Meaningful Use Workgroup Stage 3 – Preliminary Recommendations

1. Meaningful Use Workgroup Stage 3 – Preliminary Recommendations Paul Tang, Palo Alto Medical Foundation, Chair George Hripcsak, Columbia University, Co-Chair

2. Workgroup Membership Co-Chairs: Paul Tang Palo Alto Medical Foundation George Hripcsak Columbia University Members: • David Bates Brigham & Women’s Hospital • Michael Barr American College of Physicians • Christine Bechtel National Partnership/Women & Families • Neil Calman Institute for Family Health • Tim Cromwell Department of Veterans Affairs • Art Davidson Denver Public Health • Marty Fattig Nemaha County Hospital • James Figge NY State Dept. of Health • Joe Francis Veterans Administration • Leslie Kelly Hall Healthwise • Yael Harris HRSA • David Lansky Pacific Business Group/Health • Deven McGraw Center/Democracy & Technology • Latanya SweeneyCarnegie Mellon University • Greg Pace Social Security Administration • Robert Tagalicod CMS/HHS • Karen Trudel CMS • Charlene Underwood Siemens • Amy Zimmerman Rhode Island Department of Health and Human Services HITPC: MU Workgroup Stage 3 Recommendations

3. HITPC Stage 3 MU Timeline • Oct, 2012 – present pre-RFC preliminary stage 3 recs • Nov, 2012 – RFC distributed • Dec 21, 2012 – RFC deadline • Jan, 2013 – ONC synthesizes RFC comments for WGs review • Feb, 2013 – WGs reconcile RFC comments • Mar, 2013 – present revised draft stage 3 recs • Apr, 2013 – approve final stage 3 recs • May, 2013 – transmit final stage 3 recommendations to HHS HITPC: MU Workgroup Stage 3 Recommendations

4. Guiding Principles • Supports new model of care (e.g., team-based, outcomes-oriented, population management) • Addresses national health priorities (e.g., NQS, Million Hearts) • Broad applicability (since MU is a floor) • Provider specialties (e.g., primary care, specialty care) • Patient health needs • Areas of the country • Promotes advancement -- Not "topped out" or not already driven by market forces • Achievable -- mature standards widely adopted or could be widely adopted by 2016 • Reasonableness/feasibility of products or organizational capacity • Prefer to have standards available if not widely adopted • Don’t want standards to be an excuse for not moving forward MU Workgroup Stage 3 Recommendations

5. Key to reviewing items • Red items are changes from Stage 1 to Stage 2 • Blue items are changes from Stage 2 to Stage 3 recommendations • Green items are updates made following the August 1, 2012 HITPC MU Workgroup Stage 3 Recommendations

6. Improve Quality Safety, Efficiency and Reducing Health Disparities - Subgroup 1 MU Workgroup Stage 3 Recommendations

7. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

8. Improve Quality Safety, Efficiency and Reducing Health Disparities Coordinate with subgroup 3 Moved to SGRP101 MU Workgroup Stage 3 Recommendations

9. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

10. Improve Quality Safety, Efficiency and Reducing Health Disparities Ensure SOGI and disability status are included in certification and remove? MU Workgroup Stage 3 Recommendations

11. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations 11

12. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

13. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

14. Improve Quality Safety, Efficiency and Reducing Health Disparities • Move to stage 4? • Advanced medication related decision support • Capability to check for maximum dose in addition to a weight based calculation MU Workgroup Stage 3 Recommendations

15. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations 15

16. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

17. Improve Quality Safety, Efficiency and Reducing Health Disparities RFC: What are the barriers to moving this forward? MU Workgroup Stage 3 Recommendations

18. Improve Quality Safety, Efficiency and Reducing Health Disparities MU Workgroup Stage 3 Recommendations

19. Improve Quality Safety, Efficiency and Reducing Health Disparities Removed for subgroup 3 objective MU Workgroup Stage 3 Recommendations 19

20. Engaging Patients and Families – Subgroup 2 MU Workgroup Stage 3 Recommendations

21. Engage Patients and Families MU Workgroup Stage 3 Recommendations

22. Engage Patients and Families MU Workgroup Stage 2 Final Rule

23. Engage Patients and Families MU Workgroup Stage 3 Recommendations

24. Engage Patients and Families MU Workgroup Stage 3 Recommendations

25. Engage Patients and Families MU Workgroup Stage 3 Recommendations

26. Engage Patients and Families MU Workgroup Stage 3 Recommendations

27. Engage Patients and Families MU Workgroup Stage 3 Recommendations

28. Improving Care Coordination – Subgroup 3 MU Workgroup Stage 3 Recommendations

29. Improve Care Coordination MU Workgroup Stage 2 Final Rule

30. Improve Care Coordination Improve Care Coordination 30 MU Workgroup Stage 2 Final Rule

31. Improve Care Coordination Improve Care Coordination MU Workgroup Stage 3 Recommendations

32. Improve Care Coordination MU Workgroup Stage 3 Recommendations

33. Improve Care Coordination Objectives not included MU Workgroup Stage 3 Recommendations

34. Population and Public Health – Subgroup 4 MU Workgroup Stage 3 Recommendations

35. Improve Population and Public Health MU Workgroup Stage 3 Recommendations

36. Improve Population and Public Health Changed threshold to 10% from 20% for consistency MU Workgroup Stage 3 Recommendations

37. Improve Population and Public Health MU Workgroup Stage 3 Recommendations

38. Improve Population and Public Health RFC ONLY Changed threshold to 10% from 20% for consistency MU Workgroup Stage 3 Recommendations

39. Improve Population and Public Health MU Workgroup Stage 3 Recommendations

40. Improve Population and Public Health Changed threshold to 10% from 20% for consistency MU Workgroup Stage 3 Recommendations

41. Improve Population and Public Health • Changed threshold to 10% from 20% for consistency. • Changed from undetermined to stage 3. Note: This objective is the same as the previous, but adds a second registry and does not need to be jurisdictional. MU Workgroup Stage 3 Recommendations

42. Improve Population and Public Health MU Workgroup Stage 3 Recommendations

43. Improve Population and Public Health RFC ONLY MU Workgroup Stage 3 Recommendations

44. Information Exchange Workgroup MickyTripathi, Chair MU Workgroup Stage 3 Recommendations

45. Lab Orders (EHR Certification Criteria) May want to reword as standards are available. • Certification Only for EPs: The EHR must have the ability to issue an electronic order of laboratory test within a providers workflow. The capability should be compatible with the Lab Order Interface and Lab Results Interface guidelines produced by the S&I Framework Initiative. • Request for Comment for Meaningful Use with these additional questions: • Are the existing standards for laboratory orders adequate to support including this certification criterion?

46. E-Rx of Controlled Substances (modify existing objective) • MU objective: Controlled substance prescriptions should count towards the e-prescribing numerator, but not the denominator. • Certification criterion: The EHR system must be able to support the e-prescribing of controlled substances. • This approach provides an extra credit incentive for providers to e-prescribing controlled substances by counting towards their achievement of the e-prescribing numerator but not towards the denominator. This approach also obviates the need to include exemptions around state law restrictions and the capabilities of trading partners.

47. Query for Patient Information (EHR Certification Criteria) Stage 2 of Meaningful Use requires EPs, EHs & CAHs to send care summaries when patients are transitioned to another setting, with more than 10% of those summaries required to be sent digitally using certified EHR technology. The 2014 EHR Certification criteria require EHRs to have the capability to perform this function. Those criteria will help EPs, EHs & CAHs digitally transmit care summaries in circumstances where the recipient is known (or can be located through a provider directory). But these criteria will not help providers locate patient records in circumstances where the source of those records are unknown. The most common use case where this occurs is when a patient arrives in an emergency room; but there could be other circumstances where providers have a need to query a patient’s record in order to provide optimal treatment. Certified EHRs should have the capability to enable EPs, EHs & CAHs to query for a patient’s record and request that records relevant to treatment be sent. Proposed Criteria for the next phase of EHR Certification: 1. The EHR must be able to query another entity* for outside records and respond to such queries . This query may consist of three transactions: • Patient query based on demographics and other available identifiers • Query for a document list based for an identified patient • Request a specific set of documents from the returned document list *the outside entity may be another EHR system, a health information exchange, or an entity on the NwHIN, for example. 2. When receiving in inbound patient query, the EHR must be able to tell the querying system whether patient authorization is required to retrieve the patient’s records. (E.g. if authorization is already on file at the record-holding institution it may not be required). 3. The EHR initiating the query must be able to query an outside entity* for the authorization language to be presented to and signed by the patient or her proxy in order to retrieve the patient’s records. Upon the patient signing the form, the EHR must be able to either: • Send a copy of the signed form to the entity requesting it • Send an electronic notification attesting to the collection of the patient’s signature  Note: The authorization text may come from the record-holding EHR system, or, at the direction of the patient or the record-holding EHR, could be located in a directory separate from the record-holding EHR system, and so a query for authorization language would need to be directable to the correct endpoint.  Are we also establishing certification criteria for the response? For example, a response that a record for that patient does exist and the document list? Also a capability for record-holding EHR to be able to respond to such a request (e.g., release upon authorization from the record-holding EHR). Potentially also enable providers to program providers on identified on the patient’s care team to be able to receive responses automatically?  Not sure the EHR should be able to program for only one of these options – record holding EHRs should be permitted to get a copy of the signed form if they don’t want to rely on the attestation 3. Not sure the EHR should be able to program for only one of these options – record holding EHRs should be permitted to get a copy of the signed form if they don’t want to rely on the attestation 1. Are we also establishing certification criteria for the response? For example, a response that a record for that patient does exist and the document list? Also a capability for record-holding EHR to be able to respond to such a request (e.g., release upon authorization from the record-holding EHR). Potentially also enable providers to program providers on identified on the patient’s care team to be able to receive responses automatically?

48. Query Provider Directory (EHR Certification Criteria) Certification criterion: The EHR must be able to query a Provider Directory external to the EHR to obtain entity-level addressing information (e.g. push or pull addresses). Request for Comment for Meaningful Use with these additional questions: • Are there sufficiently mature standards in place to support this criteria?  What implementation of these standards are in place and what has the experience been? Priorities supported by a provider directory query which facilitates Direct messaging and queries: • Improved care coordination • Reduces readmission, redundant testing • Improves patient safety • Facilitates “hassle-free” health information exchange

49. Data Portability Between EHR Vendors (RFC) • Request for Comment for EHR Certification: • ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to switch from using one EHR to another vendor’s EHR. It also recognizes that not all data can be migrated from one EHR to another. For instance, it is unreasonable to expect audit trails to be able to be imported from one EHR into another vendor’s EHR because EHR audit trails are so intimately tied to the EHR’s internal data structure and function. In the MU2 Certification Rule, ONC required at a minimum the capability to export C-CDA summaries on all patients which includes their most recent clinical information. It was recognized that this core clinical dataset was merely a first step towards the goal of seamless data portability. ONC also encouraged, although did not require, including historical laboratory test results, immunizations, and procedures. • ONC’s HIT Policy Committee wishes to advance data portability further, and thus seeks comment to help identify reasonable actions that may further facilitate data portability. • What are the most important current and historical data elements that should be included in the exported data? Should this included data that was saved in the EHR as an image or waveform? • What associated metadata should be exported to provide context to these historical data elements? • Should there be different standards for EP versus EH EHRs with regards to which data elements to export and how far back historically to include? • ONC’s HIT Policy Committee recognizes that some data elements do not need to be transferred into the new EHRbut instead need to be archived and made available through some other non-EHR mechanism. What non-EHR mechanisms for storing, retrieving and displaying these archived data are available? Are there standards and services available to accomplish this? • What are the risks and harms of requiring EHR vendors to provide data portability beyond C-CDA summaries? • What are the risks and harms of not advancing the current state of data portability beyond C-CDA summaries?

50. Exchange of electrocardiograms (RFC) • Request for Comment for EHR Certification: • ONC’s HIT Policy Committee recognizes the importance of enabling healthcare providers to exchange electrocardiograms (EKGs). It also recognizes that there is limited experience with exchange of EKGs between healthcare providers. • ONC’s HIT Policy Committee wishes to advance the exchange of EKGs between healthcare providers, and thus seeks comment to help identify reasonable actions that may promote this exchange. • How useful is the exchange of electrocardiograms (EKGs). What is the incremental value of exchanging the actual image or waveform instead of just the textual EKG reading? • What technologies and standards are available for exchange of EKGs, and how mature are they? What vendors support these standards and to what extent are they supported? Should EKGs be exchanged as waveforms or images and why? • Are current EKG systems designed for sending and receiving EKGs? If yes, by what means and using which standards? • Are current EHR systems designed for sending and receiving EKGs? If yes, by what means and using which standards? • What examples of successful and unsuccessful exchange of EKGs are available? • What are the barriers to the exchange of EKGs? Are these barriers universal or unique to certain EKG vendors? Include in images? Include wave forms – EKGs. Question for RFC.