HIT Policy Committee Certification and Adoption Workgroup Meeting Dec 2nd, 2013 11:00am Eastern.

HIT Policy Committee

Certification and Adoption Workgroup Meeting

Dec 2nd, 201311:00am Eastern

2

Agenda

• Review of Agenda• HITPC Charge: Step Two

• Background Regarding LTPAC Providers ⁻ Who are LTPAC providers?⁻ What is the clinical utility of EHRs to LTPAC settings? ⁻ What is known about EHR adoption by LTPAC providers?

• 5 Factor Framework – Considerations related to LTPAC⁻ Presentation and Discussion of Factors 1-5

• Next Steps• Virtual Hearing – ONC EHR Certification for LTPAC, 12/12/13

• Public Comment

HIT/EHRs for LTPAC Providers: Considerations for Certification Criteria Identified in the 5 Factor FrameworkJennie Harvell, HHS/ASPE

Sue Mitchell, Independent Consultant

4

5 Factor Framework

•Advance a National Priority or Legislative Mandate: Is there a compelling reason, such as a National Quality Strategy Priority, that the proposed ONC certification program would advance?

•Align with Existing Federal/State Programs: Would the proposed ONC certification program align with federal/state programs?

•Utilize the existing technology pipeline: Are there industry-developed health IT standards and/or functionalities in existence that would support the proposed ONC certification program?

•Build on existing stakeholder support: Does stakeholder buy-in exist to support the proposed ONC certification program?

•Appropriately balance the costs and benefits of a certification program: Is certification the best available option? Considerations should include financial and non-financial costs and benefits.

When evaluating whether to establish a new certification program, ONC should consider whether the proposed certification program would:

LTPAC Providers

Inpatient Providers Home/Community-Based Providers

Nursing homes (SNF/NF)

Long-term care hospitals (LTCHs)

Inpatient rehabilitation facilities (IRFs)

Intermediate care facilities for persons with intellectual disabilities (ICF/IID)

-Home health agencies (HHA)

-Other Home and Community-Based (HCBS) Providers

(Note: Not included in Other Provider Study)

Hospice providers

A mix of inpatient (including specialty hospitals) and home and community-based providers who provide care for short or long durations, as part of interdisciplinary teams. Team members may be co-located or remote.

Clinical Utility of EHRs and Need for HIE in LTPAC• In the Other Provider Study, Clinical Utility was defined as:

– Ability of the EHR technology to support interoperability and secure information exchange among health care providers by complying with requirements of a “base EHR." a

• Need for HIE in LTPAC: High. – Patients are medically-complex, functionally impaired and require

clinicians/other team members with complete knowledge of their medical history.a

– Patients are treated by and receive services from multiple healthcare and ancillary providers during single episodes and over-multiple episodes of care. (see details in subsequent slides)

– Patients are admitted from and may be transferred to one of several providers/facilities for continuing or emergency care. (see details in subsequent slides)

• Close to 40% of Medicare beneficiaries discharged from hospitals go to post-acute care settings (e.g., rehabilitation hospitals and SNFs), but there is little capacity in the system today to support HIE across these settings. b

• 20% of Medicare patients are readmitted to the hospital within 30 days. Preventable readmissions waste $26B nationwide annually. C

Base EHR Definition (ONC Standards and Certification Criteria (2014 Ed.))

Base EHR Requirements (ONC 2014 Ed.): 2014 Certification Criteria

Patient Demographic 170.314 (a)(3) (both inpt and ambulatory)

170.314(a)(5) (both inpt and ambulatory)Clinical Health Information such asmedical history and problem lists

170.314(a)(8) (both inpt and ambulatory)Clinical Decision Support

Physician Order Entry 170.314 (a) (1)Computerized provider order entry (both inpt and ambulatory)

Capture and query informationrelevant to health care quality

170.314(c)(1),(2) and (3) Clinical Quality Measures (including (c)(1) and (2) for minimum CQMs)

Exchange electronic healthinformation with, and integrate suchinformation from other sources

170.314 (b)(1) Transitions of Care - receive, display incorporate ToC/referral summaries; and

170.314 (b)(2) Transitions of Care - create and transmit ToC/referral summary

Confidentiality, integrity, and availability of health information stored and exchanged 170.314(d)(1) through (8)

• 170.314(a)(6) Medication List • 170.314(a)(7) Medication Allergy List

• 170.314(7) Data portability

HIT/EHR Adoption Rates for LTPAC Providers

Ineligible ProviderUse an EHR?

Adoption Rates of Basic(non-certified) EHRs forSome Clinical Processes

Long-Term & Post-Acute CareHome Health Agencies (HHAs) Yes 43%a

Hospice Yes 43%a

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

Unknown

Long-Term Care Hospitals (LTCHs)

Yes 6%b

Nursing Homes (SNFs/NFs) Yes 43%c

Inpatient Rehabilitation Facilities/Units

Yes 4%b

HIT/EHR Adoption Rates for LTPAC Providers

LTPAC Provider Use of EHRs in Practice

Long-Term and Post-Acute Care EHR Use

Use in practice - ADT- Appointments- Order entry and

management- Clinical notes- Assessments- Care plan- Condition-specific

documentation- Medication and

treatment records

- Pharmacy information system

- Lab information system

- Therapy information system

- Patient portals- Patient eligibility

determinations- Billing- Staffing, payroll, and

Human Resources

Advances

Nationa

l Priority

•Advance a National Priority or Legislative Mandate: Is there a compelling reason, such as a National Quality Strategy Priority, that the proposed ONC certification program would advance?

Factor #1

National Quality Strategy

• 3 Aims: Better Care, Healthy People/Healthy Communities, Affordable Care.

• 6 Priorities – 3 of which are:–Making care safer by reducing harm caused in the

delivery of care.–Promoting effective communication and

coordination of care.–Making quality care more affordable for

individuals, families, employers, and governments by developing and spreading new health care delivery models.

•Use of HIT could support these priorities.

HIE Needed to Support Care Coordination and Safety

• Experts in transitions of care identify “improving information flow and exchange” as the most important tool to improve care transitions. ONC, 2011

• Approximately 50% of all hospital-related medication errors, and 20% of all adverse drug events attributed to poor communication during transitions of care, which can result in hospital readmissions. Barnsteiner, 2005

• When multiple physicians treat patients following a hospital discharge, information is missing 78% of the time. van Walraven, et al., 2008

• Emergency Department physicians lack important/ critical patient information 32% of the time. Stiell, et al., 2003

• Communication failures between providers contribute to nearly 70% of medical errors and adverse events in health care. Gandhi, et al., 2000

• 150,000 preventable Adverse Drug Events ($8 Billion nationwide wasted) per yr due to inadequate medication history at time of hospital admission. MedPAC, 2007

HIE Needed to Support Care Coordination and Safety

• Shared care is common for persons receiving LTPAC. For example:– In 2005, persons living in NH made approximately 2.2. million

ER visits.a – In 2008, 23.8 million Part B claims were allowed for physician

visits to NH residents.b

– In 2010, a study showed that NH residents average 7-8 medications – which would translate to over 15.8 million prescriptions for new admissions alone. C

• Only 25% of hospitals exchanged medication lists and clinical summaries with outside providers and 31% of physicians electronically exchanged clinical summaries with other providers.e

“Health IT has the potential to empower individuals and increase transparency; enhance the ability to study care delivery and payment systems; and ultimately achieve improvements in care, efficiency, and population health.” ONC Federal Health IT Strategic Plan 2011-2015

• Health information exchange can benefit persons receiving LTPAC services by “enabling secure, timely electronic information exchange to support proper medication management, seamless transitions of care, and expanded communication between numerous providers.” ONC and ASPE documents

Potential Benefits of HIT/HIE in LTPAC

Potential Benefits of HIT/HIE in LTPAC

Reported benefits in LTPAC include:• Increase efficiencies a, b (e.g., expedited NH and HHA pre-admission decisions/ start of

care, reduced time to complete assessments)

• Opportunities to re-use data a, b, e (e.g., more complete clinical picture, data re-used from and for assessments)

• Improve safety (e.g., reduced med errors) and reduce manual data entry errors e

• Re-direct staff from paperwork to caregiving a, b

• Data analytics a, b, e (e.g., identify: clinical complexity, resource requirements, safety issues (e.g., medication reconciliation))

• Quality, coordination, and cost improvements a, b, e (e.g., improved transitions and coordination of care, improved medication reconciliation, improved quality measure and reporting, reduced rehospitalizations)

• Possible lower malpractice claims and payments c, d

• Enhance market position among consumers and health care partners b, d

Generally, these benefits were reported as a result of using non-interoperable, non-certified technologies.

Potential Benefits of HIT/HIE in LTPAC• Some vendors and LTPAC providers have implemented CDS applications to support

service transformation and improve clinical decision making at the point of care to reduce costs and improve outcomes. For example:– CCITI NY assists providers with CDS and quality improvement initiatives including

implementation of CDS capabilities that capture electronic patient health data from multiple sources to create real-time alerts designed to help clinicians prevent harmful events and avoid unnecessary transfers.

– Univ. of Pitt has implemented CDS applications that use electronic patient level health information from a variety sources (e.g., LTPAC provider, hospital and physician) to create tools that alert clinicians about potential ADEs and prevent medication errors.

– SavaSenior Care has implemented data analytic tools that use electronic patient data aggregated across different LTPAC information systems (e.g., assessment data, pharmacy data, supply inventory management data) to create algorithms that identify underlying quality problems and potential solutions.

– Some LTPAC EHR vendors have incorporated data analytics and CDS applications into product

• The extent to which these LTPAC CDS applications integrate HIT standards and requirements from the ONC 2014 Ed. is unknown.

Factor 1 Conclusions

• Use of CEHRT by LTPAC providers is expected to improve HIE, improve quality, continuity, and coordination of care, and enhance safety in: LTPAC settings, physician practices, and hospitals, in both the fee-for-service and transformed service delivery environments.

• The potential quality, continuity, and coordination of care benefits of establishing a voluntary LTPAC CEHRT program and EHR certification criteria will depend on:– Adopting criteria that supports needed functionality– Aligning these criteria and associated health IT standards with those

adopted via the ONC 2014 Ed. requirements– Incorporating these functions and standards in LTPAC vendor EHR

products– LTPAC provider acquisition and use of certified products that supports the

needed functionality

Align Fed/State Programs

•Align with Existing Federal/State Programs: Would the proposed ONC certification program align with federal/state programs?

Factor #2

Programs Supporting HIT/HIE in LTPACService delivery transformation is occurring. CMS and States are implementing service delivery and payment programs that require or support HIE with and by LTPAC providers and other care providers across continuum, and with payers and regulators. Some of these programs are:

• ACOs • Bundled payment models• Balancing Incentive Programs (LTSS & HCBS)• TEFT: Testing Experience & Functional Tools• Medicaid Health Home State Plan Option (Patient-Centered Medical Homes

(PCMHs)• Dual-eligibles programs• Community-Based Care Transitions Program • State Innovations Models (SIMs)• Hospital Readmission Reduction Program• Medicare Physician Fee Schedule Enhancements for:

(i) chronic care management, (ii) services to support transition in care, and (iii) payment for telehealth visits

LTPAC – Federally Mandated Assessments

• In LTPAC settings, CMS requires the completion and electronic transmission of patient assessment data/instruments (i.e., MDS for NHs, OASIS for HHAs, IRF-PAI for IRFs, and a subset of CARE for LTCHs, IRFs & Hospice)

• Assessments support multiple purposes: Patient assessment and care planning, payment, quality monitoring/reporting, and/or survey and certification activities.

• Generally, data elements, while similar, are not equivalent across instruments

• Assessment instruments/data elements are required by CMS to be electronically transmitted using CMS specified transmission requirements

• CMS data submission specifications do not include HIT vocabulary standards identified in ONC 2014 Ed.(e.g., SNOMED for problems, CVX for immunizations)

• Data files for MDS and OASIS assessments can be transformed to a:– Clinically relevant document (i.e., the HL7 specified “LTPAC Summary Document”)

– LTPAC Summary Document represented as a CCD using the C-CDA standard

• The Keystone Beacon Community developed a transform tool for the purpose of enabling HIE between NHs/HHAs and others in the healthcare continuum a,b

Quality Monitoring & Reporting in LTPAC• For LTPAC:

– CMS calculates QMs using facility-specific and aggregate state/national data from federally-required patient assessments that are electronically submitted by LTPAC providers to CMS. These QMs are not comparable across LTPAC settings.

– CMS includes these QMs as part provider performance reports on CMS “compare” websites.

• For physicians/hospitals: CMS has established QMs across a variety of programs that are not align with the QMs established for LTPAC.– The ONC 2014 Ed. requires use of certain HIT standards for import,

export, and transmission of QMs for use physicians/hospitals.

• In contrast to EPs/EHs, LTPAC providers: – Do not calculate and transmit QMs to CMS (they transmit data

elements/assessment instruments); and – Do not use the e-CQM standards in the ONC 2014 Ed. (i.e., QRDA is not

included in the CMS data submission specifications for LTPAC providers).

ONC Certification & Alignment with LTPAC QM Requirements

• ONC Certification program will not (on its own) address/resolve:– The lack of policy alignment between CMS and

ONC submission/transmission requirements– The proliferation of non-aligned QMs across the

care continuum– Critical gap in QMs regarding: Care coordination a

LTPAC Quality Monitoring Surveys

• LTPAC providers are highly regulated (e.g., statutorily required annual surveys).

• The survey process relies resident observation and record review, and uses federally-required assessment data– Surveyors express concerns and questions about their ability to

access content of the health record (as required by law) when encountering EHRs during surveys.

• The LTPAC survey process uses either automated and/or manual data collection and analytic tools.

• LTPAC EHRs are (generally) not aligned with requirements in the ONC 2014 Ed. As a result:– the automated survey process is unable to realize potential

efficiencies (e.g., through data re-use); and– the ability to construct templates to facilitate data gathering and

analysis is constrained.


• Identification and inclusion of key EHR certification criteria and functions in a voluntary LTPAC EHR certification program could provide some alignment with and support for existing Federal/State Programs

• Implementation of a voluntary EHR certification program in LTPAC could create efficiency gains, permit re-use of data, and enable/support quality improvement and care coordination activities/efforts at Federal, State, and provider levels

Utilize

Pipeline

•Utilize the existing technology pipeline: Are there industry-developed health IT standards and/or functionalities in existence that would support the proposed ONC certification program?

Factor #3

LTPAC Standards & Certification Efforts

HL7 LTC EHR-System Functional Profile (LTC EHR-S FP) (2010):• Based on the 2007 HL7 EHR-System Functional Model (EHR-S

FM), R1 (a reference list of functions that may be present in an EHR system

• HL7 LTC EHR-S FP identifies a subset of functions from the EHR-S FM that reflects the unique aspects and needs for an EHR-S in the LTC setting

• Both the LTC EHR-S FP and EHR-S FM are ANSI approved standards

Certification Commission for Healthcare Information Technology EHR Certification 2011 – LTPAC (CCHIT Certified 2011 LTPAC)• Private sector EHR certification program for LTPAC products

created in response to request from the LTPAC community

• Offered beginning July 2010, the LTPAC certification program was new for the CCHIT 2011 testing cycle– Applied many criteria from the HL7 EHR-S LTC Functional Profile– Contains core LTPAC requirements for functionality, interoperability

and security– Offers (i) Skilled Nursing Facility (SNF) and (ii) Home Health (HH)

certification options addressing specific EHR needs for providers in those care settings

LTPAC Standards & Certification Efforts

HL7 LTC EHR-S Functional Profile and CCHIT Certified 2011 LTPAC - Issues and Themes

• The HL7 LTC EHR-S FP and CCHIT LTPAC program generally do not identify health IT standards in their conformance criteria.– Often when standards are referenced, they are named as examples

rather than being specifically required thru conformance criteria.

• Key standards identified in the HL7 LTC EHR-S FP and CCHIT LTPAC program are not in sync with requirements in the ONC 2014 Ed. See examples in notes.

– These private sector programs have not been updated since publication of the ONC 2014 Ed.

• Some requirements from the ONC 2014 Ed. are not included in the HL7 LTC EHR-S FP and CCHIT LTPAC program. For example, the:– HL7 LTC EHR-S FP does not include key criteria related to recording the

encryption status of end-user devices (e.g., USB flash drive)

– CCHIT LTPAC program does not specify criteria to: transmit/send Summary Records/CCDs created per program requirements

– HL7 EHR-S LTC FP and the CCHIT LTPAC program do not identify requirements for:

• Specific demographic data elements & vocabulary standards for these data elements; and

• Vocabulary standards for e-prescribing.

HL7 LTC EHR-S Functional Profile and CCHIT Certified 2011 LTPAC - Issues and Themes

LTPAC EHR Products

• There are approximately 50 “Fully Functional” LTPAC EHR products available in the market a

Fully Functional LTPAC EHRs Not Certified to ONC 2011 or 2014 Ed. Criteria

75%

ONC 2011 Cert. - Complete EHR3%

ONC 2011 Cert. - Modular EHR10%

ONC 2014 Cert. - Complete EHR3%

ONC 2014 Cert. - Modular EHR9%

LTPAC EHR Products

ONC-ACB Certified Products for LTPAC a:• A total of 19 products, from 10 vendors, are certified to ONC

2011 or ONC 2014 criteria.– For purposes of the EHR Incentive Programs, Eligible Professionals

(EPs)/Eligible Hospitals (EHs) must use EHRs certified to the ONC 2014 Ed. beginning January 2014.

• 18 of the 19 products are certified by CCHIT under the ONC HIT certification program (i.e., CCHIT acting as an ONC-ACB).

• EHR certification for 10 out 18 of the ONC-ACB, CCHIT-certified products will expire December 2013 (these are ONC 2011 Ed certified products).b

LTPAC EHR Products

LTPAC EHR Products

• ONC 2011 certification:– A total of 11 products, from 9 vendors, have been certified to the

ONC 2011 criteria• 3 products, from 3 vendors, were certified for the ambulatory practice

setting• 8 products, from 8 vendors, were certified for the in-patient practice

setting• 3 products, from 2 vendors, have been certified as “Complete EHRs”• 8 products, from 7 vendors, have been certified as “Modular EHRs”

• Note: 2 of the 11 products certified to the 2011 criteria were certified in the second half 2013– Suggesting continuing interest in ONC EHR Certification – However, continuing availability of the 2011 criteria and the use

of products certified to these criteria may create confusion in the market, particularly for LTPAC providers and their EP/EH trading partners

• ONC 2014 certification:– A total of 8 products, from 3 vendors, are certified to ONC

2014 criteria• 4 products, from 2 vendors, are certified for the ambulatory practice

setting• 4 products, from 2 vendors, are certified for the in-patient practice

setting• 2 products, from 1 vendor, are certified as “Complete EHRs”• 6 products, from 3 vendors, are certified as “Modular EHRs”

– 1 product is certified on the 2014 ONC Ed. Modules: Authentication/Access Control/Authorization; Automatic log-off; Emergency access; Integrity; and Quality Management System

– 1 product is certified on the 2014 ONC Ed. Modules: CPOE; Medication List; Medication Allergy List; Automated Numerator Record; Safety-Enhanced Design; and Quality Management System

– 4 other products (offered by 1 vendor) are certified on between 13 – 39 Modules from the 2014 ONC Ed.

LTPAC EHR Products

Certification by Criterion for ONC-ACBCertified Modular EHRs for LTPAC

§ 170.302 # Prod.(a) Drug-drug, drug-allergy 3(b) Drug formulary checks 5(c) Maintain up-to-date prob 9(d) Maintain active med list 9

(e) Maintain active allergy list 6(f) Record and Chart Vital Signs 3(f)(1) Record and Chart Vital 3(f)(2) Calculate BMI 3(f)(3) Plot and display growth 3(g) Smoking status 8(h) Incorporate lab test results 2(i) Generate patient lists 4(j) Medication Reconciliation 8(k) Submission to immun 2(l) Public Health Surveillance 2(m) Patient Specific Education 3

The focus of this analysis is on criteria included in the ONC 2011 Ed. given the limited number of LTPAC EHR products certified to the 2014 ONC Ed.. Number of products reflects the number of products certified to the criterion.

§ 170.302 # Prod.(n) Automated measure calc 2(o) Access Control 9(p) Emergency Access 9(q) Automatic log-off 9(r) Audit Log 9(s) Integrity 9(t) Authentication 9(u) General Encryption 9(v) Encryption when exchanging

9

(w) Accounting of disclosures 5

§ 170.304 # Prod.(a) Computerized provider OE 9(b) Electronic Prescribing 1(c) Record Demographics 5(d) Patient Reminders 2

§ 170.304 # Prod.(e) Clinical Decision Support 4(f) Electronic Copy of Health 2(g) Timely Access 2(h) Clinical Summaries 2(i) Exchange Clinical Info 2(j) Calculate and Submit Clinical 2

§ 170.306 # Prod.(a) Computerized Provider OE 7(b) Record Demographics 4(c) Clinical Decision Support 3(d) Electronic copy of Health Inf 1(d)(1) Electronic copy of health 1(d)(2) E-copy of health info 1(e) Electronic copy of discharge 4(f) Exchange Clinical Info 1(g) Reportable Lab Results 1(h) Advance Directives 6(i) Calculate and Submit Clinical 1

New Health IT Standards that Support HIE in and with LTPAC

• HL7 C-CDA (July 2012): includes refinements that address the interoperable exchange of functional status, cognitive status, and pressure ulcer content a

• HL7 CDA IG for Questionnaire Assessment*: provides guidance on implementing the assessment questionnaires , including the CARE data set used in LTCHs b

• HL7 C-CDA IG for LTPAC Summary: provides requirements for the creation of a LTPAC Summary CCD document based on content from MDS and OASIS assessments c

• HL7 C-CDA (Sept. 2013) *: includes new and enhanced templates to support Transfer Summary, Consult Request and Consult Note document types for use in transitions and referrals in care, as well as support a robust exchange of care plan, including the home health plan of care d

* These standards have not yet been implemented. Piloting of some of the new HL7 C-CDA (Sept. 2013) standards is anticipated.

New & Emerging Functionality

• DIRECT: Provides a low cost means to accelerate to HIE. DIRECT is available in most States and beginning to be used to support HIE with LTPAC providers (e.g., MO, IL) a

• KeyHIE Transform: Subscription service that converts MDS and OASIS files from CMS xml format to a CCD that can be exchanged with authorized trading partners (physicians, hospitals, HIEs) b

• IMPACT – Surrogate EHR Environment (SEE): Massachusetts initiative enabling non-EHR users to use SEE (software hosted by a trusted authority) to view, edit, and send CCD+ documents via HIE or Direct to next facility c,d

• Integration engines: Tools that facilitate exchange of information across disparate provider systems (e.g., across EP, EH, and LTPAC systems)e

• Shared care: Electronic tools to support internal communication across team members and transfers in care (e.g., Interact)

Other Needed Functionality

• The HL7 LTC EHR-S FP and CCHIT LTC EHR criteria include more specificity/ functionality in the areas listed below in comparison to the ONC 2014 Ed. :• Assessments • Care Planning• Three-way communication of medication orders between physicians, NHs,

and pharmacies• Medication administration records and Treatment administration records • Lists of medical equipment/prosthetics/orthotic devices• Advance care planning• Patient and family preferences

• Additional needed functionality:– Clinical decision support tools to help with certain clinical/

functional areas (e.g., pressure ulcers, falls)a

• Private sector efforts regarding LTPAC EHR functional requirements and certification have not been updated and are not aligned with requirements in the 2014 ONC Ed.

• Private sector efforts typically do not identify specific HIT standards in their conformance criteria

• HL7 LTC EHR-S FP and CCHIT LTPAC Program contain requirements tailored to the LTPAC environment that are not found in the ONC 2014 Ed. (e.g., assessments, care planning, advanced care planning, quality measure requirements specified by CMS for LTPAC providers, etc.)



• There are limited ONC-ACB certified EHRs available for use by LTPAC providers.

• Complete EHRs: Approximately 3% of the “Fully Functional” LTPAC EHRs are certified as complete EHRs using criteria in the ONC 2014 Ed.. ONC-ACB certification as a complete EHR:

• includes some functionality not needed by LTPAC providers• does not include all functionality needed by LTPAC

providers

• Modular EHRs: Approximately 9% of the “Fully Functional” LTPAC EHRs have certified modules, certified against the 2014 criteria:– modules that have been certified do not include certification

on critical criteria available in the 2014 Ed. – modular certification is not available for some functionality

needed by LTPAC providers

Stakehold

er Support

•Build on existing stakeholder support: Does stakeholder buy-in exist to support the proposed ONC certification program?

Factor #4

Stakeholder Support

• In response to the HHS/Request for Information (RFI) on Accelerating HIE, multiple stakeholders (i.e., LTPAC providers and associations, physician and hospital providers and associations, vendors, health information associations, standard development organizations, states and state associations, health information exchange organizations, researchers, others) expressed nearly unanimous support for:

– Implementing new payment models (e.g., hospital readmission payment reduction, bundled payments, patient centered medical homes) to create incentives to reduce redundancies, improve care coordination, and accelerate e-HIE .

– Applying the health IT standards and infrastructure required in the EHR Incentive Programs to LTPAC (and other ineligible providers), including requirements related to interoperable HIE at times of transitions in care.

• Efficiencies gains and quality/coordination of care improvements were anticipated by stakeholders though the use of interoperable technology

Stakeholder Support (cont’d)

• Near unanimous stakeholder support expressed for: – implementing health IT standards needed for

widespread, interoperable HIE, including standards emerging through the S&I Longitudinal Coordination of Care Workgroup and use of Direct

– supporting interoperable HIE of LTPAC patient assessment: data/ instruments/LTPAC Summary Documents

• Widespread stakeholder support expressed for:

– a voluntary certification program with LTPAC-specific criteria and recommendations to guide the purchase of EHR products that address the clinical processes and information needs of LTPAC providers.

– The HIT Policy Committee recommended:

– Require (if possible) or facilitate (if not) voluntary certification of technology used by providers ineligible for meaningful use, in alignment with MU requirements

– ONC should harmonize the care plan requirements so that MU eligible providers are able to receive care plans from non-MU eligible providers (e.g., NFs)

– CMS-required documentation should be harmonized to the C-CDA: MDS, OASIS and Care Tool, HH PoC (CMS 485) and IRF-PAI


• Stakeholder support expressed for:– Using QRDA for quality reports across providers and

between providers and government agencies– Encouraging e-measure definitions that can be easily

derived from existing data– Establishing a new e-specified measures of care

coordination to encourage e-sharing of summary records following ToC

– Providing technical assistance to LTPAC providers to select, implement and meaningfully use CEHRT would improve care coordination across the spectrum



• Near unanimous support was expressed in response to the RFI for:– Extending the interoperable HIT/HIE infrastructure to LTPAC

providers– Aligning the HIT/HIE infrastructure across the care continuum– Extending the HIT/HIE infrastructure to include standards needed

in LTPAC

• Stakeholder expressed widespread support for a voluntary EHR certification program for LTPAC

• Stakeholders indicated that use of standards and certified technology would likely create efficiency gains, enable the re-use of data, and support quality improvements and care coordination activities/efforts at Federal, State, and provider levels

Cost/

Benefit

•Appropriately balance the costs and benefits of a certification program: Is certification the best available option? Considerations should include financial and non-financial costs and benefits.

Factor #5

Implementing a Voluntary EHR Certification Program for LTPAC: Cost/Benefit Considerations

• If a voluntary EHR Certification Program for LTPAC products is focused on “key” standards and functions then the:

– Number of EHR products that support needed standards and functionality could increase

– Number of EHR products available to support interoperable HIE across the continuum could increase

– Integrity of the system and privacy and security data could be ensured – Costs of EHR products that include needed standards and functionality could decrease

• A voluntary EHR certification program could serve as the foundation for:– LTPAC vendors product enhancements – the standards and functions included in a

voluntary certification program could be the base for additional information systems enhancements.

– LTPAC provider EHR acquisition decisions – a voluntary certification program could reduce provider uncertainty and confusion regarding EHR acquisition decisions.

– Policy decisions by payers/regulators – use of certain/all functions and standards included in certified EHR technology could: (i) support several policy priorities (i.e., improve quality/coordination of care/interoperable HIE and reduce costs) and (ii) be supported through various policy decisions

Implementing a Voluntary EHR Certification Program for LTPAC: Considerations

Challenges: • Key Standards: Identifying the right “key” standards and functions

to include in a voluntary EHR certification program

• Accelerating Use of Certified EHR Products: Payment/regulatory policies will be needed to encourage use of certified EHR products to achieve policy priorities. Such policies will need to consider the impact on:

• quality/continuity of care beneficiaries receive;• providers; • vendor market; and• other programs and payers

NOTE: As noted by ONC during the first SWG call, the focus of a voluntary certification program is on the certification criteria, not of the use of these criteria.

“Key” standards and functions in a voluntary LTPAC EHR Certification Program: Considerations

• Which of the standards/ functions in the ONC 2014 Ed. of EHR Standards and Certification Criteria are “key” for a voluntary LTPAC EHR certification program?

170.314 (a) Clinical 170.314 (b) 170.314(c)

a)(1) Computerized provider OE

(a)(2) Drug-drug, drug-allergy

(b)(1) Transitions of Care - receive, display incorporate ToC/referral summaries (c)(1) Clinical Quality Measures—capture

and export

(a)(3) Demographics

(a)(4) Vital signs, body mass index

(b)(2) Transitions of Care - create and transmit ToC/referral summary

(c) (2) Clinical quality measures—import and calculate.

(a)(5) Problem List (a)(6) Medication List

(b)(3) Electronic Prescribing (c)(3) Clinical quality measures—electronic submission

(a)(7) Medication Allergy List

(a)(8) Clinical Decision Support

(b)(4) Clinical Information Recon. reconcile the data that represent a patient's active medication, problem, and medication allergy list

(a)(9) Electronic Notes

(a)(10) Drug-Formulary Checks

(b)(5) Incorporate Laboratory Test

(a)(11) Smoking Status (a)(12) Image Results

(b)(6) Transmission of Electronic lab test and values/results (inpt only)

(a)(13) Family Health History

(a)(14) Patient List Creation

(b)(7) Data Portability. Create a set of export summaries for all patients

(a)(15) Patient-Specific Education

(a)(16) Electronic Medication Admin record (inpt only)

(a)(17) Advance Directives (inpt only)



170.314 (d)Privacy and security

170.314 (e) Patient engagement

170.314 (f) Public health

(d)(1) Authentication, access control, andauthorization

(e)(1) View, download, and transmit to 3rd party (f)(1) Immunization Information

(d)(2) Auditable events and tamper resistance

(e) (2) Clinical Summary (f)(2) Transmission to Immunization registries

(d)(3) Audit report(s)(e)(3) Secure Messaging (f)(3) Transmission to Public Health

agencies—syndromic surveillance

(d)(4) Amendments

(f)(4) Transmission of Reportable laboratory tests and values/results (inpt only)

(d)(5) Automatic log-off

(d)(6) Emergency access

(d)(7) End-user device encryption

(d)(8) Integrity

(d)(9) Optional—accounting ofdisclosures



170.314 (g) Utilization 170.314(f) Requirements for CQM Submission

Should a voluntary EHR Certification Program for LTPAC:(a) specify a minimum number of CQMs in

certain domains that the EHR must capture and export?

(b) Is it needed/desired to align CQM across (i) LTPAC providers, and (ii) between LTPAC providers and other parts of the care continuum?

(c) Is the CQM submission requirements in the ONC 2014 Ed. needed/desired for LTPAC?

(g)(1) Automated Numerator Record 170.314(f)(5) Cancer Case Information

(g)(2) Automated Measure Calculation170.314(f)(6) Transmission to Cancer Registry

(g)(3) Safety-Enhanced Design

(g)(4) Quality Management System


• Are there key standards and functions available/needed to support workflow in LTPAC that should be included in a voluntary EHR certification program?


• The benefits of establishing a voluntary EHR certification program for LTPAC providers will likely outweigh the costs.

• The value proposition of implementing a voluntary EHR certification program for LTPAC providers will be a function of:– Nature and scope of the criteria included in such a

program– Utility of criteria to the LTPAC provider – Whether identified criteria supports policy objectives– Whether specified criteria supports continuing

technology enhancements and innovations

Questions?

• Contact Information:[email protected]

[email protected]

mailto:[email protected]

mailto:[email protected]

HIT Policy Committee Certification and Adoption Workgroup Meeting Dec 2nd, 2013 11:00am Eastern.

Documents

proposed certification

health care providers

new certification program

ancillary providers

ltpac settings

certification criteria

ltpac presentation

community based providers