HIE and Meaningful Use Stage 2 Matrix

Transcription

1 HIE and Meaningful Use Matrix December 2012

2 Healthcare Information Exchange An HIE Overview HIE and Meaningful Use Matrix Health Information Exchange (HIE) can be defined in a number of ways. In its most conservative definition, HIE (the verb) is the activity of secure health data exchange between two or more authorized and consenting trading partners. One party may be a data supplier while one or more are data receivers, or the exchange can be facilitated by one or more third parties who operate between the data supplier and the data receiver. A third party can also store data on behalf of the data supplier and transmit that data to recipients (in such case, the third party would be considered to be the data supplier). Further, a third party could be receiving data on behalf of a data receiver. Although the range of possible scenarios may be complex, HIE activity can enhance virtually any clinical function by providing a broader set of data upon which clinical decisions can be based. HIE can take place in one of two basic ways: push or pull. Data is pushed when its transmission is initiated solely by the sender (also known as unsolicited ). Data is pulled when the intended recipient solicits data from one or more sources and receives it in turn (also known as solicited ). This is important because of the different key mechanisms that are required to handle data supplied in either of the two ways. For pulled exchanges, there are necessary functions required at the data receiver to create and transmit the request, and necessary functions at the data supplier to receive, arbitrate, and respond to the request, including functions used to discover the subject of the exchange (the patient). Push exchanges are more straightforward because the data supplier simply pushes data that is identified as having a destination of the data receiver (or copies data to the receiver in the case of subscription messages), and the data receiver need only have the functionality to store and present (or ignore) any unsolicited data in the form it is received. Health Information Organizations (HIO) (the noun) convene independent stakeholders to form organizations whose primary function is data exchange of health information. There has been significant growth in these organizations across the country, with initiatives that involve both community and state level health information exchanges. These HIOs are all in some stage of defining their technology infrastructure, and identifying potential vendor partners to help build their HIE. At the same time, the HIE service vendor landscape is undergoing an evolution in an attempt to meet market demands accelerated by ARRA and the meaningful use objectives. This includes offering an Electronic Health Record (EHR), EHR Lite systems or capabilities, and/or practice management services as part of their HIE functionality. An EHR Lite typically contains a subset of EHR functionality and does not have the complete slate of features and complexity found in full-fledged EHR systems. Today, some of the EHR Lite systems can closely resemble fully functional EHR systems. Also, some EHR vendors are moving rapidly into the HIE service vendor space by offering methods to tie together customers of their products and, more recently, to incorporate interfaces to foreign EHR products into their HIEs. As a result, many HIOs are faced with a challenging decision when determining the best solution to fill their health information exchange requirements. Their options include acquiring a third party vendor product for HIE services, contracting with a known EHR vendor 2012 Healthcare Information and Management Systems Society (HIMSS) 2

3 Healthcare Information Exchange HIE and Meaningful Use Matrix who is already well established in the medical data exchange area, or identifying a unique or hybrid approach that addresses specific organizational requirements. HIE and Meaningful Use This analysis focuses on HIE activity and implications found in the Meaningful Use objectives and requirements as identified in the Medicare and Medicaid Programs; Electronic Health Record Incentive Program Final Rule. 1 This analysis considers only the direct or implied requirements around health information exchange as described in the Final Rule and does not elaborate on the benefits resulting from HIE. The analysis focuses on the event of exchanging data and does not address the actual data exchange mechanism (e.g., directly between two parties or involving a third party; push or pull) that any given provider may need to perform the exchange activity. It should be pointed out that the Stage 1 Meaningful Use objectives have been purposefully set to be achievable by providers throughout the country. With this objective in mind, the Centers for Medicare and Medicaid Services (CMS) concluded that the availability and capacity of HIE at this time is not widespread enough to fully leverage HIE in the Stage 1 Meaningful Use criteria. Consequently, many of the Meaningful Use objectives stand on their own without an HIE dependency. However, while working with Stage 1 objectives and measures, one should keep in mind that future rule making around and Stage 3 requirements will include HIE capabilities. Discussion in the final rule clearly indicates that criteria will likely include more rigorous expectations for health information exchange, including more demanding requirements for e-prescribing, incorporation of structured laboratory results and the expectation that providers will electronically transmit patient care summaries to support transitions in care across unaffiliated providers, settings and EHR systems. Increasing requirements for health information exchange in and Stage 3 will support the goal that information follows the patient (reference Pre-Publication Document [PPD] of the Rule, page 35 2 ). Expectations include not only capturing of data in electronic format but also the exchange (both transmission and receipt) of that data in increasingly structured formats in future stage criteria. The overall intent and policy goal for the secure exchange of electronic health information is to ensure support for meaningful use that encourages patient-centered, interoperable health information exchange across provider organizations (PPD page 37.) Expectations for Stage 3 Criteria include a patientcentered health information exchange (PPD page 36). Differing Perspectives Many types of organizations and individuals are involved in HIE, and this matrix can be viewed through a number of lenses. State-level HIE planners operate under the State Health Information Exchange Cooperative Agreement Program with ONC 3 (and subsequent Program Information Notice [PIN] 4 ), 1 Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare and Medicaid Electronic Health Record Incentive Program. Sep Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare and Medicaid Electronic Health Record Incentive Program PPD. Aug Office of the National Coordinator for Health Information Technology. State Health Information Exchange Cooperative Agreement Program Healthcare Information and Management Systems Society (HIMSS) 3

4 Healthcare Information Exchange HIE and Meaningful Use Matrix which provides specific objectives and requirements vis-à-vis HIE functionality and Meaningful Use. State and local public health agencies have their own requirements, usually from the Centers for Disease Control and Prevention, which provides most of their funding. Local/regional HIOs need to be responsive to their stakeholders and have yet another potential agenda which may or may not coincide with state-level plans. Finally, providers have specific Stage 1 requirements they need to fulfill in order to participate in the CMS incentive program, which may or may not be clearly supported by other stakeholders in their communities. This matrix attempts to consider all these perspectives and offer a straightforward set of observations about the implications for HIE in Stage 1 Meaningful Use. Distinguishing Enterprise HIE In the summer of 2012, HIMSS initiated an effort to provide a more robust definition of Enterprise HIE and understand how it is different from Community or Regional HIE. Three IDNs, four hospital systems, and two physician group practices were interviewed. The group s responses were aggregated into short summaries, paired with representative quotes, and then validated by the entire group of participants. How do you define Enterprise HIE? Enterprise HIE is the exchange (verb) of pertinent clinical information across separate EMRs and separate vendors. Started and funded by a single enterprise, it includes employed doctors and trusted partners caring for shared patients. Why implement Enterprise HIE? The number one reason for implementing enterprise HIE is to provide better and more efficient patient care. Business drivers behind this initiative fell into four key areas: 1) Provide better and more efficient patient care. This was the number one reason identified for implementing enterprise HIE. 2) Distribute hospital information to doctors. Patients expect that doctors know what is happening at every stage of their healthcare encounter. Dr. Karen Schogel, an internist at an independent group in Connecticut, said, I think patients expect us to know what s going on when they re not in my office, but rather in some other facility. 3) Outreach. 4) Shifting reimbursement model. In addition, one of the key attributes of the enterprise HIE model is trust. It can be much more challenging for other models, such as regional or community HIEs, to build trust. How will Enterprise HIE work? Providers have three main expectations for how Enterprise HIE will work: 4 Privacy and Security Framework Requirements and Guidance for the State Health Information Exchange Cooperative Agreement Program. Program Information Notice (PIN) ONC-HIE-PIN-003. Office of the National Coordinator for Health Information Technology. U.S. Department of Health & Human Services. March Healthcare Information and Management Systems Society (HIMSS) 4

5 Healthcare Information Exchange HIE and Meaningful Use Matrix 1) Doctors can continue to work in the EHR rather than having to access a separate portal for patient information, 2) the flow of data should be bi-directional, and 3) the data and integration should be under the control of the enterprise. Michael Oppenheim of North Shore LIJ Health System stated, We need ownership and control of the interoperability to be able to tweak it, work it, and massage it, because the subtleties in these workflows are very complicated and can change very quickly. We can t be dependent upon a third party to continually update the changes in the clinical workflows. What problems have you experienced (or do you expect) with Enterprise HIE? The research revealed a few problems with the enterprise HIE model. Because the enterprise model is limited to just the enterprise s facilities and trusted partners, the organization will always be faced with patients not staying within the enterprise. Another problem associated with enterprise HIE is that EHRs do not communicate with each other and it is often unrealistic for an IDN to transition to a single vendor. Integration projects can be very complex, time-consuming and costly Healthcare Information and Management Systems Society (HIMSS) 5

6 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities CPOE Electronic Prescribing (erx) Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local and professional guidelines. EP only: Generate and transmit permissible prescriptions electronically (erx). More than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology orders created by the EP or authorized providers of the eligible hospital's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using CPOE. More than 50 percent of all permissible prescriptions, or all prescriptions written by the EP and queried for a drug formulary and transmitted electronically using CEHRT. No explicit HIE implication. Potential / Future Implication: Focus is on intra-organization for inpatient order entry which does not indicate that associated results must be electronically transmitted. increases this specific requirement for percentage of unique patients with at least one medication in their medication list (Stage 1) from 30% to 60% and adds new requirements (30% laboratory and 30% radiology orders). If order entry goes beyond organizational boundaries, then HIE is implied and could be involved. Enterprise HIE Implication: If order goes beyond organizational boundaries, then Enterprise HIE is implied and could be involved. No explicit HIE implication. Potential / Future Implication: The requirement to transmit an e Prescription requires data exchange to a pharmacy data receiver, which can be achieved either directly between the provider and the pharmacy or through a third party. An HIE organization (public or private) is not required and may not be involved. increases the requirement for percentage of permissible prescriptions transmitted electronically from (Stage 1) 40% to 50% Healthcare Information and Management Systems Society (HIMSS) 6

7 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Demographics recording Vital Signs Smoking Status EP: Record the following demographics: preferred language, sex, race, ethnicity, date of birth. EH/CAH: Record the following demographics: preferred language, sex, race, ethnicity, date of birth, date and preliminary cause of death in the event of mortality in the eligible hospital or CAH. Record and chart changes in vital signs: height / length, weight, blood pressure (age 3 and over); calculate and display BMI; plot and display growth charts for patients 0-20 years, including BMI. Record smoking status for patients 13 years old or older. More than 80 percent of all unique patients seen by the EP or admitted to the EH s or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have demographics recorded as structured data. More than 80 percent of all unique patients seen by the EP or admitted to the EH's or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have blood pressure (for patients age 3 and over only) and height / length and weight (for all ages) recorded as structured data. More than 80 percent of all unique patients 13 years old or older seen by the EP or admitted to the EH s or CAH's inpatient or emergency departments (POS 21 or 23) during the EHR reporting period have smoking status recorded as structured data. No explicit HIE Implication. Potential / Future Implication: Indirect implication focuses around exchangeable demographic information with accurate patient matching and identification within an organization and across different healthcare organizations. For smaller practices or healthcare entities who are not engaged with an HIE organization, HL7 resources provide a common messaging structure supported by the majority of EHRs, and should ease some of the capturing/recording and exchange of demographic data. increases the requirement for percentage of unique patients seen by the EP or admitted to the EH/CAH from (Stage 1) 50% to 80%. Enterprise HIE Implication: For public enterprise HIE organizations that support and provide services with MPIs or empis, demographic data exchange facilitates patient matching and identification activities. No explicit HIE Implication. Potential / Future Implication: Future consideration is needed with new initiatives such as ACOs and population health, where vital signs can be key clinical indicators for identification and monitoring of patient (or population) diagnosis across organizational boundaries. Data must be assimilated in a manner so as to render for multiple levels of viewing, such as with single provider organizations, an enterprise HIE level viewing, and broader population views within public HIE organizations No explicit HIE Implication Healthcare Information and Management Systems Society (HIMSS) 7

8 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Clinical Decision Support Rules Use clinical decision support to improve performance on highpriority health conditions. 1. Implement five clinical decision support interventions related to four or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period. Absent four clinical quality measures related to an EP, EH or CAH's scope of practice or patient population, the clinical decision support interventions must be related to high-priority health conditions. It is suggested that one of the five clinical decision support interventions be related to improving healthcare efficiency. No explicit HIE Implication. This is an EMR-level function. Enterprise HIE - Potential / Future Implication: For Enterprise HIEs, the desired results need to be fully developed including identification of the targeted data elements, corresponding data sources and priority of need. This facilitates interface development and reaching the desired results by the Enterprise HIE. This approach assists in preventing connections to data sources that are not a priority or justified to be in need to satisfy a clinical quality measure. 2. The EP, EH or CAH has enabled and implemented the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period Healthcare Information and Management Systems Society (HIMSS) 8

9 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Lab-test Results (CEHRT) Incorporate clinical labtest results into Certified EHR Technology as structured data. More than 55 percent of all clinical lab tests results ordered by the EP or by authorized providers of the EH or CAH for patients admitted to its inpatient or emergency department (POS 21 or 23) during the EHR reporting period whose results are either in a positive/negative affirmation or numerical format are incorporated in Certified EHR Technology as structured data. No explicit HIE implication. Potential / Future Implication: This will impact those HIE organizations that provide services around lab results, including public HIE organizations. Transmission and displaying lab results is one of the more complex challenges for HIEs for many reasons. Lab results, especially for HIE organizations, come from many different sources such as reference labs (contracted 3rd party entities for lab services) and many providers including EPs and authorized providers of the EH or CAH. Also, there are numerous laboratory standards in use today ranging from SNOMED to LOINC. HIE organizations can be challenged with reconciling these challenges. Since HIE organizations vary, the participant must identify the technical requirements for lab data as well as the use of text files or structure data formats. For example, some HIEs might be required to transmit lab test results as structured data in positive/negative affirmation or numerical format; and to handle results of individual lab tests, group tests, and panel tests. If the HIE doesn't already support these transmission requirements, then some additional work might be necessary to support this objective. Patient Lists Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach. Generate at least one report listing patients of the EP, EH or CAH with a specific condition. Enterprise HIE - Potential / Future Implication: Lab results are ideally electronically incorporated into the EHR via a structured format and shared within an organization, and ultimately across both public and private HIE organizations. No explicit HIE implication. Enterprise HIE - Potential / Future Implication: Future consideration is suggested for Enterprise HIEs where information accuracy, patient identity matching and data sources are critical to generate these items across an enterprise level viewing Healthcare Information and Management Systems Society (HIMSS) 9

10 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Patient Reminders EP only: Use clinically relevant information to identify patients who should receive reminders for preventive / follow-up care and send these patients the reminder, per patient preference. More than 10 percent of all unique patients who have had two or more office visits with the EP within the 24 months before the beginning of the EHR reporting period were sent a reminder, per patient preference when available. No explicit HIE implication. Potential / Future Implication: Long-term impact on HIE organizations can be critical for effective care coordination, especially for specific disease cohorts, surgery follow-ups, and preventive care. If an HIE organization is used to support this, ideally when the EP sends reminders to a patient, a copy of the reminders should be routed through the HIE and then on to ALL providers rendering care to the patient. Electronic Medication Administration Record (emar) EH/CAH only: Automatically track medications from order to administration using assistive technologies in conjunction with an electronic medication administration record (emar). More than 10 percent of medication orders created by authorized providers of the EH s or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period for which all doses are tracked using emar. Enterprise HIE - Potential / Future Implication: Currently, this is likely to be supported by the provider's EHR. However, in the future, both public and private HIE organizations could provide this service of sending electronic reminders to patients based on the requirements of the participating HIE members. Issues to address when considering this as a service include ensuring that the provider has selected the appropriate patient populations that would benefit, and establishing the criteria for who should be contacted. Providers will need a listing of patients meeting established criteria AND tracking results (no response, contacted, go away, etc.). No explicit HIE implication. Potential / Future Implication: In the future this could impact both public and private HIEs, only if order entry extends beyond organizational boundaries Healthcare Information and Management Systems Society (HIMSS) 10

11 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Engage patients and families in their health care Patient Access (EP) EP only: Provide patients the ability to view online, download, and transmit their health information within 4 business days of the information being available to the EP. 1. More than 50 percent of all unique patients seen by the EP during the EHR reporting period are provided timely (within 4 business days after the information is available to the EP) online access to their health information subject to the EP's discretion to withhold certain information. 2. More than 5 percent of all unique patients seen by the EP during the EHR reporting period (or their authorized representatives) view, download, or transmit to a third party their health information. HIE Implication: An HIE organization can facilitate this process, which is inherently the exchange of health information. Many HIE organizations offer this basic transaction as a core service. Depending on what the EP advises / provides, Measure 2 requires that someone (which could be the HIE organization as well as the provider) record the fact that the patient viewed / downloaded / transmitted their information. Enterprise HIE - Potential / Future Implication: Currently, providers may find it easier to offer a provider/vendor-specific web portal to meet this measure. These patient portals must integrate with their EHR, and EPs should have a policy describing which data should be shared online, and what (if anything) should be "withheld." 2012 Healthcare Information and Management Systems Society (HIMSS) 11

12 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Engage patients and families in their health care Patient Access (EH/CAH) EH/CAH only: Provide patients the ability to view online, download, and transmit information about a hospital admission. 1. More than 50 percent of all patients who are discharged from the inpatient or emergency department (POS 21 or 23) of an EH or CAH have their information available online within 36 hours of discharge. 2. More than 5 percent of all patients (or their authorized representatives) who are discharged from the inpatient or emergency department (POS 21 or 23) of an EH or CAH view, download or transmit to a third party their information during the reporting period. HIE Implication: HIE organizations may provide services to support Measure 1, including ability for a patient to access discharge and ED visit summaries, which could be done through repositories or query functions if this capability is provided. (The HIE might also track the availability time and the number of records available in that timeframe.) HIEs may provide services to support Measure 2 including (1) Ability for a patient to download their ED and discharge summaries in a form that can be transmitted to and used by a third party (e.g., PDF); (2) Ability for the patient to indicate the third party that should received the ED or discharge summary and transmit the record on behalf of the patient (In this scenario, the HIE would need to track the patient's authorization for the HIE to transmit the record. It would be ideal for the HIE to have a mechanism to confirm to the patient that the records have been transmitted.); (3) Ability to track the number of views, downloads, and transmissions, and to report these back to the EH or CAH. Enterprise HIE - Potential / Future Implication: Currently, providers may find it easier to offer a provider/vendor-specific web portal to meet this measure. These patient portals must integrate with their EHR, and EPs should have a policy describing which data should be shared online, and what (if anything) would be "withheld." An IDN or Enterprise HIE may consider leveraging the patient portal functionality to make discharge instructions available online, which could be either a long-term strategy or a bridge to reaching a longterm solution. Both the Enterprise HIE and the EH/CAH ideally should have policies describing which data should be shared online, and what (if anything) should be "withheld." The requirement is that the EH/CAH will need to either utilize the Enterprise HIE portal or have their own patient portals in place that integrate with their EHR Healthcare Information and Management Systems Society (HIMSS) 12

13 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Engage patients and families in their health care Clinical Summaries Patient Education EP only: Provide clinical summaries for patients for each office visit. Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient. Clinical summaries provided to patients or patient-authorized representatives within 1 business day for more than 50 percent of office visits. Patient-specific education resources identified by CEHRT are provided to patients for more than 10 percent of all unique patients with office visits seen by the EP during the EHR reporting period. More than 10 percent of all unique patients admitted to the eligible hospital's or CAH's inpatient or emergency departments (POS 21 or 23) are provided patient-specific education resources identified by Certified EHR Technology. HIE Implication: An HIE organization, public or private, may facilitate this process based on the HIE services they provide and whether the HIE participant provides the summaries electronically. Enterprise HIE - Potential / Future Implication: This objective is focused on a single visit and does not require a summary that spans multiple encounters by multiple providers. Further, while the EP may choose to offer the summary online (directly or perhaps even via integration with the patient's PHR), other electronic mediums like CD and USB are also acceptable, and the patient is not able to stipulate which electronic medium is used to provide the summary. It is the EP's choice. However, in the future, there could be implications for Enterprise HIEs with this objective. No explicit HIE implication. Potential / Future Implication: In the future some HIE organizations may provide the sharing of these resources across their participants as a service offering (geographically or organizationally). Access to affordable patient education resources, even as a shared service within an HIE/HIO, may end up being very important for smaller practices and organizations. Enterprise HIE - Potential / Future Implication: While many hope that providers will offer this as electronic functionality, providing materials in paper format will still meet this measure for. In the future, HIE organizations could consider this as a useful service to providers if they have functionality allowing providers to electronically send this type of information to the patient while still maintaining patient privacy. Many providers may need the assistance of an HIE to provide the robust security needed to protect patient privacy when protected information is being transmitted Healthcare Information and Management Systems Society (HIMSS) 13

14 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Engage patients and families in their health care Secure Messaging EP only: Use secure electronic messaging to communicate with patients on relevant health information. A secure message was sent using the electronic messaging function of Certified EHR Technology by more than 5 percent of unique patients (or their authorized representatives) seen by the EP during the EHR reporting period. No explicit HIE implication. The measure requires that the EHR provide this functionality. Potential / Future Implication: This can be handled using a physician-patient portal, but one could utilize an HIE organization to facilitate the transmission of the message. Dependency will be upon the HIE organization s service offerings and ownership of boundaries (where data leaves the EP / enters the HIE). Patient portals are becoming a common method of communication. This patient portal may or may not be connected through an HIE which could communicate directly to the patient. This will be specific to the HIE organization and their service offering. Improve care coordination Improve care coordination Medication Reconciliation Summary Care Record The EP, EH or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation. The EP, EH or CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides a summary of care record for each transition of care or The EP, EH or CAH performs medication reconciliation for more than 50 percent of transitions of care in which the patient is transitioned into the care of the EP or admitted to the EH s or CAH's inpatient or emergency department (POS 21 or 23). 1. The EP, EH, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. 2. The EP, EH or CAH that The measure also specifically calls out the use of "Certified EHR Technology" which would eliminate separate HIE-like technology. If the patient information is being transported from an HIE (enterprise or public) into the Certified EHR Technology, then the HIE may play a role in this specific objective. Also, in the future they may become more closely linked as data flows more freely between HIE technology and the EHR. No HIE implication. Strong HIE implication: HIE organizations can support this objective criteria. Items 2 and 3 point directly to the need for HIE (public, private or enterprise) whether it be via an established HIE or via NWHIN. This will also depend on the ability of the receiving systems to accept such transactions, and on the requirements for participating in the HIE organization. The burden appears to be on the "referrer," though summary care records need to be provided for each "transition of care" as well. There should be identified clear procedures between the provider (EP) and the HIE organization of 2012 Healthcare Information and Management Systems Society (HIMSS) 14

15 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix referral. transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. roles and responsibilities in supporting each transition of care. 3. An EP, EH or CAH must satisfy one of the two following criteria: (A) Conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) and for eligible hospitals and CAHs the measure at 495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was developed designed by a different EHR technology developer than the sender's EHR technology certified to 45 CFR (b)(2); or (B) Conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period Healthcare Information and Management Systems Society (HIMSS) 15

16 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improve population and public health Immunization Registries Capability to submit electronic data to immunization registries or immunization information systems except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic immunization data from Certified EHR Technology to an immunization registry or immunization information system for the entire EHR reporting period. Potential / Future HIE Implication: This can be done with or without an HIE. If an HIE translates data from a non-proscribed to a proscribed format (e.g., CCD to HL7 v2 message) the HIE must also be CEHRT. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. (For more information see Lab-test Results (reporting) Syndromic Surveillance EH/CAH only: Capability to submit electronic reportable laboratory results to public health agencies, except where prohibited, and in accordance with applicable law and practice. EH/CAH only: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic reportable laboratory results from Certified EHR Technology to public health agencies for the entire EHR reporting period. Successful ongoing submission of electronic syndromic surveillance data from Certified EHR Technology to a public health agency for the entire EHR reporting period. Enterprise HIE - Potential / Future Implication: This measure can be met by the provider's EHR, and can be achieved with or without an HIE. It is unclear exactly what these other registries might be, but they may be operated by public health agencies, professional associations or other organizations. HIE Implication: Core services offered by HIE organizations are represented with this objective including connectivity, data integration and filtering of those who opt out or have other special requirements with clinical data sharing, such as with mental health and HIV. This can be done with or without an HIE. If the HIE organization provides services that translate data from a nonproscribed to a proscribed format (e.g., CCD to HL7 v2 message) the HIE must also be Certified EHR Technology. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. (For more information see Potential HIE Implication: This can be done with or without an HIE. If an HIE translates data from a non-proscribed to a proscribed format (e.g., CCD to HL7 v2 message) the HIE must also be Certified EHR Technology. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. (For more information see Healthcare Information and Management Systems Society (HIMSS) 16

17 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Improve population and public health Note for All Public Health Related Reporting Requirements MU Public Health s require electronic transmission of health information to public health agencies (PHAs), except where prohibited, and in accordance with applicable law and practice. The specific examples that will need to be considered include: Submitting electronic immunization data to immunization registry or information system (EPs and Hospitals - Core) Submitting electronic reportable lab results to public health agencies (Hospitals only - Core) Submitting electronic syndromic surveillance data to public health agencies (Hospitals - Core; EPs - Menu) Identifying and reporting cancer case information to cancer registries (EPs - Menu) Identifying and reporting specific case information to a specialized registry (EPs - Menu) Suggested Measure: Ongoing submission of relevant electronic health information for entire EHR reporting period. Unlike Stage 1, failed submission will not meet measure. While partnering with HIE organizations, HIEs may transport data on behalf of public health agencies. However, they cannot transform content or message. HIEs may serve as extension of Certified Electronic Health Record Technology (CEHRT) for providers for encryption/security of data stored in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3). HIEs will need to be certified for relevant EHR certification criteria in accordance with certification program and use transport standard supported by public health agency. MU would expect public health agencies to supply providers with letter affirming submission of relevant information Healthcare Information and Management Systems Society (HIMSS) 17

18 Healthcare Information Exchange CORE ITEMS HIE and Meaningful Use Matrix Ensure adequate privacy and security protections for personal health information Data Protection Protect electronic health information created or maintained by the Certified EHR Technology through the implementation of appropriate technical capabilities. Conduct or review a security risk analysis in accordance with the requirements under 45 CFR (a)(1), including addressing the encryption / security of data stored in CEHRT in accordance with requirements under 45 CFR (a)(2)(iv) and 45 CFR (d)(3), and implement security updates as necessary and correct identified security deficiencies as part of the provider's risk management process. HIE Implication: Data protection is not just privacy and security risk. Throughout most of these objectives and measures, there is a substantial demand for availability of access to the data and tools. Organizational resilience management (ORM) is the overarching discipline that includes information (privacy), physical & cyber security. However, it also includes incident management, technology recovery and business/clinical operations recovery. All of these capabilities factor into a healthcare provider's (and HIE's) ability to deliver the expected level of service when required. In terms of adjusting HIPAA Compliance to meet the Meaningful Use (MU), for Electronic Health Information Exchange (HIE), experts explain the critical relationship between HIPAA and MU Privacy & Security Regulations. (Source: MUSTAGE2-AGREENE.pdf) 2012 Healthcare Information and Management Systems Society (HIMSS) 18

19 Healthcare Information Exchange MENU ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Advance Directives Imaging Results Family Health History EH/CAH only: Record whether a patient 65 years or older has an advance directive. Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through Certified EHR Technology. Record patient family health history as structured data. More than 50 percent of all unique patients 65 years old or older admitted to the eligible hospital's or CAH's inpatient department (POS 21) during the EHR reporting period have an indication of an advance directive status recorded as structured data. More than 10 percent of all tests whose result is one or more images ordered by the EP or by an authorized provider of the EH or CAH for patients admitted to its inpatient or emergency departments (POS 21 and 23) during the EHR reporting period are accessible through Certified EHR Technology. More than 20 percent of all unique patients seen by the EP or admitted to the EH s or CAH's inpatient or emergency department (POS 21 or 23) during the EHR reporting period have a structured data entry for one or more first-degree relatives. Potential / Future HIE Implication: HIE organizations have the future potential to facilitate access to advance directives for a community. This will most likely be dependent on the services offered by the specific HIE organizations (both public and private). HIE Implication: There are several dependencies an HIE will need to address to support this objective and measure, including required bandwidth/storage, views (including longitudinal patient views) and device coordination across the enterprise and/or HIE participants. Using the assumption that most HIE organizations will not attempt to store all of the images associated with this measure, the HIE will need to store the diagnostic result AND a pointer to the image(s), and it will need to be able to pass that pointer to the requesting EMR. To support this activity, the HIE will need to have a trusted relationship with the entity where the study is performed, so that an associative trust can be established. In other words, the HIE must be able to allow a trusted user on its system to be able to access the images on the system on which the images are stored. No explicit HIE implication Healthcare Information and Management Systems Society (HIMSS) 19

20 Healthcare Information Exchange MENU ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Hospital Discharge Prescriptions EH/CAH only: Generate and transmit permissible discharge prescriptions electronically (erx). More than 10 percent of hospital discharge medication orders for permissible prescriptions (for new, changed, and refilled prescriptions) are queried for a drug formulary and transmitted electronically using Certified EHR Technology. Potential / Future Implication: The HIE may have to associate the prescriptions to discharge events. The prescription by itself tells only part of the story, whereas for better care coordination after the discharge, some view of the discharge notes or summary would provide a clear picture for follow-up or ongoing care. HIEs will need to transmit data in the formats specified by the rule. ONC notes that "in order to meet this objective and measure, an eligible hospital or CAH must use the capabilities and standards of CEHRT at 45 CFR (a)(10) and (b)(3)." HIEs will ultimately need to support transmission of prescription data as discussed in Test Procedure for (a)(10) Drug-formulary checks: edition-draft-test-procedures/ a-10-drug-formulary-checks test-procedure-draft-v1.0.pdf 2012 Healthcare Information and Management Systems Society (HIMSS) 20

21 Healthcare Information Exchange MENU ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Electronic Notes Record electronic notes in patient records. Enter at least one electronic progress note created, edited and signed by an EP for more than 30 percent of unique patients with at least one office visit during the EHR reporting period. Enter at least one electronic progress note created, edited and signed by an authorized provider of the EH s or CAH's inpatient or emergency department (POS 21 or 23) for more than 30 percent of unique patients admitted to the EH or CAH's inpatient or emergency department during the EHR reporting period. No explicit HIE implication. Potential / Future Implication: In the future, the layers of an HIE technical platform may support these objectives depending on the specific HIE organization. It will be necessary to ensure that the technologies required to achieve these results are available, cost effective and compatible. The HIE architecture will have to be designed, if not already, to accommodate requirements. Electronic progress notes must be text-searchable. Nonsearchable notes do not qualify, but this does not mean that all of the content has to be character text. Drawings and other content can be included with searchable text notes under this measure Healthcare Information and Management Systems Society (HIMSS) 21

22 Healthcare Information Exchange MENU ITEMS HIE and Meaningful Use Matrix Improving quality, safety, efficiency, and reducing health disparities Lab Results (ambulatory) Provide structured electronic lab results to ambulatory providers. Hospital labs send structured electronic clinical lab results to the ordering provider for more than 20 percent of electronic lab orders received. No explicit HIE implication. Potential / Future Implication: To support this measure in the future, HIE organizations will have to address the issue of standardizing the terminology code sets (i.e., LOINC or an alternative) and tagging the appropriate fields in multiple disparate EMRs in order to route the results appropriately to all providers. Enterprise HIE - Potential / Future Implication: According to the final rule, the measure for this objective requires that in situations where the electronic connectivity between an EH or CAH and an EP is established, the results electronically exchanged are done so using CEHRT, not using methods such as physical electronic media, electronic fax, paper document or telephone call. Further, the final rule refers to this objective as an example of what it means for an eligible hospital to use CEHRT "for the electronic exchange of health information to improve the quality of health care..." However, because the objective doesn't require the hospital to establish electronic connectivity, the effect of this objective is really just to ensure that there is a bi-directional exchange of orders/results where an HIE already exists. Thus, HIE may be considered a requirement in order for providers to meet this menu objective, but because it is a menu objective and because it doesn't require the hospital to establish electronic connectivity, it falls short of being a requirement for HIE Healthcare Information and Management Systems Society (HIMSS) 22

23 Healthcare Information Exchange MENU ITEMS HIE and Meaningful Use Matrix Improve population and public health Syndromic Surveillance Cancer Registries Specialized Registries EP only: Capability to submit electronic syndromic surveillance data to public health agencies, except where prohibited, and in accordance with applicable law and practice. EP only: Capability to identify and report cancer cases to a public health central cancer registry, except where prohibited, and in accordance with applicable law and practice. EP only: Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice. Successful ongoing submission of electronic syndromic surveillance data from CEHRT to a public health agency for the entire EHR reporting period. Successful ongoing submission of cancer case information from CEHRT to a public health central cancer registry for the entire EHR reporting period. Successful ongoing submission of specific case information from CEHRT to a specialized registry for the entire EHR reporting period. Potential / Future Implication: This can be met by the provider's EHR, and can be achieved with or without an HIE. If an HIE translates data from a non-proscribed to a proscribed format (e.g., CCD to HL7 v2 message), the HIE must also be Certified EHR Technology. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. (For more information see It is unclear exactly what these other registries might be, but they may be operated by public health agencies, professional associations or other organizations. This is more about individual healthcare settings providing the data it has to an outside entity (not tied to the HIE). If the HIE is responsible for presenting the data to the public health agencies (or if they end up going through HIEs) this will have implications. Potential / Future Implication: This can be met by the provider's EHR, and can be achieved with or without an HIE. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. It is unclear exactly what these other registries might be, but they may be operated by public health agencies, professional associations or other organizations. (For more information see Potential / Future Implication: This can be met by the provider's EHR, and can be achieved with or without an HIE. The choice of transport protocol is left up to the public health agency involved. Note that mere testing of this interface (Stage 1) is no longer enough - registration for ongoing submission must be done at least 60 days from the start of the reporting period and must continue once initiated. It is unclear exactly what these other registries might be, but they may be operated by public health agencies, professional associations or other organizations. (For more information see Healthcare Information and Management Systems Society (HIMSS) 23