Download - Meaningful Use Workgroup

Paul Tang, ChairGeorge Hripcsak, Co-Chair

Meaningful Use Workgroup

December 20, 2013

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Meaningful Use Workgroup Members

Chairs• Paul Tang , Palo Alto Medical Foundation• George Hripcsak, Columbia UniversityMembers• David Bates , Brigham and Women’s

Hospital• Christine Bechtel , National Partnership for

Women & Families• Neil Calman , The Institute for Family Health• Arthur Davidson, Denver Public Health

Department• Paul Egerman, Businessman/Entrepreneur• Marty Fattig, Nemaha County Hospital

Auburn, Nebraska • Leslie Kelly Hall, Healthwise• David Lansky, Pacific Business Group on

Health• Deven McGraw , Center for Democracy &

Technology

• J. Marc Overhage, Siemens Healthcare• Patricia Sengstack, Bon Secours Health

Systems• Charlene Underwood, Siemens• Michael Zaroukian, Sparrow Health

System• Amy Zimmerman, Rhode Island Office of

Health & Human ServicesFederal Ex officios• Tim Cromwell, Department of Veterans

Affairs• Joe Francis , Veterans Administration• Greg Pace, Social Security Administration• Martin Rice, HRSA• Robert Tagalicod, Centers for Medicare &

Medicaid Services, HHS

Workplan

Date Meeting Tasks12/20/2013

9:30-11:30 ET• Review recommendations

• Pop/public health• Affordable care • Health disparities• Follow-up items

• Review of feedback from Standards Workgroups included in recommendations review (i.e. case reports, registries, images, PGHD)

1/6/20149:30-11:30 ET

• Follow-up items• Review of recommendations

1/17/1411:00-1:00 ET


1/28/141:00-3:00 ET


2/4/14 • Present to HITPC

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Review of Population and Public Health Objectives Stage 3 MU

Arthur Davidson, MD, MSPHMeaningful Use Workgroup

December 20, 2013

Agenda

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Review Stage 1 Public/Population Health Meaningful Use Measures

Review Public Health Efforts Regarding Standards and Interoperability Framework Components

Review of proposed Stage 3 Meaningful Use Measures

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Hospital 1st v. 2nd v. 3rd yearPH Menu Objective Performance

Source: CMS Presentation – Rob Anthony, December 4, 2013

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Immunization • New guide provides improvements• Progress with providers is better • ONC test criteria are making interoperability better • PH moving toward accepting data coming form certified

products• Next version (Feb 2014) of Implementation Guide (IG) will

include bi-directional w/ History and forecast back to provider

Electronic Laboratory Reporting (ELR) • New version of IG is available to HL7 members and includes

many improvementsSyndromic Surveillance (SS)

Successful centralized infrastructure utilizing BioSensehttp://www.hl7.org/dstucomments/showdetail.cfm?dstuid=104

Update on Current Measures: - Immunization, ELR, SS

http://www.hl7.org/dstucomments/showdetail.cfm?dstuid=104

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Electronic Laboratory Reporting (ELR) – Pattern of Adherence to Standards• Public Health has consistently made efforts to abide by

standards and in turn minimize impact on clinical partners• Proof of PH’s commitment to build on standards and

processes used for other use cases,. • ELR Release 1 (HL7 Version 2.5.1: ORU^R01)1was built on

the HISTP Lab-to-EHR Implementation Guide• ELR Release 2 is the current profile for Electronic

Laboratory Reporting to Public Health (MU Stage 1 and 2).

• Public health has demonstrated readiness for standards and will credibly achieve that for Stage 3.

http://www.odh.ohio.gov/~/media/ODH/ASSETS/Files/opi/infectious%20disease%20surveillance/v251_IG_LB_LABRPTPH_R1_INFORM_2010FEB.ashx

Key Principle for PH Stage 3 MU

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• Adhere to Standards and Interoperability Framework Components Whenever Feasible

Component PurposeConsolidated CDA Standard message formatStructured Data Capture

Populate standard forms

Health eDecisions Clinical decision support (e.g., triggers for PH screening or collecting data)

Data Access Framework

Query data: 1) by provider and 2) across multiple organizations and by population

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Cancer Reporting• Stage 3 MU Cancer Implementation Guide (IG) should

move to consolidated clinical document architecture (c-CDA) because: – EHR vendors are required to use this format for

Transition of Care documents in Stage 2 MU– eliminates burden of supporting two different formats

for cancer reporting– c-CDA has harmonized and improved templates

across multiple sources– cancer program is ready to move to this new standard

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Cancer c-CDA: Next Steps• Align Cancer IG sections with c-CDA sections (high level

completed)• Add a new document-level template c-CDA R2:

"Ambulatory Healthcare Provider Cancer Event Report”• Add Cancer Diagnosis Section to c-CDA • Perform Gap and Overlap analysis of entries, data

elements, attributes, and value sets• Put new document through HL7 ballot process

Timeline– High level gap analysis performed in November 2013– Detailed gap/overlap analysis work starting in January

2014– Ballot in May 2014

Public Health and c-CDA - Progression for some areas

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Pertussis (NY State)

Pertussis (San Diego)

Tuberculosis (Delaware)

EHDI (N. Dakota)

2012 2013 2014+

EHDI (Oregon)

Cancer Registry

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Reporting protocol for

HAI

Executable expressions of detection and case reporting

algorithms

HAI detection rules applied to patient-specific

data

Additional rules applied to

populate full HAI report

Healthcare Facility

Reporting system provides protocol and algorithm

Publicly Reported HAI

data

Electronic HAI ReportClinical

DocumentArchitecture

(CDA)

Reporting system publishes facility-specific

HAI data

CDA transmission:- Manual upload- Automated send

Electronic Healthcare Associated Infection (HAI) Detection and Reporting:

Supporting Patient Safety

Specifications:•eMeasures

• Decision rules

• Computer code

Electronicsystems:

•EHR

•Pharmacy

•ADT

•Lab

CDC

CDCPrograms

CMS

PublicHealth

Healthcare

NHSN

HeD

16Sources: Communicable Disease CDA Pilot Project Report. 2012. URL: https://wiki.phdsc.org/index.php/CDAEHDI CDA Pilot Project Report. 2013. URL: https://wiki.phdsc.org/index.php/EHDI-Pilot

CDA/SDC for Public Health Pilot ProjectsPublic Health Reporting Architecture

Progress : What’s been completed

Public Health Infrastructure

Or Health

Information Exchange (HIE)

Form Manager

Form Receiver

Content Creator

Form Filler

1. Request Form

2. Provide pre-population data

3. Pre-populated Report Form

4. Populated Report Form5. Send–Receive

CDA ReportContent

Consumer

EHR VendorsCore Solutions

ConnexinAllscripts

(Test Harness)Epic 2012

(Test Harness)

Public Health Electronic

Health Record System

Provider

Information Systems:Surveillance Systems

EHDI System

Public Health Information Systems

Delaware Electronic Reporting Surveillance

System (DERSS)New Your State Universal

Public Health Node (UPHN)

San Diego County(Atlas Public Health)Oregon EHDI System

(Filemaker)North Dakota EHDI System

(OZ Systems)

CDA-based Case Reports:Tuberculossis

PertussisNewborn Hearing

Screening Outcome Report

Continuity of Care Document (CCD)

(pre-population data)

Public Health Infrastructure

(Orion Rhapsody)

HIE(OZ Systems)

Form Manager

Form Receiver

Content Creator

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Communicable Disease Reporting – CDA/SDC Pilot in NYC and WI

1. Parse2. Retrieve Form3. Pre-populate web

form

4. Send URL with pre-populated web form

Electronic Medical Record (EMR)

Vendor Test Environ-

ment

(i.e., EPIC)

Reporting Module/Form

Manager

Continuity of Care Document (CCD)

NYC and WI Public Health Infrastructure

Electronic Disease Surveillance

System

Current Progress (as December 2, 2013) – Finalize Testing in Vendor Environment

5. Physician/ICP submits addition information directly to system

Next Steps – Identify, Recruit, and Implement in Hospital using EPIC EMR System

State/Local Surveillance

System

Key Outcomes• Shift in tradition al public health

case report (PHCR) use case• Leverage existing standard

(i.e., CCD -> cCDA)• Light-weight service for EMR

vendors to connect to various jurisdiction reporting end-points

• Minimize development in EMR System

• Extensibility/ portability to other EMR vendors

• State and LHD can configure forms based on reporting and business needs specific to jurisdiction

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Structured Data Capture (SDC)- Tiger Team and Selected Pilots

• Public Health Tiger Team – Community based effort to identify, develop, and

implement SDC Public Health Pilots

• Proposed Public Health Pilots– EHDI– Cancer Reporting– Case Reporting

http://wiki.siframework.org/Public+Health+Tiger+Team+Meeting+Archives

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Health eDecisions - Use Cases

• Use Case 1: standard format for sharing CDS knowledge artifacts– Rules, order sets and documentation templates

– Goal: CDS knowledge authored in standard format can be imported and used in any EHR system

• Use Case 2: standard interface for accessing CDS Web services– Goal: CDS capability encapsulated using standard

interface can be integrated with any EHR system

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Use Case 1 Focuses on three artifact types:1. Event Condition Action Rules2. Order Sets3. Documentation Templates

Health eDecisions – Use Case 1 (CDS Artifact Sharing)

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Health eDecision - Use Case 1: Pilot Partnerships

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EHR Pilot Content SupplierDesign Clinicals

Order Set – Heart Failure

Zynx Health

Allscripts Rule – NQF 068 (Million Hearts)

newMentor

Allscripts RCKMS - San Diego Pertussis

CDC/CSTE

VA Documentation Template – UTI

Wolters Kluwer Health

22RCKMS: Reportable Condition Knowledge Management System

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Public Health State, Local, Territorial Agencies

RCKMS Long term ScopeReportable Condition

Knowledge Management System (RCKMS)

Authoring Framework

Subscription Management

Including Notifications

DatabaseWho, What, When,

Where, How

Structured Output

Generator

PH Reports

Query/View

HeD Compliant format

- Triggering Criteria- Reporting Actions- Links

DSS Web Service

Other Web Services

HeD

(1) Health eDecision (Hed)

(2) Open CDS

PH Reporters (Clinicians)

Hospital Labs

LIMS

EHR

National, Clinical & Public Health Laboratories

LIMS

Ambulatory Care

EHR

Web Service

(3) Open CDS

Local

Output file Options1) HeD file download2) OpenCDS in Cloud3) OpenCDS Locally Deployed

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S&I Data Access Framework Use Cases

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Data Access Framework - examples

DRAFTImproving population and public health: Stage 3 Priorities

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• Efficient and timely completion of case reports

• Efficient and timely means of defining and reporting on patient populations to drive clinical care and identify areas for improvement

• Shared information with public health agencies or specialty societies

• Bidirectional public health data exchange

Target Outcome GoalsMU Outcome Goals

• Providers know the health status of their patient population

• Public health officials know the health status of their jurisdiction

• Providers and specialty societies can track and manage domain specific events related to practice and devices

• Providers and public health officials share information to improve individual and population health

• Patient lists• Sharing immunization

data• Cancer and specialty

registry• Electronic lab reporting• Submission of electronic

syndromic surveillance data

Stage 3 Functionality Goals MU Outcome GoalsStage 1 + 2 Functional

Objectives

DRAFTImproving population and public health: Case Reports

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Functionality Needed to Achieve Goals

• CEHRT uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.

• Recommended as certification criteria only

Stage 3 Functionality Goals

DRAFTImproving population and public health: Registries

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• EPs/EHs use CEHRT to electronically submit standardized (i.e., data elements, structure and transport mechanisms), commonly formatted reports to two registries (e.g., local/state health departments, professional or other aggregating resources)

• EP/EH Registries examples: cancer, children with special needs, and/or early hearing detection and intervention or external entities that maintain the registry (e.g., hypertension, diabetes, body mass index, devices, and/or other diagnoses/conditions) that could include accountable care organization, public health agency, professional society, or specialty community. EHs Only: health-care associated infections


DRAFTImproving population and public health: Immunization history

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• Eligible Professionals, Hospitals, and CAHs receive a patient’s immunization history supplied by an immunization registry or immunization information system, allowing healthcare professionals to use structured historical immunization information in the clinical workflow

• Recommended CEHRT Functionality– Ability to receive and present a standard set of structured,

externally-generated immunization history and capture the act and date of review within the EP/EH practice






DRAFTImproving population and public health: Electronic lab reporting

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No Change from Stage 2

EH Objective: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practiceMeasure: Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period.


DRAFTImproving population and public health: Syndromic Surveillance

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No Change from Stage 2EP MENU Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice

EH Objective: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice

EP/EH Measure: Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period


DRAFTFormer Objective Details Proposed Merged Registry Objective(404, 405, 407 - EH objective)

EH Objective: Capability to electronically submit standardized (i.e., data elements, structure and transportmechanisms), commonly formatted reports to two registries (e.g., local/state health departments,professional or other aggregating resources) from the Certified EHR Technology, except where prohibited,and in accordance with applicable law and practice. This objective is in addition to and does not replaceprior requirements for submission to an immunization registry. Measure: Documentation (or registry acknowledgement) of ongoing successful electronic transmission ofstandardized reports from the CEHRT to two registries (either mandated or voluntary)). Attestation ofsubmission for at least 10% of all patients who meet registry inclusion criteria during the entire EHRreporting period as authorized, and in accordance with applicable State law and practice.

Registries include: cancer, health-care associated infections, children with special needs, and/or earlyhearing detection and intervention or external entities that maintain the registry (e.g., hypertension,diabetes, body mass index, devices, and/or other diagnoses/conditions) that could includeaccountable care organization, public health agency, professional society, or specialty community)should maintain the registry

Certification criteria: EHR is able to build and then send a standardized report (e.g., standard messageformat) to an external mandated or voluntary registry, maintain an audit of those reports, and track totalnumber of reports sent.

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DRAFTFormer Objective Details Case reports – 402B

Stage 3 Proposed for Future StageCertification criteria: The EHR uses external data to prompt the end-user when criteria are met for case reporting. The date and time of prompt is available for audit. Standardized (e.g., consolidated CDA) case reports are submitted to the state/local jurisdiction and the data/time of submission is available for audit.

EP Objective: Capability to use externally accessed or received knowledge (e.g. reporting criteria) to determine when a case report should be reported and then submit the initial report to a public health agency, except where prohibited, and in accordance with applicable law and practice.

Measure: Attestation of submission of standardized initial case reports to public health agencies on 10% of all reportable disease or conditions during the entire EHR reporting period as authorized, and in accordance with applicable state/local law and practice.

Certification ONLY

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Affordable care:Stage 3 Priorities

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• CDS support to avoid duplicative care

• CDS support to avoid unnecessary or inappropriate care

MU Outcome Goals

• Eliminate duplicative testing

• Use cost-effective diagnostic testing and treatment

• Minimize inappropriate care (overuse, underuse, and misuse)

• Formulary checks• Generics


Objectives

Affordable care:Clinical Decision Support

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Examples of Functionality Needed to Achieve Goals

• Demonstrate use of multiple CDS interventions that apply to quality measures in each of the six NQS domains. Recommended interventions include:

– Preventive care– Chronic disease management (e.g., diabetes,

coronary artery disease) – Appropriateness of lab and radiology orders – Advanced medication-related decision support

(e.g., renal drug dosing) – Improving the accuracy/completeness of the

problem list– Drug-drug and drug-allergy interaction checks

• CEHRT should provide tools that enable the ability to provide these interventions

• Related work that can inform: S&I HealtheDecisions, HITSC Clinical Quality WG


• CDS support to avoid duplicative care

• CDS support to avoid unnecessary or inappropriate care

Reducing health disparities:Stage 3 Priorities

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• Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

MU Outcome Goals

• Eliminate gaps in quality of health and health care across race, ethnicity, and sexual orientation

• Language• Gender • Race• Ethnicity


Objectives

Reducing health disparities:Additional Patient Information

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• CEHRT provides the ability to capture– Patient preferred method of communication*– occupation and industry codes– Sexual orientation, gender identity (optional fields) – Disability status

o Differentiate between patient reported & medically determined

• Communication preferences will be applied to the clinical summary, reminders, and patient education objectives

– Providers should have the ability to select options that are technically feasible for them, these could include: Email, text, patient portal, telephone, regular mail

• Recommended as certification criteria only


• Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

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Reduction of Disparities – previous deeming recommendations

• Reduction of disparities in gap area• Identify areas where attesters should be

required to demonstrate they have reduced health care disparities in high-risk populations

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Follow-up Items

Feedback from HITSCImaging Sharing and PGHD

Improving quality of care and safety:Imaging

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•For both Eligible Professionals and Hospitals imaging results should be assessable through CEHRT. Results consisting of the image itself and any explanation or other accompanying information•Recommended as a Menu Item for EPs and Core for EHs



• All relevant data accessible through EHR

• CDS supports timely, effective, safe, efficient care and prevention

• CDS helps avoid inappropriate care

HITSC Clinical Operations WG Charge

12/18/2013 41

• How full image sets or designated key images are shared between different facilities and specialists: the high level architecture e.g. role PACS, Archives, and EMRs

• How this is deployed with central and distributed reading facilities

• What methods and technical standards are used to push, pull, or view images in one place that originated or were interpreted in another place

• Issues encountered sharing reports and interpretations, or auditing, with or alongside the images themselves

• Inclusion of time series data in scope in addition to radiological images

Recommendations for Image Sharing

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TIER 1Exchange of Text-Based

Reports

TIER 2Exchange of

Non-Radiology/Cardiology Images

TIER 3Exchange of

Radiology/Cardiology Images - Full Study

TIER 4 Exchange of

Radiology/Cardiology Images- Key Images

CONTENT

Plain text +/- structured headings,

scanned/rendered document

"Clinical Capture" images with or without metadata

Complete set of images of diagnostic quality

IHE Key Image Note (KIN) and images referenced therein

ENCODING

PDF, HL7 2.x OBX segment content, CDA L1, or CDA L2 + CCDA

DIR template

Without metadata: JPEG, PNG, DNG, PDF, H.264; with

metadata: DICOM

DICOM (object appropriate to modality)

VOCABULARY

LOINC to describe study/procedure, LOINC for structured headings

LOINC to describe study/procedure (in DICOM

header/XDS metadata)

LOINC to describe study/procedure

LOINC to describe study/procedure, DICOM

DCID 7010 for titles

PUSHHL7 V2 ORU/MDM

MLLP over VPN/TLS, DIRECT SMTP or XDR

preferred

DIRECT SMTP or XDR, DICOM DIMSE/ULP or STOW

over VPN/TLS, IHE XDR-I

DICOM DIMSE/ULP or STOW over VPN/TLS, IHE XDR-I

DICOM DIMSE/ULP or STOW over VPN/TLS, IHE XDR-I

PULL

IHE XDS IHE XDS-I, DICOM WADO-URI or WADO-RS over VPN/TLS

IHE XDS-I, DICOM WADO-URI or WADO-RS over VPN/TLS

IHE XDS-I, DICOM WADO-URI or WADO-RS over VPN/TLS

VIEW

IHE IID, else pull (WADO-URI+/-XDS-I for rendered JPEGs when

sufficient)

IHE IID, else pull (WADO-URI+/-XDS-I for rendered

JPEGs when sufficient

Abbreviations/Terminology

12/18/2013 43

• Metadata: in this context, patient identifiers, dates, acquisition technique

• KIN: IHE Key Image Note • KOS: DICOM Key Object Selection • DIMSE: DICOM Message Service Element (traditional DICOM PS 3.7)• ULP: Upper Layer Protocol (traditional DICOM PS 3.8 TCP/IP

protocol)• MLLP: HL7 V2 Minimal Lower Layer Protocol (used by all IHE HL7 V2

stuff)• IID: IHE Invoke Image Display• STOW: DICOM Store Over the Web by RESTful Services (STOW-RS)

Discussion from HITSC

• Very difficult to set certification criteria with so much optionality in recommended standards

• Need guidance on specific purposes and use case scenarios for certification

• “Our challenge was to provide a parsimonious collection of constrained standards for consumer and professional applications in tightly coupled (modality to PACS), and loosely coupled (web-based, cloud hosted image exchange) architectures. We all agreed that we need to be very careful when writing certification criteria to avoid optionality such that vendors will be forced to implement many different standards (the "OR" of meaningful use becomes the "AND" of certification)” http://geekdoctor.blogspot.com/2013_12_01_archive.html

04/19/2023 Office of the National Coordinator for Health Information Technology 44

http://geekdoctor.blogspot.com/2013_12_01_archive.html

DRAFTEngaging patients and families in their care: Patient Generated Health Data

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• Enabling active participation by patients and families to improve health and care

• Provide ability to contribute information in the record, including patient reported outcomes (PRO)

• Patient preferences recorded and used


• Eligible Providers and Hospitals provide the capability for patients to electronically submit patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status), secure messaging or provider-selected devices using CEHRT. (Provider-selected devices pending consideration by HITSC)

• Recommended as a Menu item• Low threshold

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Standards Recommendations

• ONC should consider the Direct transport standard for secure messaging and data from devices

• ONC should consider the HL7 Care Team Roster standard

• ONC should consider the HL7-CCDA for structured and unstructured questionnaires

• ONC should consider the Continua standard for data from devices

• We encourage standards that support mobile access to patient data and PGHD given the proliferation of mobile devices. However, we do not recommend mandating a specific standard at this time given that might stifle innovation.

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Recommendations for Development of Consumer Standards

• ONC should consider an S&I Initiative to create needed collaborative care document structure to address versioning, expanded provenance, reconciliation, data governance and curation.

• ONC should consider creating a process to align consumer product and provider standards

• ONC should consider using BlueButton+ API approach to accommodate PGHD

• Trust Framework expanded for consumer/patient adoption in emerging technologies (BB+)

• ONC should ask the HITSC to prioritize consumer vocabularies to support wider consumer, patient and family engagement

HITSC Discussion

• The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data. Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices.

• As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases.

• Continua will provide us a list of the named standards so that we can validate the maturity and adoption of Continua's recommendation.

• We will also ensure that the CCDA templates include the appropriate vocabularies that will enable incorporation of patient generated data into EHRs.

• http://geekdoctor.blogspot.com/2013_12_01_archive.html

04/19/2023 Office of the National Coordinator for Health Information Technology 48



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