Certification / Adoption Workgroup

Larry Wolf, chairMarc Probst, co-chair

Certification / Adoption Workgroup

January 17, 2014

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Agenda

• Review of Agenda• HITPC Charge: Step Two – Presentation by Michelle Dougherty: Roadmap for Health

IT in LTPAC & Alignment with Certification – Continued discussion of proposed LTPAC health IT

Certification Criteria• Next Steps• Public Comment

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Updated Call Schedule

Date Call Schedule 10/25/2013 Overview of new charge11/4/2013, 11/18/2013 Develop a framework for certification12/2/2013, 12/12/20131/10/2014, 1/17/2014, 1/21/2014

LTPAC EHR background presentation, virtual hearing, draft recommendations

1/24/2013, 1/28/2014,2/7/2014, 2/14/2014

BH EHR background presentation, virtual hearing, draft recommendations

2/21/2014, date TBD Workgroup review and finalization of recommendations

3/11/2014 Recommendations to HITPC3/26/2014 Recommendations to HITSC

*Dates in red are changes from previous call schedule.

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ROADMAP FOR HEALTH IT IN LTPAC & ALIGNMENT WITH CERTIFICATION

Roadmap for Health IT in LTPAC & Alignment with Certification

LTPAC HIT

Michelle Dougherty, MA, RHIA, CHPSenior Director of Research and DevelopmentAmerican Health Information Management Association Foundation

Presented to: HIT Policy Certification and Adoption WorkgroupJanuary 17, 2014

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LTPAC HIT Collaborative

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Publishes an Biennial Road Map

2006-2008

2008-2010

2010-2012

2012-20147

Road Map Priorities over the Years

Business Imperative and Emerging Care Delivery & Payment Model s

Increase Adoption and Use of EHRs/HIT in LTPAC

Advance HIT Standards & Certification

Health Information Exchange and Interoperability

Transition of Care and Care Coordination

E-Prescribing & Medication Management

Quality Measurement & Improvement

Consumer/Caregiver Engagement & Access to Health Information

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Strategizing Certification, HIE & Interoperability over the Road Maps

2006-2008• Certify EHR and e-

prescribing solutions to reduce risk.

• Advocate, participate in development, & adopt content & messaging standards to promote interoperability across settings.

2008-2010• Certify EHR and e-

prescribing solutions to enhance safe medication prescription and administration

• Demonstrate interoperability of HIT products through use of emerging standards

2010-2012• Establish EHR

certification criteria for LTPAC to promote adoption & coordination.

• Foster inclusion and participation of LTPAC in emerging HIEOs.

• Promote use of HIT for transition of care and for e-prescribing.

2010-2012Achieve enhanced care coordination between hospitals, physicians, & other providers…by facilitating standards, interoperability and certification efforts of LTPAC.

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Thank You on behalf of the

LTPAC HIT Collaborative

Michelle [email protected]

312-233-1914

The LTPAC HIT Road Maps are available at www.ltpachealthit.org

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mailto:[email protected]

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REVIEW & FRAMING FOR CERTIFICATION DISCUSSION

Review & Framing for Certification Discussion

HITPC Charge to the C/A Workgroup

• Recommend a process for prioritizing health IT capabilities for EHR certification that would improve interoperability across a greater number of care settings

• Recommendations shall take into account previously adopted ONC certification criteria and standards and identify the key heath IT capabilities needed in care settings by providers who are ineligible to receive EHR incentive payments under the HITECH Act

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The Scope of Work for the Charge

Step 1: Draft a process that could be used to identify and prioritize certification criteria for health IT that is used by providers outside of the Meaningful Use Program and for which an ONC certification program would be helpful.

Began on12/2/13

Complete

Step 2: Recommend a specific application of this process for EHRs used in long-term/post-acute care (LTPAC) and behavioral health (BH) settings.

By3/2014

Step 3: Revise Step 1 recommendations, if needed, based on experience applying them during Step 2.

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Focus of Recommendations: Guiding Principles

– Health IT privacy and security – Transitions of care– Interoperability– Setting specific health IT (patient assessments;

survey and certification)

Guiding Principles: Build on and align with existing criteria/standards in the health IT sector (MU, HL7 & CCHIT); address the health IT needs of the LTPAC community, including in the areas of:

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Basis for Recommendations

• HIE RFI• LTPAC Hearing Testimony & Submitted Letters• Mapped comparison of prior, industry-led certification efforts,

including HL7 LTC Functional Profile (FP) and CCHIT (sponsored by ASPE) – Note: these efforts pre-date the MU certification program– However, these efforts demonstrate areas of importance for criteria

development (as identified by the industry)– Mapping also linked testimony from the LTPAC EHR hearing

• Analysis of ONC 2011/2014 certification modules adopted by LTPAC vendors (sponsored by ASPE)

• New, emerging health IT standards that could support LTPAC HIE (e.g. HL7 TOC and Care plan standards)

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What does “Interoperability” mean?

ONC follows the definition of “interoperability” provided by the IEEE dictionary which defines interoperability to mean:

“the ability of two or more systems or components to exchange information and to use the information that has been exchanged.”

Source: http://www.healthit.gov/sites/default/files/generalcertexchangeguidance_final_9-9-13.pdf

http://www.healthit.gov/sites/default/files/generalcertexchangeguidance_final_9-9-13.pdf

Building on existing criteria and standards

Proposed Recommendations

MU MU 2 Base MU 2 Interoperability Criteria

Privacy and Security MU2 xSummary Care Record atTOC/Referral MU2, MU3* x x

Data Portability MU3* x x

View, Download, and Transmit to3rd Party

MU2 x

Clinical Summaries MU, M3* xPatient-Specific EducationalResources MU2 x

Incorporating Laboratory Tests &Values/Results MU2 x

Clinical Decision Support MU2 x xAdvance Care Planning MU2, MU3*Patient Demographics MU2 x

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Building on existing criteria and standards

Proposed Recommendations

MU MU 2 Base MU 2 Interoperability Criteria

Clinical Health Information:•Problem list•Medication list•Medication allergy list

MU2 x

•Clinical Information Reconciliation MU2 x

•Electronic Notes MU2

Medication Related: •e-MAR•Drug-formulary checks

MU2

•Electronic prescribing x

CPOE MU2 x

Public Health (Immunizations) MU2 x

LTPAC Setting Specific: PatientAssessment

LTPAC Setting Specific: Survey andCertification

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Review of the Proposed Areas of Certification

• Consider each proposed area of certification by:– Briefly highlighting LTPAC hearing testimony of

relevance to the proposed area of certification– Discuss the proposal (blue box)– Determine whether the proposed area of

certification is a “key heath IT capability needed” in the LTPAC care setting

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Proposed Areas for Certification

Proposed Areas for Certification

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Clinical Quality Measures

• “if [EHR]certificationrequirements for LTPAC… were to include… the ability to exchange…interoperable data elements required for good transitions and …longitudinal coordination of care… this could be a quality metric that could drive some of the adoption of the EHR, [and] fundamentally improve the process of care.”

• “CMS believes that datauniformity…across settings, is critical to facilitate … transfer of information…and ….implement measures that can be harmonized across settings...”

• C/A Workgroup requests that HITPC Quality Measures WG discuss clinical quality measures further and provide recommendations to C/A WG on potential LTPAC CQM opportunities for LTPAC EHR certification.

• Neither the LTC FP northe CCHIT criteria require the ability to capture the data required by the specified Data Element Catalogs, use the HL7 QRDA standard, or require the ability to calculate quality measures as specified in the ONC 2014 edition.

LTPAC Hearing Proposed Areas for Certification

Prior LTPAC Certification Efforts (HL7 LTC FP /

CCHIT LTPAC)

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Privacy and Security

• “there should be anoverarching standard around security and privacy” • “.. if my IT department had not evaluated the [EHR]software—I would've implemented a piece of software that, on a daily basis, would have been a HIPAA data breach violation”

• Authentication, Access Control, and Authorization

• Auditable Events and Tamper-Resistance

• Audit Report(s) • Amendments• Automatic Log-Off• Emergency Access • End-User Device Encryption • Integrity • Optional – Accounting of

Disclosures

• Previous certificationefforts have supportedprivacy, security andintegrity criteria



CCHIT LTPAC)

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Summary Care Record at TOC/Referral

• “electronic exchange ofstandardized, interoperable clinical information between different IT platforms becomes the essential tool for care integration between and among acute and LTPAC providers”

• “As the patientexperiences care transitions, interoperability will lead to efficiencies…”

• Support the ability toreceive, display, incorporate, create and transmit summary care records with a common data set in accordance with the Consolidated Clinical Document Architecture (CCDA) standard and using ONC specified transport specifications

• Support the inclusionof emerging TOC and care planning standards being reconciled as part of Aug. HL7 CCDA ballot [MUWG-identified MU 3 criteria]

• Previous certificationefforts have supportedTOC/referral summaries

• The LTC FP and CCHITLTPAC program pre-datethe ONC 2014 transportstandards.

• The LTC FP and CCHIT LTPAC program pre-datethe HL7 Consolidated CDA standard.



CCHIT LTPAC)

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Clinical Summary

• “…are pressured byreceiving EHs for better information and getting pressure from EHs to be part of the system”

• “The focus of [LTPAC EHR]certification should be to support transitions of care”

• “standards used inmeaningful use, such as CCDA, SNOMED, LOINC, and RxNorm, can be and are supported within the EHR products to help obtain greater parity in the exchange of information regardless of formal certification”

• Support the ability to create a clinical summary in accordance with the CCDA standard in order to provide it to a patient.

[Consistent with MUWG- Support for identified criteria under consideration in MU3; update forthcoming.]

• Previous certificationefforts have supported theCreation of a clinical summary



CCHIT LTPAC)

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Data Portability

LTPAC panelists:

• “..recommendedestablishment of standards and incentives to help long-term services providers adapt their existing EHR system or purchase a new one that meets requirements for interoperability, transfer of information, and enabling of monitoring for quality.”

• “The focus of [LTPAC EHR]certification should be to support transitions of care”

• Support the ability to create a set of export summaries for all patients, formatted in accordance with the CCDA.

• Support the ability to enable patients who switch providers to have their care continue seamlessly (no repeat tests, missing key clinical information, etc). [MU 3 goal from IE WG]

• Support the ability to enable providers switching EHR systems to continue providing seamless care to patients (coded data in old system is consumable by the new system so clinical decision support still works). [MU 3 goal from IE WG]

• Previous certificationefforts have supported the creation of a clinical summary



CCHIT LTPAC)

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View, Download, and Transmit to 3rd Party

• “As we view, download, and transfer, the provider should protect … information, but the patient should continue…to direct it, so the work being done in Blue Button would have a great application in transitions of care and [LTPAC]”

• Support the ability to provide secure online access to health information for patients and authorized representatives to electronically view, download their health information in accordance with the CCDA standard

• Support the ability to transmit such information using ONC specified transport specifications

• Neither the LTC FP northe CCHIT LTPAC program include requirements providing patients with an online means to view, download, and transmit specified data to a 3rd party.

• 12/2 C/A WG call: Patientportals are available across all LTPAC provider types. However, frequency and breadth of use is unknown.



CCHIT LTPAC)

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Patient-Specific Educational Resources

• “75 percent of [long term care] provided by families in the home, and by non-licensed personnel and agencies going into the home.”• “we need to figureout the presentation layer that appeals to patients and families, … have one record that all parties can tap into, upload to, download from, right through to the end of the person’s life…”

• Support the ability to use ONC specified standards to electronically retrieve patient-specific education from content/knowledge resources.

• Previous certificationefforts have supported the process for patient educational resources

• 12/2 C/A WG call: Patientportals are available across all LTPAC provider types. However, frequency and breadth of use is unknown.



CCHIT LTPAC)

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Incorporating Laboratory Tests & Values/Results

“The [CDS] systems thatwe've developed use signals that require the presence of admission, discharge, transfer, lab, and medication data…there are existing standards for lab, including LOINC and medications, NCPDP, and are widely available to support [AD detection and management].” “Due to our recentcertification process, we've built in some key capabilities. We can now import lab results…”

“Indeed, we find that sharing…lab results and just the exchange of demographics … have been the primary interest.”

• Support the ability to electronically receive, incorporate, and display clinical laboratory tests and values/results in accordance with the HL7 Version 2.5.1 Implementation Guide and with laboratory tests represented in LOINC

• Previous certificationefforts have supported receiving and incorporating, displaying lab results

• Neither the LTC FP northe CCHIT LTPAC criteria explicitly identify the ONC specified lab data components, for a test report



CCHIT LTPAC)

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Clinical Decision Support

• “CDS can greatly improvethe detection and management of [adverse consequences] and improve [regulatory compliance] and inclusion of medication specific CDS should provide alignment with and support existing federal and state programs...” • “the level ofopportunity for using [CDS] at the time of prescribing can be quite significant. For example, …clear opportunity to optimize the way antibiotics are being used and other antimicrobials”

• “we should try and link[CDS rules] to those harm related events to try and reduce that ”

Support the ability to have:• Evidence-based decision

support interventions. • Linked referential clinical

decision support. • Clinical decision support

configuration.• Automatically and

electronically interact• Source attributes• Drug-drug, drug-allergy interaction checks.

• Prior certification effortshave supported CDS interventions based on problems, medications, medication allergies, demographics & labs

• No match on referenceinformation, source attribution, and electronic triggering for clinical decision support.



CCHIT LTPAC)

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Clinical Health Information

• “…documents to meetCMS documentation requirements of an annual comprehensive med review. This structured document contains the pharmacist provided reconciled active med list, allergy list, indications for each active medication, and special instructions for the patient…can be used by pharmacists and other health care providers in all practice settings including LTPAC and behavioral health.”

• Support the ability to record, change, and access the:o Problem listo Medication listo Medication Allergy listusing ONC specified standards

• Support clinical information reconciliation.

• Support Electronic Notes.

• Prior certification effortshave supported the ability to electronically record, change, and access problem list, medication list , medication history, active medication allergy list and medication allergy history.



CCHIT LTPAC)

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Patient Demographics

“exchange of demographics and using some of the older ADT standards have been the primary interest…”

• Support the ability to record, change, and access patient demographic data

using ONC specified standards

• Neither LTC FP nor CCHITcriteria identify explicit demographic data elements to be captured and maintained.

• Neither LTC FP nor CCHITinclude criteria addressing the ability to record, change, and access preliminary cause of death in the event of a mortality.



CCHIT LTPAC)

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Advance Care Planning

• “We need advanced plansin all records, we need to know who the surrogate is, and not just a yes/no. We need to be able to code the major decisions…We need to make the core elements available to the patient, family, and caregiver. “

“…it is becoming actually harmful and dangerous to have in the electronic record only a yes/no on an advanced directive. Now, a majority of states accept the POLST—we could readily digitize most of the POLST entries, and we could readily scan and attach to the record a real document”

• Support the ability to recordwhether an advance directive exists for the patient

• Support the ability to store anadvance directive document in the record or provide a link to the advance directive in a repository or other location. [MUWG-identified MU3 Criteria under consideration]

• Support the ability to retain versions of the advance

directive document in the record or enable links to earlier versions of the advance directive document. [MUWG-identified MU3 Criteria under consideration]

•Future work: Standards for content of the advance directive

Prior certification has indicated:

• the type of advance directives completed

• when last reviewed, time stamp entry of information

• name and relationship of party completing the advance directive

• location and or source of legal documentation

*More info in supplemental mapping materials



CCHIT LTPAC)

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Medication Related Criteria

• “the practice ofprescribers entering orders electronically into the EHR will decrease the chance for errors in the interpretation of prescriber orders.”

• “a significant number oforders are changed today verbally or via telephone, …..keystroke errors are frequently identified in our business as contributors to adverse events that result in patient harm.”

• “Pharmacistselectronically accessing and exchanging clinical information in these settings are vital to meeting institutional quality and safety medication management processes.”

Support for: • e-MAR• Electronic prescribing• Drug-formulary checks

• Previous certificationefforts have supported the ability to:

o record, change and access each of the order types (i.e., meds, labs, radiology /imaging)

• Verify right patient• NCPDP SCRIPT v10.6• Automatically andelectronically check whether a drug formulary exists for patient or drug



CCHIT LTPAC)

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Computerized Provider Order Entry (CPOE)

• “A subset of the criteriarules, such as e-prescribing, labs and other diagnostic data, and activities of daily living [from the ONC 2014 certification criteria would support TOC], could apply”

• Support the ability to electronically record, change, and access the following order types: (i) Medications; (ii) Laboratory; and (iii) Radiology/imaging.

• Previous certificationefforts have supported the ability to record, change and access each of the order types (i.e., meds, labs, radiology/imaging)



CCHIT LTPAC)

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Public Health - Transmission to Immunization Registries

• “defining a health ITstandard for… influenza vaccine administration… would enable…information…exchanged between… providers as well as … state vaccination registries. This could reduce duplication of immunization …among different…providers caring for the same person, reduce… individual’s risk of receiving multiple vaccinations…, and provide [PH] with reliable information and vaccine coverage within communities”

• Support the ability toelectronically generate immunization information for electronic transmission using ONC specified standards.

• Previous certificationefforts have supported the ability to record, change, and access immunization information.

• Neither the LTC FP northe CCHIT LTPAC criteria address creating immunization information for transmission using the HL7 v2.51 Immunization Messaging standard or HL7 Standard Code Set CVX – Vaccines Administered.



CCHIT LTPAC)

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LTPAC Setting-Specific Criteria: Federally Required Patient Assessments

• “The handling of theMDS, … census data, care planning, quality assurance activities, by and large …are primarily used for internal operations of the SNF. There are a number of SNFs that would like to be able to transmit data… but the interoperability structure in the state is not terribly well developed for communicating between hospitals and SNFs, SNFs and home health or home care, assisted living.

• Support the ability to create,maintain, and transmit (in accordance with CMS requirements) assessment instruments and data sets for LTPAC: MDS 3.0, OASIC-C , IRF-PAI, CARE subset for LTCH, and a Hospice Item Set.

• Support the use of acceptedvocabulary standards to enable the reuse of assessment data for:

o various clinical purposes; and

o administrative purposes.

• Support the ability of the provider or a designated third party to create and exchange interoperable LTPAC Assessment Summary CDA documents

• Previous certificationefforts have supported the ability to create, maintain, transmit, and reuse assessment content.



CCHIT LTPAC)

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LTPAC Setting-Specific Criteria: Federally Required Patient Assessments

• “LTPAC reportingrequirements should be harmonized with clinical data required for patient care.”

• CMS believes that datauniformity…across settings, is critical to facilitate … transfer of information. It’s also what’s needed…to develop and implement measures that can be harmonized across settings... “

Future work: • Harmonization of federalcontent and format for patient assessments with ONC specified EHR standards (e.g. consistent standards on demographics).

• Make the dataelement library publically available and link content to nationally accepted standards.

• Previous certificationefforts have supported the ability to create, maintain, transmit, and reuse assessment content.



CCHIT LTPAC)

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LTPAC Setting-Specific Criteria: Survey and Certification

• “Surveyors need promptand complete access to the EHR to complete surveys as required.”

• “It would be interestingto consider if an EMR certification program could also include certain interoperability with this QIS [Quality Indicator Survey] software.”

•“it [is] imperative for the surveyors …to look across modules of the EMR to understand the timeline of how the different care components fit together.”

• Support the ability topromptly provide surveyors with access to the complete EHR, consistent with federal requirements.

Future work:• Support surveyornavigation of the EHR. (e.g. Implementation guide describing the functions in the EHR that surveyors need). More work is needed in this area. • Support the QIS process.More work is needed in this area.

• Prior certification hassupported surveyor access to the complete EHR, consistent with federal requirements.



CCHIT LTPAC)

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Tracking LTPAC EHR Adoption and Use Trends

Additional Proposals:• As ONC advances LTPAC certification, ONC

should track national trends in LTPAC health IT adoption. Such efforts should include tracking use by functionality and criteria.

• National survey data on LTPAC EHR adoption and use should utilize definitions that are consistent with those in the MU program.

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Certification / Adoption Workgroup

Documents