S&I Framework PROPOSED INITIATIVE SUMMARIES

S&I FRAMEWORK PROPOSED INITIATIVE SUMMARIES

Dr. Douglas Fridsma

Office of Interoperability and Standards

December 10, 2010

Executive Summary

» The Standards and Interoperability (S&I) Framework represents a unique approach to evolve a new model of health information exchange

» What is needed to achieve this future are specific initiatives that can be harnessed into health information exchange initiatives to guide the design and development of a fully connected health information infrastructure that will enhance efficiency, quality and effectiveness in healthcare delivery.

» The information exchange foundation envisioned through the S&I Framework would leverage existing and new investments in technology, take advantage of health IT innovations, and identify opportunities for new investments through the management of health information exchange initiatives within a portfolio

» This presentation is a summary of the initiatives under consideration, for review and selection by ONC leadership, in consultation with appropriate steering bodies and advisory groups.

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Clinical Summary

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Challenge

The exchange of Clinical Summaries is hampered by the lack of unambiguous common definitions of what data elements must at a minimum be exchanged, how they must be encoded, and how those common semantic elements map to MU specified formats (C32/CCD and CCR). Further, the CCD and CCR standards are overly complex and hinder simple information exchange. Finally, the lack of a robust toolset to aid in development and validation of conformant Clinical Summaries is a major impediment to the widespread adoption of the standards.

Scope Statement

Collaborate with stakeholders and SDOs to create a minimum baseline data set for the clinical summary including use of unstructured text and coded data elements that allow for provider adoption in accordance with Stages 1-3 of meaningful use requirements.

Target Outcomes

• Enable Clinical Summary validation services to be available such as if an organization passes validation, they have a high degree of confidence that any other organization passing the same validation has a 99.9% opportunity to understand the same clinical summary specification

• Reduce template development time through new tools developed through the S&I Framework and public/private activities (such as Open Health Tools) by a factor of 1.5x. Reduce time to create a new minimal unstructured summary and structured summaries based on the CCD/CCR by 10% in 2011 and by 25% in 2013

Meaningful Use Alignment

Exchange key clinical information among providers of care and with patients and other authorized entities electronically

Related Use Cases/Stories

• Consultations and Transfers of Care, medication summaries and public health case reporting (ONC/AHIC)

• Endocrinology Referral (HIMSS) • Dermatology Referral (HIMSS)

• NHIN Direct User Stories (see notes for more):• Primary care provider refers patient to

specialist including summary care record• Primary care provider refers patient to hospital

including summary care record• Specialist sends summary care information

back to referring provider

Templated Clinical Documents

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Challenge

In addition to clinical summaries, there are other structured and unstructured documents produced and exchanged in delivering patient care and providing information to other trusted organizations for the purpose of patient empowerment, public health, quality reporting, research and financial and administrative purposes. Currently there are multiple implementation guides, referenced standards, and terminologies published by different sources as paper documents with extensive redirection to other paper documents. This makes unambiguous implementations and validation very difficult. There is a clear need for a set of simple to use tools to create and validate clinical documents that can be constrained for different business purposes.

Scope Statement

Collaborate with stakeholders and SDOs to create computable implementation guide and validation tools for clinical documents including standard headers, sections and data elements that can be constrained by templates to meet specific information exchange and interoperability requirements.

Key Outcomes

• Enable Clinical Summary validation services to be available such as if an organization passes validation, they have a high degree of confidence that any other organization passing the same validation has a 99.9% opportunity to understand the same clinical summary specification whether as unstructured data or structured and encoded data.

• Reduce template development time through new tools developed through the S&I Framework and public/private activities (such as Open Health Tools) by a factor of 1.5x. Reduce time to create a new unstructured and structured documents based on the HL7 CDA by 10% in 2011 and by 25% in 2013


Exchange key clinical information among providers of care and with patients and other authorized entities electronically based on level of system capability, i.e., human readable, unstructured text or full interoperable structured data


• Use cases and coordinated requirements to support direct care and secondary use will be developed as input to sections and data entries

Lab Interface Improvement

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Challenge

There is a lack of harmonized specifications standards and code sets to enable the exchange of lab results. The cost and time to initiate new electronic laboratory results interfaces hampers broad adoption of such interfaces. The field by field details of HL7 v2 implementation guides used by clinical labs and EHRs vary, creating a need for mapping or configuration per interface, and the prevalence of core subsets of LOINC codes for common tests and analyses also varies, causing downstream issues in decision support and quality reporting.

Scope StatementLimited to address this challenge for the subset of lab reporting to primary care (internal medicine, family practice, pediatrics)

Target Outcomes• Achieve cost savings of up to 90% due to lab interface development improvements by 2015• Reduce total lab interface implementation time by up to 20% by 2013


Incorporate lab results into EHR as structured data


• Electronic Health Record (Laboratory Result Reporting) (ONC/AHIC)

• EHR Lab Scenarios (ONC/AHIC)• Laboratory sends lab results to ordering provider

(NHIN Direct)

Medication Reconciliation Improvement

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Challenge

Medication reconciliation is a critical clinical workflow step that is often manual, time-consuming and error prone. When medication and medication allergy and adverse reaction data are electronically available from multiple sources (e.g., e-prescribing hubs, care summaries sent on transitions of care, HIEs) it should be possible to partially automate comparisons in medication lists and flag potential changes, deletions, and additions, but there is no clear guidance on how this should be done, and the lack of guidance has hampered implementation of this function in clinical IT.

Scope Statement

Medication reconciliation improvement would be scoped to focus on improving medication reconciliation tools, with the medications templates and entries undergoing further refinement as ambiguities are addressed.

Target Outcomes

• Develop a new standardized medication reconciliation toolset that lowers total costs of medication reconciliation by 10-20% from current costs by 2013

• Develop tools to improve medication reconciliation execution time by up to 25% from current response times by 2013

• Increase adoption of medication reconciliation tools up to 25% by 2013.


Perform medication reconciliation at relevant encounters and each transition of care and referral


• Medication Management (ONC/AHIC) • Medication Management (NHIN)

• Pharmacist sends medication therapy management consult to primary care provider (NHIN Direct)

Provider Directories

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Challenge

There is no consistent practice or infrastructure across the industry to support the development and maintenance of provider directories. There is also no universal availability of provider information to locate providers. Without clear guidance as to how to set up a directory in a way that provides consistent information and promotes interoperability, EHRs and directories will have to deal with different directory instances that provide overlapping information on the same entity. In addition, there will be no clear guidance on how to incorporate interoperable endpoints (e.g. Direct Addresses, HIO SOAP endpoints) in directories.

Scope Statement

This specification would focus on developing a specification to allow third parties to build a provider directory that is interoperable with other provider directories

Target Outcomes

• Develop a provider directory specification to allow for rapid development of federated provider directories that can communicate provider information with initial adoption projected at 10% by 2013.

• Develop a content specification for provider directory data elements with a commensurate increase in response time of 25-50%


Exchange key clinical information among providers of care and patient authorized entities electronically


• Healthcare Provider Directory (IHE) • Entity Level Provider Directory (ONC HITPC Information Exchange Workgroup)

Syndromic Surveillance

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Challenge

The overall adoption rate for syndromic surveillance is extremely low, yet meaningful use requirements demand an increased level of surveillance reporting. There is a direct need for a simplified way of reporting standardized data to appropriate public health authorities that will enable meaningful use requirements associated with surveillance to be fulfilled. It is debatable as to whether providers can meet existing and future surveillance requirements with the current implementation guidance available.

Scope Statement

Develop a syndromic surveillance service specification to be used by vendors to deploy a standardized syndromic surveillance service within their infrastructure

NOTE: This initiative would complement the work conducted by ISDS and CDC to develop Stage 1 meaningful use recommendations for syndromic surveillance. The ISDS recommendations are available for public comment and review at :

http://www.syndromic.org/uploads/files/ISDSRecommendation-PROVISIONAL_vFINAL.pdf

Target Outcomes

• Increase syndromic surveillance reporting by 10% by 2013• Increase syndromic surveillance data collection response times for at least 2 conditions by 20%


Provide electronic syndromic surveillance data to public health agencies


• Public Health Case Reporting (ONC/AHIC)• Hospital or provider send chief complaint data to

public health (NHIN Direct)

• Laboratory reports test results for some specific conditions to public health (NHIN Direct)

Quality Measures

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Challenge

There is no clear linkage and guidance between defined standards and vocabularies and the quality measures required by CMS. A root cause of this challenge is the lack of good, easy to use tooling, modeling, and mapping between semantic health concepts and quality measures. The lack of a defined linkage creates downstream problems in mapping between data received via interoperability (e.g., care summaries, electronic labs, medication history) and the associated quality reports leading both to additional cost incurred by providers and to poor quality data received by CMS and other agencies.

Scope Statement

Focus on quality reporting format specification to help meet Stage 1 meaningful use requirements, with initial scope highlighting the most critical quality measures needed.

Target Outcomes

• Develop a quality measure development standard for the 44 Stage 1 Clinical Quality Measures by 2012

• Promote adoption of quality measure specification by 25% of eligible providers by 2013.


Report ambulatory quality measures to CMS or the States


• Quality (ONC/AHIC)• Quality Use Case Requirements (NHIN)• NHIN Direct User Stories:

• Provider or hospital reports quality measures to CMS

• Provider or hospital reports quality measures to State

• Provider or hospital sends update to regional or national quality registry

• HIMSS Use Cases• Public Health Quality Monitoring using

eMeasure• Ambulatory Quality BMI eMeasure Utilization• Hospital Quality eMeasure Utilization• Quality ACE ARB eMeasure Utilization

Population Health Query

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Challenge

Meaningful use places additional demands on providers to provide and report public health information. Traditional centralized models for public health data management have proven to be costly, difficult to maintain, a inflexible to across population health conditions. To date, various distributed query models have been implemented to facilitate public health situational awareness, quality monitoring, and research. A standardized query approach is needed to help determine how clinical providers, hospital systems and public health will share and report information important for public health situational awareness, clinical decision support, and quality monitoring and prevention.

Scope StatementDevelop detailed specifications focused on enabling distributed query mechanisms to aggregate data from multiple public health data sources into a single view

Target Outcomes

• Development of a common query standard for all population health data sources, which can be reused by all population health query systems by 2012

• Reduce total population health query costs by at least 20%• More than 25% of total unique providers using population health query standard by 2013


None


None

Clinical Decision Support

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Challenge

Clinical decision support is a key function of EHR systems that is expected to improve care. In Stage 1 of the meaningful use requirements, provider and hospital EHR systems must execute clinical decision rules and alerts. There will be a need to standardize these rules and alerts across EHRs using interoperable templates. There also will be value in enabling interoperability between an EHR system and a CDS provider, e.g., to notify a provider that a patient or panel of patients require a test. Without a set of standards to guide development, rule development will be localized, costly, and non-standardized.

Scope Statement

Development of a standard content specification for implementation and exchanging clinical decision support rules and alerts across various EHR platforms

Target Outcomes

• Develop a common standardized format for submitting patient data to CDS service providers that is adopted by up to 20% of providers by 2013.

• Develop standardized format for submitting and generating CDS rules that is adopted by 20% of CDS vendors by 2013.

• Increase total deployment cost savings for clinical decision support service capabilities by 25%• Generate a total increase in clinical decision support usage of 10%


Implement Clinical Decision Support Rules


• Medical Home: Problem Lists & Practice-Based Registries (ONC/AHIC)• Care of the Stroke Patient in the Acute Care Setting (HIMSS)

Blue Button

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Challenge

The Blue Button, should it become ubiquitous on health institutions’ patient portals (or for smaller practices, simply on their website), payer-based PHRs, employer-based PHRs (often just a PHR provided by payer), and even regional or state-wide HIEs, the effort that it would take for an average consumer to gather their data to create a longitudinal record could be simplified significantly. In order for the blue button to work, though, there is a need to develop a common standard for downloadable information (a common standard for the downloaded text files) so that a text file can be processed as patient readable.

Scope Statement

The focus would be on developing a standard content specification for how the text file would be structured to make it readable for patients, and ensuring the structure could be mapped and/or transformed to the CCD (so that documents using those standards could be transformed into the common text file format).

Target Outcomes

• Develop a common format for representing the blue button text file that is adopted by VA and CMS in 2011.

• Increase in blue button deployment to 10 additional organizations in 2012.• Develop the capability to map a blue button standardized text file to C32 summary documents by

2013.


Provide clinical summaries to patients


None

Green Button

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Challenge

Providers often need to transition from one EHR system to another. Such transitions occur when providers purchase new EHRs or EHR modules or move practices. There is no standardized mechanism to allow data transfer to occur in EHR system transitions, creating a less dynamic market for EHR systems by encouraging lock-in.

Scope StatementDevelop clear standard format for how data from one EHR can be transferred to another EHR using a green button specification

Target Outcomes• Achieve cost reduction of at least 25% compared to paper transfer options by 2012.• Promote VLER adoption of green button standard by 2013.


Exchange key clinical information among providers of care and patient authorized entities electronically


None

Value Set Development

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Challenge

For a given meaningful use requirement needing a value set, experts would need to define the value sets appropriate to the specific requirement with due consideration of harmonization with similar and existing solutions. The infrastructure and format for maintaining the actual value sets and making them available as needed would also require specification. This would include issues of intellectual property and versioning. Stakeholders would have to agree to use or map value sets from master(s) code sets like SNOMED rather than maintaining domain specific codes. Without this value set development flow in place, the localized developed of value sets is likely to continue, leading to less value set adoption.

Scope Statement

There is a specific need for standardized value sets in areas such as:• Lab Orders – critical for meaningful use• Reportable Conditions• Lab Results – for the most frequently reported tests

Target Outcomes

• Initial value sets ready to support meaningful use by end of 2011• Align 2011 developed value sets to existing vocabularies and vocabulary mappings by 2012.• Reduce value set development response time by 50% by 2013


Foundational to Meaningful Use


None

S&I Framework PROPOSED INITIATIVE SUMMARIES

Documents

summary care information

summary care recordspecialist

simple information exchange

transfers of care

providers of care

advantage of health

new tools

structured summaries