1. Interoperability and Health Information Exchange Workgroup March 5, 2015 Micky Tripathi, chair Chris Lehmann, co-chair

2. Agenda Review Workgroup comments 2

3. Interoperability and HIE Workplan MeetingsTask √February 10, 2015 – HITPC Meeting Charged by the HITPC with commenting on the Interoperability Roadmap V.1 √February 25, 2015 2:30-4pm ET Comment on Interoperability Roadmap V.1 March 5, 2015 3:30-5pm ET Comment on Interoperability Roadmap V.1 March 10 th – HITPC Meeting Early Interoperability Roadmap Recommendations to HITPC Anticipated date to be charged by the HITPC with commenting on the MU3 NPRM March 19, 2015 3:30-5pm ET Comment on Interoperability Roadmap V.1 April 2, 2015 2:30 – 4pm ET Finalize Interoperability Roadmap Comments April 7, 2015- HITPC Meeting Interoperability Roadmap Recommendations to HITPC April 17, 2015 2:30-4pm ET Comment on MU3 NPRM (anticipated date for planning purposes) April 30, 2015 3:30-5pm ET Finalize MU3 NPRM Comments (anticipated date for planning purposes) May 12 th – HITPC Meeting MU3 NPRM Comments to the HITPC (anticipated date for planning purposes) 3

4. Process for Responding Review Interoperability Roadmap Comment Develop Consensus Submit Comments to HITPC Roadmap Overview Discuss assigned section and questions Members draft comments offline & submit comments to ONC staff ONC staff aggregates comments Workgroup meets to refine and finalize comments Co-chairs present early thinking to HITPC Co-chairs present final comments to HITPC Today’s Discussion Feb 25, 2015March 3, 2015 (due to Co-chairs and ONC) Mar 5 Mar 19 April 2 Mar 10, 2015 Apr 7, 2015 4

5. Review Workgroup Comments 5

6. Summary We received comments from 8 Workgroup members – thank you! – All the comments were included in the collated comments document. We will review the comments and gather additional input from the Workgroup. 6

7. HITPC - Interoperability & HIE WorkgroupInteroperability & HIE ONC FACA WG Lead(s)Kory Mertz Chair / Co-Chairs Micky Tripathi, Chair, Massachusetts eHealth Collaborative Christoph Lehmann, Co-Chair, Vanderbilt School of Medicine General Questions (as they apply to the assigned Roadmap section) Are the actions proposed in the draft interoperability Roadmap the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Roadmap Section M. Accurate Identity Matching N. Reliable Resource Location Section Specific Question(s) In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? (M. Accurate Identity Matching) 7

8. Summary (continued) General themes 1.In general, comments were supportive of the importance of accurate and reliable individual data matching and resource location 2.Concerns raised about the aggregate number and complexity of the “critical actions” and the ability of the industry to accomplish these goals in the 2015-2017 timeline 3.Concerns raised about the lack of definition of “coordinated governance” and the need to more specifically delineate what types of levers would be appropriate to motivate accomplishment of each goal and action 4.There were a number of comments reinforcing the importance of the Roadmap continuing to articulate an interoperability floor not a ceiling (i.e. should be able to go beyond the minimum data matching elements). 8

9. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M1. 2015-2017 Send, receive, find and use a common clinical data set Comments 1.ONC and SDOs should standardize the minimum recommended data elements to be consistently included in all queries for patient clinical health information, and to be used to link patient clinical health information from disparate systems. Take into consideration NCPDP work on patient matching As ONC and SDOs undertake this work, it will be helpful if they ensure that it is possible to use more than the minimum when additional information is known. We need to be aware that organizations will move forward at their pace to implement the recommended data elements, best practices and matching. How do we measure success during this period of transition? Other data elements to be considered: Mother’s maiden name Aliases Social Security number Known medical record numbers Email Patient’s ID number at the requesting site Parents 2.Through coordinated governance, public and private stakeholders should work with standards development organizations to require a set of data elements in all individual identity query and record linking transactions. Public and private stakeholders will want to adopt industry standards that are developed as part of step 1 above. We should also remember that people change addresses routinely and allow for queries to contain and to process historical addresses. When one moves cities, they also often move doctors. 9

10. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M1. 2015-2017 Send, receive, find and use a common clinical data set Comments 3. Through coordinated governance, public and private stakeholders should establish and document best practices for the following processes: patient registration, patient verification of information and patient updates and corrections to information. Some agreed while others felt this formal coordinated governance step was not necessary to improve patient matching Patients have an important role to play in the verification of information, provide updates, and corrections – as well as in identifying which record matches are correct and which are not, especially where there is a question. This process is being used in online applications for health coverage under the Health Insurance Exchange. 4.Through coordinated governance, public and private stakeholders should designate the API capabilities necessary to support individual identity search and individual identity linking transactions. Existing protocols such as XCPD, PIX, and PDQ already define the APIs to do patient matching, so we are uncertain what this step suggests. Should include API development for Relationship Listing Services. This goes beyond simply presenting patient demographics, but also identifies and classifies patient relationships to healthcare organizations/providers (including primary care physician, care manager, etc…), sources of data (e.g. registries, advance directives, PACs images, etc…), and patients’ authorizations related to these. This should be a priority before building any other data interfaces. Sometimes just knowing that your patient was seen in “x” facility helps to coordinate care. 10

11. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M1. 2018-2020 Expand interoperable health IT and users Comments 5.Health IT developers should reliably include standardized identity matching data elements in exchange transactions. Which health IT developers are the focus of this action? Who will ensure compliance? The standard set of data elements will need to be defined with sufficient lead time to ensure they can be incorporated into relevant HIT. 6.Through coordinated governance, public and private stakeholders should ensure that identity matching services use standardized attributes in standardized data formats to match individuals to their data for care coordination, individual use and access. What is envisioned to be the role of coordinated governance here? 7.Through coordinated governance, public and private stakeholders should identify, test and adopt additional identity matching data elements, including voluntary data elements. There was disagreement on the value of this action step. Some felt market forces would drive this while others saw a role for coordinated governance. Should add “practices” to this list (i.e., “… matching data elements and practices …”). “Practices” includes such steps as patient involvement in confirming/rejecting questionable matches, and is used in (3) above. 11

12. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M1. 2018-2020 Expand interoperable health IT and users Comments 8. As evidence suggests, ONC and SDOs should standardize additional, required elements for identity matching. General agreement M1. 2021-2024 Achieve nationwide LHS Comments 9.Providers and health IT developers should use best practices for data quality and algorithms to enhance identity matching accuracy in a majority of identity matching services. General agreement 12

13. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M2. 2015-2017 Send, receive, find and use a common clinical data set Comments 1.Through coordinated governance, public and private stakeholders should develop and pilot tools and technologies for establishing performance metrics for individual identity, query and internal individual matching/record linking. Can you clarify the role coordinated governance would play in this work? This work might benefit from simple ONC defined measurement criteria or occasional audits or studies done upon request. We need to be aware that organizations will move forward at their pace to implement the recommended data elements, best practices and matching. How do we measure success during this period of transition? 2.ONC will coordinate with industry stakeholders and other HHS initiatives to test scenarios that represent a variety of matching settings with the purpose of providing further direction for scalable solutions, standards and best practices. General agreement 3.ONC will coordinate with industry stakeholders to study voluntary collection of additional identity attributes, which may include biometric technologies, cell phone number, email address, etc. General agreement 13

14. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M2. 2018-2020 Expand interoperable health IT and users Comments 4. Stakeholder input requested M2. 2021-2024 Achieve nationwide LHS Comments 5.Stakeholder input requested 14

15. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M3. 2015-2017 Send, receive, find and use a common clinical data set Comments 1.ONC among other stakeholders should begin coordination and dissemination of best practices on identity matching. General agreement M3. 2018-2020 Expand interoperable health IT and users Comments 2.A broad range of health care settings, including long term care, infusion centers and mental health facilities should consistently use identity matching technologies and processes. General agreement but interest in additional detail on how this goal will be reached. For instance does it require a specific action plan or will success with patient matching in other parts of the industry naturally migrate to these settings. 15

16. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5. In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? M3. 2021-2024 Achieve nationwide LHS Comments 3.All health IT systems should continue to exchange data that includes standardized identity matching data elements. General agreement, with one caution around the need for all types of health IT to have this functionality (for example, submission of non-identified, aggregated data to registries). 4.Through coordinated governance, public and private stakeholders should ensure that data quality rates within source systems and identity matching services are within acceptable levels as defined by agreed upon performance metrics. Some were supportive of the requirement while others felt existing law and practice are better suited to addressing the issue. 16

17. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N1. 2015-2017 Send, receive, find and use a common clinical data set Comments 1.Through coordinated governance, public and private stakeholders should identify the architecture and workflow for resource location as part of a learning health system, including the individual and IT system actors, roles and access requirements. Varying viewpoints were expressed. Some felt this action step was too complicated for 2015- 2017 and that focus should be placed on standardizing national immunization registries, specialty registries and basic exchange so that it operates at a ubiquitous level. Others advocated for even more aggressive actions for instance identifying resource capabilities (e.g. which messaging and document standards are supported). Standards should be developed for automatically populating and maintaining directories that are part of this architecture. Resources should be able to be located by a number of related attributes. (name, physical address, aliases or prior names, other relationships with other entities) 2.Through coordinated governance, public and private stakeholders should prioritize the participants and services that are to be discoverable using resource location and identify a near-term goal for the first small set of resources to be included in an initial implementation. General agreement 17

18. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N1. 2015-2017 Send, receive, find and use a common clinical data set Comments 3.From the architecture, SDOs and health IT developers should determine or develop standard(s) and API(s) for discovering participants and resources (including other directories if the architecture is federated), determine whether any of the current standards or legacy services already incorporated in products can be used or extended and develop a Roadmap to implementation of new standard(s) and API(s), if necessary. Diverging opinions. Some felt it was the right action for the right time, some felt is was an reasonable action but needed to be moved to the 2018-2020 timeframe with some felt it was not a priority. 18

19. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N1. 2015-2017 Send, receive, find and use a common clinical data set Comments 4.Through coordinated governance, public and private stakeholders should identify rules of the road for participating in distributed management of resource location, if appropriate for the architecture and actors. This includes establishing policies and procedures for operation of resource location services, including curation of directory information to maintain data quality. Diverging opinions some felt it was the right action while others felt it wasn’t a priority. 5.Through coordinated governance, public and private stakeholders should work with SDOs and health IT developers to demonstrate standard(s) and API(s) in a trial implementation, beginning with the prioritized set of resources. Diverging opinions. Some felt it was the right action for the right time, some felt is was an reasonable action but needed to be moved to the 2018-2020 timeframe with some felt it was not a priority. 19

20. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N1. 2015-2017 Send, receive, find and use a common clinical data set Comments 6.Through coordinated governance, public and private stakeholders should develop a glide path for moving from current provider directories to future resource location techniques. Diverging opinions. Some felt it was the right action for the right time, some felt is was an reasonable action but needed to be moved to the 2018-2020 timeframe with some felt it was not a priority. N1. 2018-2020 Expand interoperable health IT and users Comments 7.Stakeholder input requestedAs this work matures, goals/actions need to extend beyond clinical health resources and broadened to address social determinants of health. N1. 2021-2024 Achieve nationwide LHS Comments 8.Stakeholder input requested 20

21. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N2. 2015-2017 Send, receive, find and use a common clinical data set Comments 1.As an interim step, ONC will work with others to encourage initial uptake of current provider directory activities General agreement 2.ONC will recommend to CMS that NPPES implement support for the provider directory information query API and data model as specified in the IHE HPD Profile. CMS should maintain Direct addresses and ESI in NPPES General agreement. Suggestions to improve the action included: Should be a similar expectation for private sector care providers Ensure ESI concept is flexible and extensible NPPES should be able to handle multiple names, aliases, prior names, physical addresses (payment address, treating address, ROI address), relationships to other entities along with workflow or profile information. 3.CMS/HRSA/OIG should advance the proposed effort to consolidate/synchronize national credentialing support systems General agreement 21

22. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N2. 2015-2017 Send, receive, find and use a common clinical data set Comments 4.ONC and other certification bodies will determine how to support provider directories through certification processes General agreement, though some concern about timing and the readiness of standards and testing tools. 5.ONC will lead the effort to coordinate across federal agencies on the use of existing standards (e.g. provider directory standards) General agreement 6.ONC will support testing through its Standards Implementation and Testing Environment (www.sitenv.org) General agreement 22

23. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N2. 2018-2020 Expand interoperable health IT and users Comments 7.Through coordinated governance, public and private stakeholders should adopt national standards for locating participants and resources. General agreement 8.Through coordinated governance, public and private stakeholders should adopt guidance on data quality, maintenance and update processes. General agreement 9.Through coordinated governance, public and private stakeholders should work with health IT developers to identify and publish best practices for resource location operational issues that could include data quality, maintenance and update processes General agreement 23

24. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? N2. 2021-2024 Achieve nationwide LHS Comments 10.Stakeholder input requested 24

25. Next Steps HITPC presentation March 10 th Continuing reviewing and refining discussion during next IOWG call on March 19 th. 25

26. Appendix A: Assigned Critical Actions 26

27. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS M1. Standards and Best Practices 1. ONC and SDOs should standardize the minimum recommended data elements to be consistently included in all queries for patient clinical health information, and to be used to link patient clinical health information from disparate systems. 2. Through coordinated governance, public and private stakeholders should work with standards development organizations to require a set of data elements in all individual identity query and record linking transactions. 3. Through coordinated governance, public and private stakeholders should establish and document best practices for the following processes: patient registration, patient verification of information and patient updates and corrections to information. 4. Through coordinated governance, public and private stakeholders should designate the API capabilities necessary to support individual identity search and individual identity linking transactions. 5. Health IT developers should reliably include standardized identity matching data elements in exchange transactions. 6. Through coordinated governance, public and private stakeholders should ensure that identity matching services use standardized attributes in standardized data formats to match individuals to their data for care coordination, individual use and access. 7. Through coordinated governance, public and private stakeholders should identify, test and adopt additional identity matching data elements, including voluntary data elements. 8. As evidence suggests, ONC and SDOs should standardize additional, required elements for identity matching. 9. Providers and health IT developers should use best practices for data quality and algorithms to enhance identity matching accuracy in a majority of identity matching services. 27

28. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS M2. Pilots and Further Study 1. Through coordinated governance, public and private stakeholders should develop and pilot tools and technologies for establishing performance metrics for individual identity, query and internal individual matching/record linking. 2. ONC will coordinate with industry stakeholders and other HHS initiatives to test scenarios that represent a variety of matching settings with the purpose of providing further direction for scalable solutions, standards and best practices. 3. ONC will coordinate with industry stakeholders to study voluntary collection of additional identity attributes, which may include biometric technologies, cell phone number, email address, etc. 4. Stakeholder input requested 5. Stakeholder input requested 28

29. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? In what ways does the draft approach need to be adjusted to sufficiently address the industry needs and address current barriers? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS M3. Adoption 1. ONC among other stakeholders should begin coordination and dissemination of best practices on identity matching. 2. A broad range of health care settings, including long term care, infusion centers and mental health facilities should consistently use identity matching technologies and processes. 3. All health IT systems should continue to exchange data that includes standardized identity matching data elements 4. Through coordinated governance, public and private stakeholders should ensure that data quality rates within source systems and identity matching services are within acceptable levels as defined by agreed upon performance metrics. 29

30. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS N1. Developme nt of New Architectur e and Standards 1. Through coordinated governance, public and private stakeholders should identify the architecture and workflow for resource location as part of a learning health system, including the individual and IT system actors, roles and access requirements. 2. Through coordinated governance, public and private stakeholders should prioritize the participants and services that are to be discoverable using resource location and identify a near-term goal for the first small set of resources to be included in an initial implementation. 3. From the architecture, SDOs and health IT developers should determine or develop standard(s) and API(s) for discovering participants and resources (including other directories if the architecture is federated), determine whether any of the current standards or legacy services already incorporated in products can be used or extended and develop a Roadmap to implementation of new standard(s) and API(s), if necessary. 7. Stakeholder input requested 8. Stakeholder input requested 30

31. N1 continued Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS N1. Developme nt of New Architectur e and Standards 4. Through coordinated governance, public and private stakeholders should identify rules of the road for participating in distributed management of resource location, if appropriate for the architecture and actors. This includes establishing policies and procedures for operation of resource location services, including curation of directory information to maintain data quality. 5. Through coordinated governance, public and private stakeholders should work with SDOs and health IT developers to demonstrate standard(s) and API(s) in a trial implementation, beginning with the prioritized set of resources. 6. Through coordinated governance, public and private stakeholders should develop a glide path for moving from current provider directories to future resource location techniques. 31

32. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS N2. Refinement and Adoption of Standards and Best Practices 1. As an interim step, ONC will work with others to encourage initial uptake of current provider directory activities 2. ONC will recommend to CMS that NPPES implement support for the provider directory information query API and data model as specified in the IHE HPD Profile. CMS should maintain Direct addresses and ESI in NPPES 3. CMS/HRSA/OIG should advance the proposed effort to consolidate/synchronize national credentialing support systems 4. ONC and other certification bodies will determine how to support provider directories through certification processes 5. ONC will lead the effort to coordinate across federal agencies on the use of existing standards (e.g. provider directory standards) 6. ONC will support testing through its Standards Implementation and Testing Environment (www.sitenv.org) 7. Through coordinated governance, public and private stakeholders should adopt national standards for locating participants and resources. 8. Through coordinated governance, public and private stakeholders should adopt guidance on data quality, maintenance and update processes. 9. Through coordinated governance, public and private stakeholders should work with health IT developers to identify and publish best practices for resource location operational issues that could include data quality, maintenance and update processes 10. Stakeholder input requested 32