advanced health models and meaningful use workgroup stage 3 nprm group 1: overall approach paul...

Advanced Health Models and Meaningful Use Workgroup

Stage 3 NPRMGroup 1: Overall Approach

Paul Tang, chairJoe Kimura, co-chair

April 27, 2015

Advanced Health Models and Meaningful UseWorkplan

Meetings Task

April 7, 2015 – HIPTC Meeting • Interoperability Roadmap V.1: Use Case Prioritization Process presented to HITPC

April 9, 2015 10:00-11:30 ET (canceled public call)

• Small group meetings

April 23, 2015 4:00-5:45 ET • Small group meetings

April 27, 2015 9:00-11:00 ET • Report out from small groups• Group 1: Assess overall approach • Group 2 Report Out: CDS+• Group 3 Report Out: Population and Public Health• Group 4 Report Out: Quality Measures

May 7, 2015 10:30-1:00 ET • Report out from HITPC workgroups • Interoperability and HIE• Consumer• Privacy and Security

May 12, 2015 – HITPC Meeting • Draft MU3 NPRM Comments to the HITPC

May 22, 2015, 11:00-12:30 ET • Final MU3 NPRM Comments to the HITPC

June 2, 2015, 9:00-5:00 ET • Hearing on HIT Infrastructure for Accountable Health Communities

June 3, 2015, 9:00-1:00 ET • Draft Initial recommendations for HIT Infrastructure on Accountable Health Communities

Advanced Health Models and MUNPRM Assignments

• Small Group Assignments– Group 1: Assess overall approach – Group 2: CDS+

• Review objectives 2, 3, 4

– Group 3: Population and Public Health• Review objective 8

– Group 4: Quality Measures

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Group 1: Assess overall approach

• Membership– Paul Tang, Lead– Mark Savage– Charlene Underwood– Shaun Alfreds– Frederick Isasi

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Assessment of Overall Approach

• Assessment of CMS Approach to Stage 3 Meaningful Use NPRM – Simplify the programs– Reduce burden– Provide more flexibility

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Simplification - Comments

• Positives– Single stage is simpler

• Easier to understand• Synchronizes interoperability components for HIE

– Aligned reporting period is simpler• Easier to understand• Streamlines quality measurement effort and reporting

– Single definition – simplifies the program– Quality measurement program can be aligned with other programs

and can be updated more frequently• Challenges

– Some concern related to reporting period the first year on a stage• A shorter reporting period (?90d) could help ease the transition• Would need to be synchronous to help with HIE

– Some concern that certification requirements could impact timeline

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http://www.cms.gov/EHRIncentivePrograms/

To reduce the reporting burden, the proposed rule:

Reduces number of objectives to 8

Includes single set of measures slightly tailored for EPs and hospitals

Removes redundant measures or measures that received widespread adoption

Realigns reporting period into one for all providers (hospitals to participate on calendar instead of fiscal year)

Aligns quality data reporting; focuses on electronic submission

Stage 3 NPRM Eases Burden

http://www.cms.gov/EHRIncentivePrograms/

To make the EHR Incentive Programs more flexible, the Stage 3 NPRM:

•Allows providers the option to start Stage 3 in either 2017 or 2018 (required in 2018) [Modification rule proposes 2018]

•Simplifies reporting requirements by allowing flexible measures under:

• health information exchange

• Providers must meet the thresholds of 2 of 3 measures and must attest to the numerators and denominators of all three measures

• consumer engagement

• Providers must meet thresholds of 2 or 3 measures and must attest to the numerators and denominators of all three measures

• public health reporting

• EPs must report on 3 measures and EHs and CAHs must report on 4

Stage 3 NPRM Increases Flexibility

Flexibility - Comments

• Some members agreed with the Modification NPRM proposing 2018 as the time for everyone to be on stage 3– There was concern expressed that the timing should

remain as stated in the MU3 NPRM – 2017• Agree with flexibility related to the following

measures:– Health information exchange– Consumer engagement– Public health reporting

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Eases Burden - Comments

• [Placeholder – Matrix analysis]– Working with EHRA to assess new functionality

related to vendor effort– Provider effort will also be considered

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Stage 3 NPRMGroup 2: CDS+

(eRx, CDS, CPOE)

April 27, 2015

Advanced Health Models and MUNPRM Assignments

• Small Group Assignments– Group 1: Assess overall approach – Group 2: CDS+ (eRx, CDS, CPOE)

• Review objectives 2, 3, 4

– Group 3: Population and Public Health• Review objective 8

– Group 4: Quality Measures

04/18/23 12

Group 2: CDS+ (eRx, CDS, CPOE)

• Michael Zaroukian, Lead• Devin Mann• Lisa Marsch• Marty Fattig

04/18/23 13

Predecisional – Do Not Disclose – ONC Only

Objective 2: E-Prescribing (p. 67)

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Objective: •EP: Generate and transmit permissible prescriptions electronically •EH: Generate and transmit permissible discharge prescriptions electronically

Measure: •EP Measure: More than 80% of all permissible prescriptions written by the EP are queried for a drug formulary and transmitted electronically using CEHRT.•EH Measure: More than 25% of hospital discharge medication orders for permissible prescriptions (for new and changed prescriptions) are queried for a drug formulary and transmitted electronically using CEHRT.

Exclusion: •EP: Any EP who: (1) writes fewer than 100 permissible prescriptions during the EHR reporting period; or (2) does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP's practice location at the start of his or her EHR reporting period.•EH: Any eligible hospital or CAH that does not have an internal pharmacy that can accept electronic prescriptions and there are no pharmacies that accept electronic•prescriptions within 10 miles at the start of their EHR reporting period.


Objective 2 WG Comments

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Element Comment2.1 Overall Objective Comments • Consider expanding definition of "permissible prescriptions" to optionally

allow (EP can decide as long as done consistently) for any medication that an EP adds to a patient medication list and coveys to pharmacy (print, fax, eRx).

• 25% may be reasonable for EH but group should recognize frequent uncertainty by patient of what pharmacy they would like to use, or transmittal to SNF, or assisted living facility that is not connected to eRx.

• Hard to justify requiring querying for a formulary when one is likely not to be present for the patient's insurance, and lack of transparency and helpful CDS in formularies (including cost, e-preauthorization, etc.), this requirement adds little if any value that I'm aware of.

2.2 Should we allow for inclusion of scheduled drugs where such drugs are permissible to be electronically prescribed?

• Agree. Consider allowing providers to include controlled substance Rxs effective a specified implementation date, even if it falls within the reporting period.

2.3 Should we continue to exclude OTC medicines in this objective for Stage 3?

• Disagree with exclusion of OTC medicines. Allowing (but not requiring) OTC medications to be ePrescribed and to count would enhance our ability to ensure that patients are "prescribed" the right meds (including OTCs) and potentially get fill histories on whether they do so, check for drug interactions, etc.

2.4 Should we limit measure to only new and changed prescriptions (exclude refills previously included in Stage 2)?

• Disagree with removal of “refill” prescriptions. Important to encourage patient-centered practice to “renew” medication at discharge for a patient who needs one and a prescriber who is comfortable providing one.


Objective 3: Clinical Decision Support(p. 75)

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Objective: Implement clinical decision support (CDS) interventions focused on improving performance on high priority health conditions.‑

Measures (must meet both measures): •Measure 1: The EP, eligible hospital and CAH must implement five clinical decision support interventions related to four or more CQMs at a relevant point in patient care for the entire EHR reporting period. Absent four CQMs related to an EP, eligible hospital, or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high priority health conditions.•Measure 2: The EP, eligible hospital, or CAH has enabled and implemented the functionality for drug drug and drug allergy interaction checks for the entire EHR reporting period.

CDS Encouraged in the following areas:• Preventive care; • Chronic condition management; • Heart disease and hypertension; • Appropriateness of diagnostic orders or procedures such as labs, diagnostic imaging, genetic

testing, pharmacogenetic and pharmacogenomic test result support or other diagnostic testing; �• Advanced medication-related decision support, to include pharmacogenetic and pharmacogenomic

test result support.

Exclusion: None



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Element Comment3.1 Overall Objective Comments • For Measure 1, CMS should provide more guidance about the definition of

"high priority health conditions.“ (not clearly synonymous with “CMS Encouraged” areas

• For Measure 2, CMS should provide more guidance about how providers may calibrate/filter drug-drug interaction alerts, e.g. to optimize usability by focusing on high priority alerts, while still meeting measure.

• CMS should reiterate current policy that “licensed health professionals” includes credentialed medical assistants, akin to policy for CPOE.

• Consider behavioral health as an additional priority area.

3.2 Recommends that providers explore a wide range of potential CDS interventions and determine the best mix for their practice and patient population. (Highlights Million Hearts and PAMA Sec 218)

• Support discussion of wide range of CDS applications beyond interruptive alerts.


Objective 4: CPOE (p. 81)

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Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant; who can enter orders into the medical record per state, local, and professional guidelines.

Measure (Must meet all 3 measures): •Measure 1. More than 80 percent of medication orders created are recorded using computerized provider order entry.

•Measure 2: More than 60 percent of laboratory orders created are recorded using computerized provider order entry.

•Measure 3: More than 60 percent of diagnostic imaging orders created are recorded using computerized provider order entry.

Exclusion: Eligible Professional can be excluded out of each respective measure if they write fewer than 100 diagnostic imaging, lab, or imaging orders during the EHR reporting period.



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Element Comment4.1 Overall Objective Comments • Agree with all proposed measures.

4.2 Should we expand the objective to include diagnostic imaging, which is a broader category including other imaging tests such as ultrasound, magnetic resonance, and computed tomography in addition to traditional radiology?

• Agree, but CMS should provide more guidance about whether providers have flexibility to define diagnostic imaging broadly, e.g. is an order for dermatology images (e.g., wound) a diagnostic image if it is accompanied by a report? How about an ECG? EEG?

4.3 Should we continue to allow, but not require, providers to limit the measure of this objective to those patients whose records are maintained using CEHRT?

• Agree with flexibility but larger concern with this measure should be raised. Trying to count the orders never entered into the CEHRT is 1) far too burdensome and 2) invites people to under-report because it is virtually impossible to count accurately.

4.4 Are there circumstances which might warrant an additional exclusion for an EP such as a situation representing a barrier to successfully implementing the technology required to meet the objective?

• Agree there are circumstances that would warrant such an exclusion. Likely many groups that will face barriers to implementation given resources needed, and weak usability provided by vendors (certified but poorly usable for implementation and maintenance).

4.5 Are there circumstances where an eligible hospital or CAH which focuses on a particular patient population or specialty may have an EHR reporting period where the calculation results in a zero denominator for one of the measures?

• Disagree this will be a likely circumstance. If so, EH or CAH may use the proposed exclusion for less than 100 orders.


Stage 3 NPRMGroup 3: Population and Public Health

April 27, 2015

Objective 8 Commentary Structure

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1. Overview of Objective 8 2. Comments on Objective

a) Engagement Optionsb) Creation of Clinical Repositoryc) Measure Attestation Mechanics

3. Comments on Specific Measuresa) Immunization Registry Reportingb) Syndromic Surveillance Reportingc) Case Reportingd) Public Health Registry Reportinge) Clinical Data Registry Reportingf) Electronic Reportable Laboratory Result Reporting

4. Summary of Key Points

Group 3: Population and Public Health Objective 8

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• Joe Kimura, Lead• Amy Zimmerman• Arthur Davidson• Neal Patterson• Terry O’Malley

• Jim Daniel, ONC Staff Lead

Objective 8: Public Health and Clinical Data Registry (CDR) Reporting

• Proposed Objective: The EP, eligible hospital, or CAH is in active engagement with a Public Health Agency (PHA) or CDR to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice.

• Six possible measures to meet the objective– Eligible professionals must meet 3 measures– Eligible Hospitals and Critical Access Hospitals must meet 4 measures

23(Source: CMS Stage 3 NPRM)

Proposed Measures: EP Measure: EPs would be required to choose from measures 1 through 5, and would be required to successfully attest to any combination of three measures. EH and CAHs Measure: required to choose from measures one through six, and would

be required to successfully attest to any combination of four measures

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Measure Standard Implementation Guide

Measure 1 – Immunization Registry Reporting

170.315(f)(1) HL7 Version 2.5.1: Implementation Guide for Immunization Messaging, Release 1.5 (October 2014)

Measure 2 – Syndromic Surveillance Reporting

170.315(f)(2) PHIN Messaging Guide for Syndromic Surveillance: Emergency Department, Urgent, Ambulatory Care, and Inpatient Settings, Release 2.0, September 2014 (“Release 2.0”)

Measure 3 – Case Reporting 170.315(f)(5) IHE Quality, Research, and Public Health Technical Framework Supplement, Structured Data Capture, Trial Implementation (September 5, 2014)

Measure 4 - Public Health Registry Reporting

170.315(f)(4)

170.315(f)(6)

170.315(f)(7)

HL7 Implementation Guide for CDA© Release 2: Reporting to Public Health Cancer Registries from Ambulatory

Healthcare Providers Release 1 HL7 Implementation Guide for CDA ® Release 2—Level 3: Healthcare Associated Infection Reports, Release 1, U.S. Realm (August 2013)

HL7 Implementation Guide for CDA ® Release 2: National Health Care Surveys (NHCS), Release 1—US Realm, Draft Standard for Trial Use (December 2014),

Measure 5 - Clinical Data Registry Reporting

Measure 6 - Electronic Reportable Laboratory Results

170.315(f)(3) HL7 Version 2.5.1 Implementation Guide: Electronic Laboratory Reporting to Public Health, Release 2 (US Realm), DSTU R1.1, 2014 or “Release 2, DSTU R1.1

Proposed Objective: The EP, eligible hospital, or CAH is in active engagement with a PHA or CDR to submit electronic public health data in a meaningful way using certified EHR technology, except where prohibited, and in accordance with applicable law and practice. "Active engagement" may be demonstrated by any of the following options:

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Active Engagement Option 1:Completed Registration to Submit Data

The EP, eligible hospital, or CAH registered to submit data with the PHA or, where applicable, the CDR to which the information is being submitted; registration was completed within 60 days after the start of the EHR reporting period; and the EP, eligible hospital, or CAH is awaiting an invitation from the PHA or CDR to begin testing and validation. This option allows providers to meet the measure when the PHA or the CDR has limited resources to initiate the testing and validation process. Providers that have registered in previous years do not need to submit an additional registration to meet this requirement for each EHR reporting period.

Active Engagement Option 2:Testing and Validation

The EP, eligible hospital, or CAH is in the process of testing and validation of the electronic submission of data. Providers must respond to requests from the PHA or, where applicable, the CDR within 30 days; failure to respond twice within an EHR reporting period would result in that provider not meeting the measure.

Active Engagement Option 3: Production

The EP, eligible hospital, or CAH has completed testing and validation of the electronic submission and is electronically submitting production data to the PHA or CDR.

Comments:Option 1: Agreed.Option 2: Need definition of a response for validation phase. Proposal from Neal for consensus: "Providers must

respond to PHA or, where applicable, the CDR within 30 days of request through acknowledgement of request and process for investigation."Reason: This change allows for acknowledgement and intent to fix, not for code change and fix within 30 days of request.

Option 3: Also need to address how to deal with issues while in production. Proposed to use same definition for response as in Option 2.

Proposal: Provide support to providers seeking to meet the requirements of this objective by creating a repository of national, state, and local PHA and CDR readiness. Additionally, comment on the use and structure of the centralized repository

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Comments:Neal suggests changing to:"Provide support to providers seeking to meet the requirements of this objective by creating a centralized repository of national, state, and local PHA and CDR readiness. National, state, and local PHA and CDRs must register readiness of ability to accept each measure or intent to accept future registry data within 12 months prior to reporting period. National, state, and local PHA and CDRs registration must include type of settings currently accepting or intent to accept, including any exclusion or specialties they are not accepting from. If a separate required implementation guide if other than CEHRT guide is required by the registries or through state flexibility, a link to the required implementation guide must be included. If PHA or CDR registers current readiness or intent to accept then EP, eligible hospital, or CAH and the provider chooses this measure to attest exclusion for the measure can count toward the total of the required measures. To ensure registries options are available, PHAs at the state level must register a minimum of three registries as currently accepting or intent to accept in future."

This change allows: 1)providers to appropriately plan, purchase, implement and develop based on available measures, 2)states time to develop readiness for current and new development of systems, and 3)vendors to develop systems for meeting applicable implementation guides.

•Public Health would need commit to develop once system is placed on the list•Providers would meet measure by registration of intent if PH ended up not being ready.

•Also calls for CMS repository to be ready Jan 2017

Proposed Measures: EP Measure: EPs would be required to choose from measures 1 through 5, and would be required to successfully attest to any combination of three measures. EH and CAHs Measure: required to choose from measures one through six, and would

be required to successfully attest to any combination of four measures.

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Comments:

•If same data being sent to or used by more that one registry - still meeting the intended specific registry purpose and participation in multiple registries should be allowed. Recommend that this is acceptable and should be called out.

•An EP/EH/CAH should be allowed to send the same data to multiple unique registries. As long as the data sent to each registry satisfies the data criteria & purpose of each specific registry, it should not matter that an EP/EH/CAH has used the same data

Measure 1 - Immunization Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to

submit immunization data and receive immunization forecasts and histories from the public health immunization registry/immunization information system (IIS).

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Exclusion:

Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the immunization registry reporting measure if the EP, eligible hospital, or CAH: (1) does not administer any immunizations to any of the populations for which data is collected by their jurisdiction's immunization registry or immunization information system during the EHR reporting period; (2) operates in a jurisdiction for which no immunization registry or immunization information system is capable of accepting the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no immunization registry or immunization information system has declared readiness to receive immunization data at the start of the EHR reporting period.

Comments:

•Clinical goal of this measure is to improve overall immunization rates for the population. •Mechanism of action is to improve the timeliness and reliability of data used in immunization processes to both proactively and retrospectively identify, outreach, and immunize patients•Concerns about forecast should be from IIS or EHR; groups clarified that CMS rule says forecast and history only needs to be received - rule does not dictate what is done with that information; ONC cert rule certifies display, but CMS rule does not require.•What if state is not ready to do bi-directional exchange? If IIS is not bi-directional, clarify in the exclusion that providers could take an exclusion.

Measure 2 - Syndromic Surveillance Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit

syndromic surveillance data from a non-urgent care ambulatory setting for EPs, or an emergency or urgent care department for eligible hospitals and CAHs (POS 23).

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Exclusion for EPs:

Any EP meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the EP: (1) does not treat or diagnose or directly treat any disease or condition associated with a syndromic surveillance system in their jurisdiction; (2) operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from EPs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from EPs at the start of the EHR reporting period.

Exclusion: EHs/CAHs:

Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the syndromic surveillance reporting measure if the eligible hospital or CAH: (1) does not have an emergency or urgent care department; (2) operates in a jurisdiction for which no public health agency is capable of receiving electronic syndromic surveillance data from eligible hospitals or CAHs in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3) operates in a jurisdiction where no public health agency has declared readiness to receive syndromic surveillance data from eligible hospitals or CAHs at the start of the EHR reporting period.

Comments:•Clinical goal is to better enable public health agencies to detect early indicators of new public health threats in order to protect the community.•Mechanism of Action is to ensure reliable & timely event data capture from targeted EP/EH/CAH care settings where patients are most likely to seek early symptomatic care for significant disease•Keep EH and Urgent care as noted; ambulatory syndromic surveillance may have more Population Health meaning and should be part of measure 4 and could include hospital data as well if required.

Measure 3 - Case Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit case reporting of reportable conditions. *NEW reporting option that was not part of Stage 2

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Exclusion:

Any EP, eligible hospital, or CAH meeting one or more of the following criteria may be excluded from the case reporting measure if the EP, eligible hospital, or CAH: (1)does not treat or diagnose any reportable diseases for which data is collected by their jurisdiction's reportable disease system during the EHR reporting period; (2)operates in a jurisdiction for which no public health agency is capable of receiving electronic case reporting data in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3)operates in a jurisdiction where no public health agency has declared readiness to receive electronic case reporting data at the start of the EHR reporting period.

Comments:•Clinical and regulatory goal is to enable public health agencies to reliably receive case reports of reportable conditions in a timely manner to better protect the community.•Mechanism of action is to promote electronic reporting to facilitate case reporting•Need to address bi-directional component (e.g., use of knowledge management systems for triggers) in the measure definition as well as in the exclusions.•How to address the differences in data collected - actually both standards address that. Need to ensure that jurisdictions have the capacity to receive the data. CDC/ASTHO are working on a Public Health Community Platform as a shared service for all health departments to share this & other services.•Does CMS rule need to include bi-directionality and requirement for electronic aspect?

Measure 4 - Public Health Registry Reporting: The EP, eligible hospital, or CAH is in active engagement with a public health agency to submit data to public health registries.

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Exclusions:

Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the public health registry reporting measure if the EP, eligible hospital, or CAH: (1)does not diagnose or directly treat any disease or condition associated with a public health registry in their jurisdiction during the EHR reporting period; (2)operates in a jurisdiction for which no public health agency is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3)operates in a jurisdiction where no public health registry for which the EP, eligible hospital, or CAH is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.

Comments:•Clinical goal is better enable public health agencies to comprehensively report on community-determined measures based on local capacities in order to better understand community health needs and to promote better health for the community. •Agreement that Measure 4 and 5 are good ideas.•Mechanism of action is ambiguous and needs to be clarified. Many Stage 2 specialized registries seem not to count.•How to regulate what is eligible. Should other standards such as TOC that are part of CEHRT be OK? Currently no standards called out for Measure 5 and only 3 specific ones for Measure 4. Some previous Specialized Registries would not longer count for Measure 4 and Measure 5.Ambultory syndromic may be a better fit here. Confusing to split PH and CDR into two measures - need to have better definition; could this play out as in the CMS Repository.•No concept of bi-directionality discussed - such as PDMP when it might be appropriate; note it might not be appropriate for all options.•Exclusions for both need to acknowledge existence of national registries independent of jurisdiction.

Measure 5 - Clinical Data Registry Reporting: The EP, eligible hospital, or CAH is in active engagement to submit data to a clinical data registry.

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Exclusions:

Any EP, eligible hospital, or CAH meeting at least one of the following criteria may be excluded from the clinical data registry reporting measure if the EP, eligible hospital, or CAH: (1)does not diagnose or directly treat any disease or condition associated with a clinical data registry in their jurisdiction during the EHR reporting period; (2)operates in a jurisdiction for which no clinical data registry is capable of accepting electronic registry transactions in the specific standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3)operates in a jurisdiction where no clinical data registry for which the EP, eligible hospital, or CAH is eligible has declared readiness to receive electronic registry transactions at the beginning of the EHR reporting period.

Comments:•Clinical goal is for EP/EH/CAH to engage community or non-profit organizations sponsored clinical registries to enable broader and more comprehensive measurement of health outcomes that can strategically direct and promote improvement activities•Mechanism of action is ambiguous and needs to be clarified. Many Stage 2 specialized registries seem not to count.•How to regulate what is eligible. Should other standards such as TOC that are part of CEHRT be OK? Currently no standards called out for Measure 5 and only 3 specific ones for Measure 4. Some previous Specialized Registries would not longer count for Measure 4 and Measure 5.Ambultory syndromic may be a better fit here. Confusing to split PH and CDR into two measures - need to have better definition; could this play out as in the CMS Repository. Would FDA (Mini-sentinel )or PCORI (PCORnet) be acceptable? What standard are they using?•No concept of bi-directionality discussed - such as PDMP when it might be appropriate; note it might not be appropriate for all options.•Exclusions for both need to acknowledge existence of national registries independent of jurisdiction.

Measure 6 - Electronic Reportable Laboratory Result Reporting: The eligible hospital or CAH is in active engagement with a public health agency to submit

electronic reportable laboratory results.

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Exclusions

Any eligible hospital or CAH meeting one or more of the following criteria may be excluded from the electronic reportable laboratory result reporting measure if the eligible hospital or CAH: (1)does not perform or order laboratory tests that are reportable in their jurisdiction during the EHR reporting period;(2)operates in a jurisdiction for which no public health agency is capable of accepting the specific ELR standards required to meet the CEHRT definition at the start of the EHR reporting period; or (3)operates in a jurisdiction where no public health agency has declared readiness to receive electronic reportable laboratory results from an eligible hospital or CAH at the start of the EHR reporting period.

Comments:

•Regulatory goal is for public health to receive all laboratory reports consistent with local regulations.•Agree. Define difference b/w ELR and syndromic. Note that syndromic includes some lab data, but this would not count towards ELR.•How should laboratories benefit from the knowledge management system used for measure 3?

Objective 8 Commentary Structure

04/18/23 34

1. Overview of Objective 8 2. Comments on Objective

a) Engagement Optionsb) Creation of Clinical Repositoryc) Measure Attestation Mechanics

3. Comments on Specific Measuresa) Immunization Registry Reportingb) Syndromic Surveillance Reportingc) Case Reportingd) Public Health Registry Reportinge) Clinical Data Registry Reportingf) Electronic Reportable Laboratory Result Reporting

4. Summary of Key Points

Objective Topic Comment SummaryEngagement Options Option 1: Agreed.

Option 2: Need definition of a response for validation phase. Proposal from Neal for consensus: "Providers must respond to PHA or, where applicable, the CDR within 30 days of request through acknowledgement of request and process for investigation."Option 3: Also need to address how to deal with issues while in production. Proposed to use same definition for response as in Option 2.

Creation of Clinical Repository National, state, and local PHA and CDRs must register readiness of ability to accept each measure or intent to accept future registry data within 12 months prior to reporting period. National, state, and local PHA and CDRs registration must include type of settings currently accepting or intent to accept, including any exclusion or specialties they are not accepting from.

Measure Attestation Mechanics An EP/EH/CAH should be allowed to send the same data to multiple unique registries. As long as the data sent to each registry satisfies the data criteria & purpose of each specific registry, it should not matter that an EP/EH/CAH has used the same data

Measure 1Immunization Registry Reporting

Concerns about forecast should be from EITHER IIS or EHR; ONC cert rule certifies display, CMS rule does not require.What if state is not ready to do bi-directional exchange?

Measure 2Syndromic Surveillance Reporting

Keep EH and Urgent care as noted; ambulatory syndromic surveillance may have more Population Health meaning and should be part of measure 4 and could include hospital data as well if required.

Measure 3Case Reporting

Need to address bi-directional component in the measure definition as well as in the exclusions.How to address the differences in data collectedDoes CMS rule need to include bi-directionality and requirement for electronic aspect?

Measure 4 & Measure 5 Public Health Registry ReportingClinical Data Registry Reporting

How to regulate what is eligible. No concept of bi-directionality discussed Exclusions for both need to acknowledge existence of national registries independent of jurisdiction.

Measure 6Electronic Reportable Lab Reporting

Define difference b/w ELR and syndromic. Syndromic includes some lab data, but this would not count towards ELR.How should laboratories benefit from the knowledge management system used for measure 3?


Stage 3 NPRMGroup 4: Quality Measures

Cheryl Damberg, LeadApril 27, 2015

Group 4: Quality Measures

• Cheryl Damberg, Lead• Ginny Meadows• Norma Lang• Sumit Nagpal

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CQM: Key Questions for Comment

What are the number(s) of measures vendors must certify to?

In the NPRM, CMS believes EHRs should be certified to more than the minimum number of CQMs required by one or more CMS quality reporting reports.

What are the key considerations in the context of alignment with the rest of CMS quality programs-comments on the aligned approach to quality measurement?

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Overarching Framing Comments

Group 4 identified the following overarching comments related to advancing the ability of EHRs to support quality measurement as context for framing focused recommendations specific to the NPRM:

It is essential to improve the availability of standards to further interoperability, as it pertains to the ability to measure the quality of care across settings and time for a patient. Pilots for new standards being worked on via the Clinical Quality Framework focus on CDS do not yet address ways to advance quality measurement.

o Interoperability must advance to support patient-centered measurement and improvement of patient outcomes and move beyond quality measurement that focuses primarily on assessing care processes delivered by individual providers.

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Overarching Framing Comments Continued

Currently, most electronic clinical quality measures are retooled from manual or claims-based process measures that focus on individual provider processes. Electronic quality measurement should look across longer periods of time, utilize more data sources, and consider care in other settings beyond hospitals and ambulatory care such as long-term post acute care, behavioral health, and palliative care.

– These capabilities are critical as we move towards new payment models, as EHRs play an important role in supporting and enabling value based payment.

– A change in the existing paradigm is necessary in order to support care delivery while moving toward the use and development of longitudinal “lifespan” measurement.

– It is important to broaden the focus beyond EP and EH and recognize other providers, individuals and family as accessing information systems for input, throughput, and output.

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EHR Technology Certification Requirementsfor Reporting of CQMs- Recommendation

CMS proposes 3 options for the addressing the number of measures a vendor must certify to:

Option 1- EP vendors certify to all CQMS

Option 2- Phased approach over time until the EHR is certified to all applicable CQMs

Option 3- EHRs certified to more than the minimum number (but not to all) of CQMs

Group 4 recommends HITPC conditionally support option 1 requiring EHRs be certified to all CQMs.

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Option 1 Recommendation – Supporting Comments

• Many EHR vendors eventually implemented all CQMs to meet the varied quality measurement needs of their provider clients; a phased approach does not reduce burden.

• CQM specification and certification tools must be accurate, complete, and fully tested when released allowing at least 18 months for EHR vendor implementation, certification and roll-out to providers, as well as provider implementation. The Cypress testing tool, test procedures and test data must also be available within the same time frame.

• CMS annual updates should be limited to changes that do not have a significant impact on clinician workflow or provider implementation time, or require extensive software code changes or recertification of the EHR software. If a measure specification requires more extensive modification, then alternative avenues for scheduling such changes should be considered that would provide ample time to accommodate these activities.

• All CQMs are not relevant to all providers or practice settings. There should be flexibility to allow EHR vendors to certify specialty EHRs to those measures that are relevant to the particular specialty. The role of the specialists and their measurement needs should be a key consideration in weighing CQM requirements.

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Alignment with CMS Quality Measurement Programs- Recommendation

• Group 4 strongly supports efforts to align quality measurement and requirements across CMS quality measurement and reporting programs. Additionally, Group 4 supports, where feasible, greater alignment of quality measurement across private and public payer initiatives to reduce the burden on providers.

• This alignment should include utilizing the same measure specifications and data collection requirements for measures looking at the same concept, as well as alignment of reporting formats, standards utilized and reporting periods and data submission timelines.

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Next Meeting: Thursday, May 7, 2015 10:30 AM-1:00 PM Eastern Time

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advanced health models and meaningful use workgroup stage 3 nprm group 1: overall approach paul...

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