Consultations and Transfers of Care HITSP Interoperability Specification (IS) 09

1. Consultations and Transfers of Care HITSP Interoperability Specification (IS) 09 Webinar 3 March 12, 2009 | 2:00 – 3:30 pm (Eastern) Presenters: Michael Lincoln, M.D., F.A.C.M.I, U.S. Department of Veterans Affairs Suzi Hines, Principal, Sage Consulting, LLC

2. Learning Objectives Explore the scope of the Consultations and Transfers of Care Interoperability Specification, including: the information exchange needed when a provider requests and a patient receives a consultation from another provider; and the information exchange needed when a provider requests a transfer of care for a patient and the receiving facility admits the patient Examine the data exchange requirements for requesting a consultation and patient receiving a consultation from another provider, and for requesting a transfer and a patient being transferred to another facility Discover how the requirements of the Consultations and Transfers of Care Use Case map to HITSP constructs Learn about HITSP’s next steps in 2009, which include Incorporating Long Term Care–Assessments and Nursing Documentation

3. Agenda Steve’s Story – current and future What is HITSP? Overview of Interoperability Specification (IS) 09: Consultations and Transfers of Care Consultation scenario Transfer of Care scenario Next Steps/Future Directions Conclusion Questions and Answers

4. Steve’s Story . . . current situation healthcare interoperability . . . problems and solutions • Patient is a 27-year-old man who had a brain tumor removed as a child • When Steve develops a new onset of seizures, he visits his general practitioner. • The general practitioner refers Steve to a neurology consultant. • The neurology consultant chooses to admit Steve to the local hospital’s neurology service for further evaluation. • The problem: in today’s system, neither the neurologist nor the hospital has easy access to Steve’s recent health records, or his full medical history, including his pediatric neurology records.

5. Steve’s Story . . . future healthcare interoperability . . . problems and solutions • The solution: In the HITSP future, all of Steve’s health records will be interoperable. His health information will be seamlessly and securely exchanged among providers and care settings. With Steve’s consent, providers will gain instant access to past data, such as • active and past medication lists • allergies • current and previous problems and diagnoses • visit summaries • labs, images, and other test results • registration and insurance information

6. What is HITSP?

7. HITSP is a volunteer-driven, consensus-based organization that is funded through a contract from the Department of Health and Human Services The Panel brings together experts from across the healthcare community from consumers to doctors, nurses, and hospitals; from those who develop healthcare IT products to those who use them; and from thegovernment agencies who monitor the U.S. healthcare system to those organizations that are actually writing healthcare IT standards. Overview

8. Roles and Responsibilities Harmonizes and recommends the technical standards that are necessary to assure the interoperability of electronic health records Creates HITSP-recommended Interoperability Specifications (IS) that specify how and what standards should be used for a particular Use Case/Value Case Supports deployment and implementation of these IS Works with Standards Development Organizations (SDOs) to identify gaps and maintain, revise or develop new standards as required to support the IS

9. Each HITSP Interoperability Specification defines a set of reusable building blocks or “constructs” that: specify how to use selected standards to meet the business needs of a Use Case / Value Case; and define a Roadmap to use emerging standards and to harmonize overlapping standards when resolved. In essence, a HITSP IS represents a suite of documents that integrate and constrain existing standards to satisfy a Use Case / Value Case Deliverables and Mode of Operation

10. What Are Consultations and Transfers of Care? • ConsultationsA provider requests and a patient receives a consultation from another provider • Transfers of careA provider requests a transfer of care for a patient and the receiving facility admits the patient

11. IS 09: Consultations and Transfers of Care • The Consultation and Transfers of Care Interoperability Specification (CTC IS) focuses on the electronic exchange of information to support consultations between clinicians, including specialty services and second opinions. The CTC IS specification also focuses on the exchange of clinical information needed during transfers of care. When you go from one doctor or specialist to the next - your information goes with you.

12. IS 09: Clinician Perspectives Today’s consult results: Communicated via meeting, telephone, postal mail HITSP IS 09 future: send interoperable consult results Consulting neurologist* Steve’s family MD* * Or MD internist, nurse practitioner, psychologist physician assistant, pharmacist, cardiologist….

13. IS 09: Care-setting Perspectives Today: send paper patient records overland HITSP IS 09 future: send patient records electronically Local hospital Consulting neurologist* * Or nursing home, long term care facility, home healthcare setting, hospice, rehabilitation facility….

14. Other CTC Perspectives Patient perspective e.g., guardians, family caregivers, surrogates Patients or their representatives and surrogates may transfer information among PHRs, health record banks, and provider EHRs as part of a consultation or transfer or care Health Information Exchange (HIE) perspectivee.g., Regional Health Information Organizations (RHIOs), care delivery networks, public health networks These entities may support specific functional capabilities which assist in transferring health information, e.g., for reportable diseases sent to public health entities

15. Data Requirements in Consultations Focuses on sharing information to support consultations Includes the consultation request, the consultation itself, and resulting of consult back to origin point Includes administrative and clinical information Sends a core set of clinical information, and then allows consultant to request additional information as needed Information includes reason for consult, images, labs, procedure reports, patient summary information, etc.

16. Data Requirements in Transfers of Care Use Case Focuses on sharing information to support transfers Includes the transfer request, the transfer approval message Includes administrative and clinical information Sends a core set of clinical information, and then allows transfer target facility to request additional information as needed Information includes core information, such as discharge summary, plan of care, procedure documentation, and clinical results.

17. Scenario 1: Consultations

18. Scenario 1: Sample of Consultation Data Flows 1 1 4 4

19. Scenario 2: Samples of Transfer of Care Data Flows 3 3

20. Information Exchange Requirements (IER)

21. Information Exchange Requirements (continued)

22. Data Requirements for Consultations and Transfers of Care

23. Data Requirements for Consultations and Transfers of Care (continued)

24. HITSP Constructs for IS 09 • C32 – Summary Documents using CCD * • C37 – Lab Report Document * • C48 – Encounter Document * • C62 – Unstructured Document * • C74 – Remote Monitoring Observation • C78 - Immunization Content • C84 – Consult and History & Physical Note * • T29 - Notification of Document Availability • T31 - Document Reliable Interchange • T33 - Transfer of Documents on Media • T40 - Patient Health Plan Eligibility Verification • T68 - Patient Health Plan Authorization Request and Response • T79 - Pharmacy to Health Plan Authorization Request and Response • TP89 – Sharing Imaging Results * * Key constructs for IS 09

25. CTC IS 09 Base Standards IS 09 relies upon base standards, for example: Documents are formed according to HITSP C32, a summary document that uses the HL7 Continuity of Care Document (CCD) standard Document transfer uses: Document Reliable Interchange (HITSP T31) using the IHE Cross-Enterprise Document Sharing (XDS) standard Transfer of Documents on Media – the patient carries a pen drive –(HITSP T33) using IHE Cross-Enterprise Document Media Interchange standard and others

26. HITSP Security and Privacy Constructs Safeguard Information Exchanged during Transfer and Consultations • T17 – Secured Communication Channel • TP13 – Manage Sharing of Documents • TP20 – Access Control • TP30 – Manage Consent Directive • C19 – Entity Identity Assertion • C26 – Non-repudiation of Origin • T15 – Security Audit Trail • T16 – Consistent Time For more information about how HITSP addresses security and privacy, refer to the August 2008 Security and Privacy Webinar at http://www.hitsp.org/archived_webinars.aspx

27. IS 09: Constructs, IERs, and CRs in Consultations To fulfill Data Requirement 57 (Demographic data, consultation and transfer) Interoperability Requirements (IER) IER1-Provide authorization and consent IER-11-Identify provider by patient preference IER 14-Send/receive health plan eligibility (…) Transactions/packages used TP22 PIX Query TP 23-Patient demographics query T29-Send/receive notification (…) HITSP IS 09 future: send interoperable consult results Consulting neurologist* Steve’s family MD* * Or MD internist, nurse practitioner, psychologist physician assistant, pharmacist, cardiologist….

28. IS 09: Constructs in Transfers of Care To fulfill Data Requirement 2 (Patient clinical information) Transactions/packages used T 29-Notification of document avail. T 31-Document reliable interchange T 64-Identify communication recipients (…) Interoperability Requirements (IER) IER 13-Send/receive notice of document avail. IER 17-Send/receive transfer of care data IER 22-Send/receive additional patient information (…) HITSP IS 09 future: send patient records electronically Local hospital Consulting neurologist* * Or nursing home, long term care facility, home healthcare setting, hospice, rehabilitation facility….

29. Scope limits and assumptions Decision support systems (DSS) are not specifically addressed in this IS because they are ubiquitous Patients may bring portable media from one health system to another Consultations continue until they are formally terminated (“Thank you for referring this very interesting patient, we are signing off….”) Transport team notifications are always personal and are not within scope of this IS (see also IS 04, Emergency Responder/EHR) Medication reconciliation is done via HITSP IS 07, Medication Management

30. HITSP IS-09 CTC specification: Location and Status Located at http://www.hitsp.org Currently at version 1.0 Accepted by the Secretary of HHS in January 2009 Released for one-year period of implementation The reason we’re here today

31. Gaps remaining Clinical data such as ECG, EEG do not have a identified standard and are a gap Medication information cannot be completely communicated (stopped, modified, or “on hold” medications) Send/receive decision support data not defined Functional assessments need a CDA implementation guide No good standard for nurses’ notes

32. Next Steps for 2009 Incorporating following 2009 Extensions/Gaps Clinical Note Details Order Sets Long Term Care – Assessments

33. Conclusion

34. Benefits of IS 09 – Consultations and Transfers of Care • Better communication among providers means better patient care • When data is carried forward, tests do not need to be re-done • Patients do not need to continue to fill out paper work with the same information • Patients will know right away if their consultation and/or procedure is approved/covered by their insurance • Critical information is not lost in the transfer • Ensures that the right information and right treatment is linked to the right patient

35. Steve’s Story . . . future healthcare interoperability . . . problems and solutions • The solution: In the HITSP future, all of Steve’s health records will be interoperable. His health information will be seamlessly and securely exchanged among providers and care settings. With Steve’s consent, providers will gain instant access to past data, such as • active and past medication lists • allergies • current and previous problems and diagnoses • visit summaries • labs, images, and other test results • registration and insurance information

36. The 2009 Webinar Series www.HITSP.org/webinars   

37. View the Complete Set of HITSP Deliverableswww.HITSP.org

38. Use or specify recognized HITSP Interoperability Specifications in your HIT efforts and in your Requests for Proposals (RFPs) Ask for CCHIT certification Leverage Health Information Exchanges to promote HITSP specifications to make connections easier in the future Ask . . . Is there a HITSP standard we could be using? Get involved in HITSP . . . Help shape the standards How YOU can become involved

39. Join HITSP in developing a safe and secure health information network for the United States Visit www.hitsp.orgor contact: Michelle Deane, ANSI mmaasdeane@ansi.org Re: HITSP, its Board and Coordinating Committees Jessica Kant, HIMSS Theresa Wisdom, HIMSS jkant@himss.orgtwisdom@himss.org Re: HITSP Technical Committees

40. Sponsor Strategic Partners www.HITSP.org

41. Consultations and Transfers of Care Questions and Answers