to the visit in the format requested as indicated by the patient (e.g., available online, via email, print out of summary, etc.),if the provider has the technical capability within 1 business day for more than 50 percent of office visits. Certification criteria #1: Intent is to make sure the EHR can draw from the range of existing specified information and enable providers to include and exclude data based upon patient needs. Certification criteria #2: HITSC to identify what the communication preferences options should be. Providers should have the ability to select options that are technically feasible, these could include: Email, patient portal, regular mail. Former Objective Details Clinical Summary/AVS - 205 13

15. DRAFT Engaging patients and families in their care: Patient Education 14 Functionality Needed to Achieve Goals Eligible Providers and Hospitals use CEHRT to provide patient specific educational material in the patient’s preferred non- English language and preferred format (e.g., online, print- out from CEHRT) It is recommended that disability status needs are defined and flagged at the point of entry (e.g. registration or appointment gathering) using infobutton Stage 3 Functionality Goals Patients understand their disease and treatments Patients participate in shared decision making Patient preferences honored across care teams Former Objective Objective: Provide patient specific educational material in at least one non- English language, in the format preferred by the patient, if the provider has the technical capability Measure: Deliver at least one patient specific educational material to one patient in that patient’s preferred non-English language identified by CEHRT and in the patient’s preferred format (e.g., online, print-out from CEHRT). Certification criteria #1: Expand the InfoButton standard to include disability status. Disability status needs to be defined and flagged at the point of entry (e.g. registration or appointment gathering). Certification criteria #2: HITSC to identify what the communication preferences options should be. Providers should have the ability to select options that are technically feasible, these could include: Email, patient portal, regular mail. EHRA Overall estimate: Large to Jumbo Small, if patient education vendor has support for patient education in the required languages. If this requires translation or more complex search of patient education materials, then large. Infobutton to include disability status – small. What standard will be used for disability status, estimate could be dependent on standard. Note that not all registration clerks might be comfortable capturing the information. Small: Updated reporting for revised measure.

16. DRAFT Former Objective Details Patient Education - 206 15 Stage 2 Final RuleStage 3 Recommendations EP/EH Objective: Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient EP CORE Measure: Patient specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period EH CORE Measure: More than 10 percent of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) are provided patient- specific education resources identified by Certified EHR Technology Objective: Provide patient specific educational material in at least one non-English language, in the format preferred by the patient, if the provider has the technical capability Measure: Deliver at least one patient specific educational material to one patient in that patient’s preferred non-English language identified by CEHRT and in the patient’s preferred format (e.g., online, print-out from CEHRT). Certification criteria #1: Expand the InfoButton standard to include disability status. Disability status needs to be defined and flagged at the point of entry (e.g. registration or appointment gathering). Certification criteria #2: HITSC to identify what the communication preferences options should be. Providers should have the ability to select options that are technically feasible, these could include: Email, patient portal, regular mail.

17. DRAFT Engaging patients and families in their care: Secure Messaging 16 Functionality Needed to Achieve Goals Eligible Professionals use CEHRT to provide patients with the ability to use secure electronic messaging for communication It is recommended that CEHRT include functionalities that assist the provider by providing a means to: – Measure and report response times to patients – Indicate whether a response is needed – Identify the mode the response was provided in (e.g., telephone, secure message) Stage 3 Functionality Goals Provide patient and caregivers online access to health information Provide ability to contribute information in the record, including PRO Patient preferences recorded and used Former Objective Measure: More than 5% of patients use secure electronic messaging to communicate with EPs Certification requirement: Provide the capability to: 1.measure and report the response timeframe 2.for the patient to indicate that no response is needed 3.mode of response (e.g., telephone, secure message) EHRA Overall estimate: Jumbo Additional tracking of response timeframe including multiple modes of response – large. Patient indication of no response needed – small. Tracking of mode of response – small. (See first estimate for support for multiple modes of response.) Small: Updated reporting for revised measure.

18. DRAFT Former Objective Details Secure Messaging - 207 17 Stage 2 Final Rule Stage 3 Recommendations Proposed for Future Stage EP Objective: Use secure electronic messaging to communicate with patients on relevant health information EP Measure: A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period Measure: More than 5% of patients use secure electronic messaging to communicate with EPs Certification requirement: Provide the capability to: 1.measure and report the response timeframe 2.for the patient to indicate that no response is needed 3.mode of response (e.g., telephone, secure message) Create capacity for electronic episodes of care (telemetry devices, etc) and to do e- referrals and e-consults

19. DRAFT Improving population and public health: Stage 3 Priorities 18 Efficient and timely means of defining and reporting on patient populations to identify areas for improvement Shared information with public health agencies Target Outcome Goals MU Outcome Goals Providers know the status of their patients’ health Bidirectional public health data exchange Patient lists Sharing immunization data Cancer and specialty registry Electronic lab reporting Submission of electronic syndromic surveillance data Stage 3 Functionality Goals MU Outcome Goals Stage 1 + 2 Functional Objectives

20. DRAFT Improving population and public health: Case Reports 19 Efficient and timely means of defining and reporting on patient populations to identify areas for improvement Shared information with public health agencies Functionality Needed to Achieve Goals CEHRT uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit. Recommended as certification criteria only Stage 3 Functionality Goals Stage 3 or future? Follow-up with HITSC for feedback Former Objective Certification criteria ONLY: The EHR uses external data to prompt the end- user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.

21. DRAFT Former Objective Details Case reports – 402B Stage 3Proposed for Future Stage Certification criteria: The EHR uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit. EP Objective: Capability to use externally accessed or received knowledge (e.g. reporting criteria) to determine when a case report should be reported and then submit the initial report to a public health agency, except where prohibited, and in accordance with applicable law and practice. Measure: Attestation of submission of standardized initial case reports to public health agencies on 10% of all reportable disease or conditions during the entire EHR reporting period as authorized, and in accordance with applicable state/local law and practice. Certification ONLY 20

22. DRAFT Improving population and public health: Registries 21 Efficient and timely means of defining and reporting on patient populations to identify areas for improvement Shared information with public health agencies Functionality Needed to Achieve Goals EPs/EHs use CEHRT to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) EP/EH Registries examples: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. EHs Only: health-care associated infections Stage 3 Functionality Goals Former Objective EP Objective: Capability to electronically submit standardized commonly formatted reports to two registries from the CEHRT. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of Standardized reports from the CEHRT to two registries (either mandated or voluntary)). Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to a registry, maintain an audit of those reports, and track total number of reports sent. How do you certify?

23. DRAFT Former Objective Details Proposed Merged Registry Objective (404, 405, 407- EP) EP Objective: Capability to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) from the Certified EHR Technology, except where prohibited, and in accordance with applicable law and practice. This objective is in addition to and does not replace prior requirements for submission to an immunization registry. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of Standardized reports from the CEHRT to two registries (either mandated or voluntary)). Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. Registries examples include: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to a registry, maintain an audit of those reports, and track total number of reports sent. 22

24. DRAFT Former Objective Details Proposed Merged Registry Objective (404, 405, 407 - EH objective) EH Objective: Capability to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources) from the Certified EHR Technology, except where prohibited, and in accordance with applicable law and practice. This objective is in addition to and does not replace prior requirements for submission to an immunization registry. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission of standardized reports from the CEHRT to two registries (either mandated or voluntary)). Attestation of submission for at least 10% of all patients who meet registry inclusion criteria during the entire EHR reporting period as authorized, and in accordance with applicable State law and practice. Registries include: cancer, health-care associated infections, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community) should maintain the registry Certification criteria: EHR is able to build and then send a standardized report (e.g., standard message format) to an external mandated or voluntary registry, maintain an audit of those reports, and track total number of reports sent. 23