Interoperability and Health Information Exchange

Workgroup

April 30, 2015

Micky Tripathi, chairChris Lehmann, co-chair

Agenda

• Whirlwind review of “Send”, “Capture”, and “Reconcile”

• Start review of governance questions

• Complete unfinished business off-line

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Current Interoperability and HIE Schedule

Meetings Task

April 17, 2015 2:30-4 pm ET • Comment on MU3 NPRM

April 24, 2015 11:00 am – 12:30 pm ET • Comment on MU3 NPRM

April 30, 2015 3:30-5 pm ET • Finalize MU3 NPRM Comments

May 7 – Advanced Health Models • Chairs present comments with other Workgroups assigned review of MU3 topics

May 12th – HITPC Meeting • MU3 NPRM Comments to the HITPC

May 14, 2015 3:30-5 pm ET • Address any changes or questions from the HITPC

May 22nd– HITPC Meeting • Finalize Any Comments the HITPC Requested Changes or Additions to

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Summary

Objective 7 (Health Information Exchange) comprises 3 measures:

• Measure 1: Send electronic summary of care record for 50% of outgoing transitions or referrals

• Measure 2: Receive and incorporate electronic summary of care record for 40% of incoming transitions or referrals of new patients

• Measure 3: Reconcile clinical information for 80% of transitions or referrals of new patients

Measure 1 increases threshold of Stage 2 measure, whereas Measure 3 increases threshold as well as the scope of the Stage 2 measure

Measure 2 is a new measure – introduces query/retrieve objective

Only have to meet 2 out of 3 of the measure thresholds

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Setting thresholds

In general, the IOWG agrees with increasing the measure thresholds for Measures 1 and 3 – Important for quality and safety– Gaining traction in the market

However, we remain concerned about setting thresholds that are unrealistically high– Don’t want to have to backtrack on the threshold, as has

happened with VDT– Want to motivate providers to “own” the problem, but not

penalize them for factors that are genuinely out of their control

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What is current experience with Stage 2?

• Reported rates for Measures 1 and 3 for those who have attested to Stage 2 suggest that higher thresholds may be achievable, though there may be strong selection bias in these results– A high percent of providers (76% of qualifying EPs and 35% of qualifying EHs) are either

taking hardship exemptions, leveraging the flex rule, or have not yet attested in 2014– A very high percent (86%) of EPs have taken the exclusion from the “send” measure– Those who have attested to Stage 2 are likely better positioned for successful

achievement of the measures than those who haven’t

• Among those who have attested, reported Stage 2 rates are generally are below proposed rates for Measure 1 and well above for Measure 3 (med rec only)– EP = 40% and EH = 36% versus proposed threshold of 50%– Also, Stage 2 required only medication reconciliation – Stage 3 proposal is to add med

allergies and problems, and raise the threshold to 80% for all three

• Stage 3 proposed rule also changes exclusions– May want to consider trade-offs between thresholds and exclusions– Keep threshold high if also allowing exclusions, or conversely, lower threshold if not

allowing exclusions6

NOTE: Data needs to be updated

Current data on Stage 2 (through March 2015)

Stage 2 threshold

Average rate Allowable exclusions

% taking exclusion

Measure 1 (Send)

10% Mean: 40%Median: tbd

n=7,669

<100 transitions

of care

86%

Measure 3 (Reconcile)*

50% Mean: 93%Median: 98%

n=52,112

No transitions

of care

3%

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Eligible Professionals# of EPs attesting to Stage 2: 53,998

# of EPs scheduled for Stage 2: 223,000

Eligible Hospitals# of EHs attesting to Stage 2: 1,823

# of EHs scheduled for Stage 2: 2,796

Stage 2 threshold

Average rate Allowable exclusions

% taking exclusion

Measure 1 (Send)

10% Mean: 36%Median: 29%

n=1,823

None allowed

0%

Measure 3 (Reconcile)*

50% Mean: 87%Median: 91%

n=1,823

None allowed

0%

*Note: MU Stage 2 required only med reconciliation

NOTE: Data needs to be updated

Measure 1 Description

MU Stage 3 NPRM Measure Changes from MU Stage 2Send electronic summary of care record for 50% of outgoing transitions or referrals

• Increase from 10%• Requires electronic transport but

does not specify use of a standard (i.e., no longer requires Direct transport)

• Allows inclusion of patient self-referrals

• Allows inclusion of transitions/referrals to providers on the same EHR

• Summary of care must include CCDS data elements

• Exclusion for providers in counties with low broadband penetration

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Measure 1 Recommendations Discussion

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Changes from MU Stage 2 Recommendation from IOWG

• Increase from 10% • Agree. Threshold should be increased, but still need to determine by how much.

• Requires electronic transport but does not specify use of a standard (i.e., no longer requires Direct transport)

• Agree. This allows other modes of electronic exchange to qualify.

• Suggests allowing a higher threshold because it will be theoretically easier to accomplish

• Allows inclusion of patient self-referrals

• Disagree. Requires very cumbersome workflow for relatively little benefit to providers

• Suggests allowing a lower threshold because some qualifying encounters would now be excluded

• Allows inclusion of transitions/referrals to providers on the same EHR

• Disagree. Disproportionately favors large providers and does not add health care benefit.

• Suggests allowing a lower threshold because some qualifying encounters would now be excluded

• Exclusion for providers in counties with low broadband penetration

• Disagree. This exclusion is appropriate for patient engagement measures, but not for providers.

• Suggests allowing a lower threshold because some exclusions would no longer be allowed

Measure 2 Description

MU Stage 3 NPRM Measure Changes from MU Stage 2Receive and incorporate electronic summary of care record for 40% of incoming transitions or referrals of new patients

• New measure – no Stage 2 precedent

• Allows for “active” or “passive” receipt; allows any type of query

• Applies to any transitions/referrals and any encounter with new patients never before encountered

• Exclusion for encounters where information “unavailable” – requested manually and not fulfilled, and either tried through an HIE and not fulfilled OR provider has no access to HIE with query capability

• Allow “utilization alerts”?

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Measure 2 Recommendations Discussion

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Changes from MU Stage 2 Recommendation from IOWG

• 40% threshold? • Recommend lowering threshold – too high for a new measure• Sending (Measure 1) is only going as high as 50%, and manual

query entails cumbersome workflow to document and electronic query is not widely available

• Need to “incorporate” summary of care record

• Recommend allowing discretion for “clinical relevance” – mirrors approach for Measure 1

• Allows for “active” or “passive” receipt; allows any type of query

• Recommend agree? Need to allow flexibility in how to meet nascent query requirement

• Remove “never before encountered” • Even if the patient had been seen two days before and was seen in the meantime in another ED, capturing that data could be helpful but would be excluded under the current proposal?

• Exclusion for encounters where information “unavailable” – requested manually and not fulfilled, and either tried through an HIE and not fulfilled OR provider has no access to HIE with query capability

• Need to specify what “access to HIE functionality” means• Recommend specifying that access to an HIE means in useful

production through the entire reporting period, as attested to by provider?

• Allow utilization alerts • Recommend no? – will make calculation difficult as it will be difficult to determine what is a “qualifying alert” when disconnected from an transition or referral encounter

Measure 3 Description

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MU Stage 3 NPRM Measure Changes from MU Stage 2Measure 3: Reconcile clinical information for 80% of transitions or referrals of new patients

• Increase threshold from 50%• Increase scope to now include med

allergies and problems as well as medications – all must be over threshold

• Applies to any transitions/referrals and any encounter with new patients

• Automation versus manual?• Allow MAs to perform?• Specialists’ workflow?

Measure 3 Recommendations Discussion

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Changes from MU Stage 2 Recommendation from IOWG

• Increase threshold from 50% to 80% • Agreement that it should be increased, but by how much? Range received was 60% to 100%

• Include “drug indication”? • One person felt that the requirement should include drug indication (in addition to name, dosage, frequency, and route)

• Increase scope to now include med allergies and problems as well as medications

• Most felt that requiring meds and med allergies makes sense, with problems being optional; One person felt that all should required

• Suggests threshold should be lower

• Applies to any transitions/referrals and any encounter with new patients

• All agreed that it should apply to all referrals & transitions of care but not new patients – added benefit not worth cost of compliance

• Suggests threshold should be lower

• Automated versus manual? • All agreed that the rule should focus on outcomes (what is reconciled), not process (how it is reconciled)

• Allow credentialed MAs to perform med rec?

• Most agreed that this should be allowed; one person felt that it should not be allowed for info rec nor for CPOE

• Suggests threshold should be higher

• Applicability to specialists • Most agreed that some specialties with narrow scope should not be required to perform this information reconciliation; one person felt that it should be required 100% of the time for all specialties

• Exclusions • Agreed to remove exclusion for counties with low broadband penetration

Governance Discussion

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MU Stage 3 NPRM Questions Straw approach to recommendation

For Measure 1 or Measure 2, should providers be allowed to use any electronic means, OR only “in a manner consistent with governance mechanism ONC establishes for nationwide health information network”

How should governance mechanism established by ONC at later date be incorporated into EHR incentive program?

For Measure 1 and Measure 2, providers should be allowed to use any electronic means that meets Federal and State privacy and security laws

Recommend that future objectives that require HIE capabilities focus on the “what” (outcomes), not on the “how” (process). It should be the providers responsibility to assure that the means used for electronic exchange satisfy Federal and State privacy and security laws, their business needs, and their patients clinical needs

It would be a bad precedent for the Federal government to pick “winners and losers” among data sharing arrangements – too much heterogeneity and very dynamic

Appendix

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Measure 2 (Capture) (2 of 2)

• To address concerns about bloat and duplication of information in patient records providers should be able to determine what information from the received clinical summary is clinically relevant for incorporation into their EHR. The concept of clinical relevance should mirror the approach used for sending clinical summaries as outlined in the NPRM.– “We believe that while there may be a benefit and efficiency to be gained in the potential to limit

laboratory test results or clinical notes to those most relevant for a patient's care; a single definition of clinical relevance may not be appropriate for all providers, all settings, or all individual patient diagnosis. Furthermore, we note that should a reasonable limitation around a concept of "clinical relevance" be added; a provider must still have the CEHRT functionality to include and send all labs or clinical notes. Therefore, we defer to provider discretion on the circumstances and cases wherein a limitation around clinical relevance may be beneficial and note that such a limitation would be incumbent on the provider to define and develop in partnership with their health IT developer as best fits their organizational needs and patient population. We specify that while the provider has the discretion to define the relevant clinical notes or relevant laboratory results to send as part of the summary of care record, providers must be able to provide all clinical notes or laboratory results through an electronic transmission of a summary of care document if that level of detail is subsequently requested by a provider receiving a transition of care or referral or the patient is transitioning to another setting of care. We note that this proposal would apply for lab results, clinical notes, problem lists, and the care plan within the summary of care document.”

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Common Clinical Data Set

• The Stage 3 NPRM proposes requiring summary of care documents used to meet Objective 7 measures must include the requirements and specifications included in the Common Clinical Data Set (CCDS), as specified in the 2015 Edition.

• In circumstances where there is no information available to populate one or more of the fields included in the CCDS, either because the EP, eligible hospital, or CAH can be excluded from recording such information (for example, vital signs) or because there is no information to record (for example, laboratory tests), the EP, eligible hospital, or CAH may leave the field blank and still meet the requirements for the measure.

• However, all summary of care documents used to meet this objective must be populated with the following information using the CCDS certification standards for those fields (can record there are no problems, no medications or no medication allergies recorded): – Current problem list (Providers may also include historical problems at their discretion).– A current medication list,– A current medication allergy list. 17

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• The Common Clinical Data Set includes key health data that should be exchanged using specified vocabulary standards and code sets as applicable

Patient name Lab values/results

Sex Vital signs

Date of birth Procedures

Race Care team members

Ethnicity Immunizations

Preferred language Unique device identifiers for implantable devices

Problems Assessment and plan of treatment

Medications Goals

Medication allergies Health concerns

Lab tests

2015-2017Send, receive, find and use a common clinical data set to improve health and health care quality.

ONC Interoperability Roadmap Goal

CCDS Elements Required in 2015 Edition

Measure 3 (Reconcile)

• For more than 80 percent of transitions or referrals received and patient encounters in which the provider has never before encountered the patient, the EP, eligible hospital, or CAH performs clinical information reconciliation. The provider would choose at least two of the following three clinical information sets on which to perform reconciliations: – Medication. Review of the patient's medication, including the name, dosage,

frequency, and route of each medication. – Medication allergy. Review of the patient's known allergic medications. – Current Problem list. Review of the patient's current and active diagnoses.

• Exclusions: – EP & EH/CAH: Any EP, eligible hospital or CAH for whom the total of transitions or

referrals received and patient encounters in which the provider has never before encountered the patient, is fewer than 100 during the EHR reporting period is excluded from this measure.

– EP and EH/CAH: Any EP that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a location) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude from the measure.

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Measure 1 (Send)

• Areas of agreement:– Selfies should not be counted towards the measure– Patient self-referrals should not be included in the measure– No ecosystem exclusion– Remove broadband exclusion– Based on these recommendations the proposed 50%

threshold should be reduced• Areas of continued discussion:– What is the appropriate threshold?

• 30 or 40% were thrown out during the last call

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Measure 2 (Capture) (1 of 2)

• The 40% threshold was considered too high. – What threshold would the Workgroup like to propose?

• “Never before encountered” should be removed from the measure. Workgroup members feel that even if the patient had been seen two days before and was seen in the meantime in another ED, capturing that data could be helpful but would be excluded under the current proposal.– Is their a time horizon or other modifier the Workgroup would like to include for measure 2 to replace

“never before encountered”? (Perhaps two weeks since last encounter?)

• Additional specificity is needed on the definition of “unavailable” to determine if it strikes an appropriate balance. The Workgroup had a number of questions:– What does HIE functionality mean? Could any entity provide these services?– What does it mean to have access to HIE functionality? Does this mean if there is HIE functionality

available in your region you would have to join or not be able to meet the definition of unavailable? What if the functionality is cost prohibitive or if you have signed up but haven’t been on boarded yet?

• Remove the exclusion for EP and EH/CAH that conducts 50 percent or more of his or her patient encounters in a county (or, for EH/CAH, is located in a county) that does not have 50 percent or more of its housing units with 4Mbps broadband availability according to the latest information available from the FCC on the first day of the EHR reporting period may exclude the measures.

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