Beacon Community ProgramBuild and Strengthen – Improve – Test innovation

Beacon-EHR Vendor Full Affinity GroupAugust 30, 2013

• Roll call – Lynda Rowe• Welcome to Participants (Adele, Chuck)• Review of Affinity Group Goals, and Progress (Adele, Chuck)• Orientation to the Problem (Lynda Rowe)• Goals and Outcomes of the Meeting(s) (Lynda Rowe)

– Timeline– Outcomes

• Deep Dive Numerator/Denominator Calculations (All)• Next Steps

– Future meeting to complete work– Output deliverable and distribution

Today’s Goals

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Affinity Group Goals

• The ONC Beacon EHR Vendor Affinity Group convened and collaborated to advance mutually agreed to EHR adoption and interoperability goals between November 2011 and September 2012

– Original charter available on the ONC Beacon EHR Vendor AG HITRC portal http://wiki.statehieresources.org/Beacon+EHR+Affinity+Group

• On February 1st, 2013, all members confirmed an interest to align the activities of the group to support achievement of MU Stage 2 in the following manner:

– Explore the transport standards associated with Transitions of Care (TOC)– Explore how to achieve the View online, Download, and Transmit(VDT) measures– Act as a venue to pilot and test the implementation of the transport standards outlined in

the ONC Standards and Certification Criteria Final Rule for TOC and optionally VDT objectives– Act as a means to extend the knowledge gained and deliverables created by collaboration to

vendors and communities outside of this affinity group

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Orientation to the Problem & Goals

• Problem– MU Stage 2 TOC provides ways for HIEs/HIOs to support measure 2– HIE/HIO participating in TOC need to provide evidence of message receipt – contribute

to overall numerator– Counting methods not yet defined

• Goals– Establish a proposed set of specifications for N/D calculations for EHRs and HIOs

participating in MU2 TOC– Establish a process and timeline for completing the work– Determine appropriate processes for getting broader buy-in and dissemination

Meaningful Use & Certification Relationship “Transitions of Care” (ToC) Objective

• For Meaningful Use Stage 2, the ToC objective includes 3 measures:

– Measure #1: requires that a provider send a summary care record for more than 50% of transitions of care and referrals.

– Measure #2 requires that a provider electronically transmit a summary care record for more than 10% of transitions of care and referrals using CEHRT or eHealth Exchange participant

– Measure #3 requires at least one summary care record electronically transmitted to recipient with different EHR vendor or to CMS test EHR

Meaningful Use 2014 Edition Certification• Two 2014 Edition EHR certification

criteria

– 170.314(b)(1) : Transitions of care—receive, display, and incorporate transition of care/referral summaries.

– 170.314(b)(2) : Transitions of care—create and transmit transition of care/referral summaries.

Feature Focus: ToC Measure #2 & 170.314(b)(2)

• The eligible provider, eligible hospital 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 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.

ToC Measure #2 170.314(b)(2)• Transitions of care—create and

transmit transition of care/referral summaries.

– (i) Enable a user to electronically create a transition of care/referral summary formatted according to the Consolidated CDA with, at a minimum, the data specified by CMS for meaningful use.

– (ii) Enable a user to electronically transmit CCDA in accordance with:

– “Direct” (required)– “Direct” + XDR/XDM (optional, not

alternative)– SOAP + XDR/XDM (optional, not

alternative)

eHealth

eHealth Exchange Example

1.EHR generates CCDA2.EHR sends CCDA to eHealth Exchange Participant3.eHealthExchange Participant sends to Provider B

Provider A Provider B

CEHRT

eHealth Exchange Participant(formerly NwHIN Exchange)

Example 1

Transmit Summary Care Record Using eHealth Exchange Participant

An eHealth Exchange Participant does not have to be certified in order for Provider A’s transmissions to count for MU.

However, Provider A must still use CEHRT to generate a standard summary record in accordance with the CCDA.

Provider 1 Provider 2 Provider 3 Provider 4

Provider 5

• Providers #1-4 (1) have CEHRT, and (2) use the CEHRT’s transport capability (Direct or SOAP) to send a CCDA to a HISP/HIE that enables the CCDA they’ve sent the HISP/HIE to be subsequently pulled by Provider #5.

HISP/HIE

Transmit Summary Care Record Using “Pull” or “Query” Infrastructure

In this scenario, the HIE does not have to be certified.

Provider 1 Provider 2 Provider 3 Provider 4

Provider 5

• If Providers #1-4 do not have CEHRT, their EHR technology will either

– Need to be certified as a pair with HISP/HIE to be able to create the CCDA and transmit it to Provider 5 (per the prior slides).

– Need to use an HIE that has been certified to support this criteria (per the prior slides).

HISP/HIE

Transmit Summary Care Record Using “Pull” or “Query” Infrastructure

Provider 1 Provider 2 Provider 3 Provider 4

Provider 5

• Regardless of certification path, Provider #5 needs to “pull” the summary care record in order for Provider #1-4 to potentially count the pull in their numerator.

• For all Providers where the patient meets the denominator requirements, when Provider #5 pulls they can then count that pull in their numerator as a transmission to Provider #5 (e.g., Providers #1-3 saw the patient during the reporting period but #4 did not; thus only Providers #1-3 could count the pull). HISP/HIE

Transmit Summary Care Record Using “Pull” or “Query” Infrastructure

In the “pull” scenario, accurately counting transactions for the providers’ numerators and denominators represents a non-trivial challenge.

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Options for HIOs to participate in MU2 TOC

• There are a number of options for an HIE/HIO to participate in TOC MU2 exchange

– Become certified for TOC (transport, content)– Partner with an EHR and become relied upon software– Become an eHealth Exchange (N/D)– Push content delivered by CEHRT (receipt confirmation) – repackaged

and deliver with any transport– Pull/Query – messages must be delivered using CEHRT (N/D)

• Focus today is on those options requiring tracking of numerator and denominator values to calculate the measure and meet audit requirements

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Possible Pilot Scenarios 1 - 5

Pilot #

Query OR Push

Provider A Transport Method

Certified Transport Entity

Transport Method To Provider B

C-CDA Generation

MU 2 Metric Reporting

Description

Pilot 1

Push Direct (SMTP + S/MIME)

EHR Technology Transport is directly from provider A

Provider A EHR Provider A EHR

EHR Supports all aspects of DIRECT Transport

Pilot 2

Push Any Edge Protocol

HISP /HIE/HIO Direct (SMTP + S/MIME) HISP/HIE/HIO HISP/HIO/HIE HISP/HIE/HIO must be certified to the TOC objective, i.e. supportThe Direct Applicability statement/produce a C-CDA

Pilot 3

Push Any Edge Protocol

EHR module Certified with Associated HISP/HIO (relied upon software)

Direct (SMTP + S/MIME) EHR Vendor and relied upon software

EHR Vendor and relied upon software

EHR vendor + relied upon softwaremust meet MU2 criteria

Pilot 4

Push Direct (SMTP + S/MIME)+ XDR/XDM

EHR Transport is directly from provider A

Provider A EHR Provider A EHR

Same as Pilot 1, except adding the optional XDR/XDM transport

Pilot 5

Push Any Edge Protocol

HISP /HIE/HIO Direct (SMTP + S/MIME)+ XDR/XDM

HISP/HIE/HIO HISP/HIO/HIE HISP/HIE/HIO must be certified to the TOC objective, i.e. supportThe Direct Applicability statement/produce a C-CDA

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Possible Pilot Scenarios 6 - 10

Pilot #

Query OR Push

Provider A Transport Method

Certified Transport Entity

Transport Method To Provider B

C-CDA Generation

MU 2 Metric Reporting

Description

Pilot 6 Push Any Edge Protocol

EHR module Certified with Associated HISP/HIO (relied upon software)

Direct (SMTP + S/MIME)+ XDR/XDM

EHR Vendor and relied upon software

EHR Vendor and relied upon software

EHR vendor + relied upon softwaremust meet MU2 TOC criteria

Pilot 7 Push SOAP + XDR/XDM EHR – Must be certified for optional SOAP transport

Transport Directly From Provider A

Provider A EHR Provider A EHR

EHR Hosted SOAP + XDR/XDM

Pilot 8 Push Any MU2 Certified Transport (Direct or SOAP)

CEHRT natively or with relied upon software

Repackage by HIE/HIO and send to Provider B using any transport

Provider A EHR HIO/HIE/HISP must provide delivery assurance

Content may be repackaged by HISP/HIO for provider B

Pilot 9 Push OR Query

Any Transport HIO as an eHealth Exchange participant

Query or push to provider via eHealth Exchange certified protocol

Provider A EHR HIO or CEHRT HIO must be a certified eHealth Exchange participant

Pilot 10

Query Any MU2 Certified Transport (Direct or SOAP)

CEHRT natively or with relied upon software

Any transport via an HIE/HIO/HISP

Provider A EHR HISP/HIO/HIE must report Numerator

Provider A must be using CEHRT

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Numerator/Denominator for TOC measure #2

• Measure 1: The EP, eligible hospital 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% of transitions of care and referrals.

• Measure 2: The EP, EH or CAH that transitions or refers its patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transition and referrals either:

– Electronically transmitted using CEHRT to a recipient; or– Where the recipient receives the summary of care record via exchange facilitated by an organization that is an eHealth Exchange participant

• Denominator: Number of transitions of care and referrals during the CEHRT reporting period for which the EP or eligible hospital’s or CAH’s inpatient or emergency department (Place or Service 21 or 23) was the transferring or referring provider

• Numerator: Number of transitions of care and referrals in the denominator where a summary of care record was 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 an eHealth Exchange participant. The organization can be a third-party or the senders own organization.

• Of note:– EP/EHs may only count transmissions in the measures numerator if the are accessed by the provider to whom the sending provider is referring or

transferring the patient– An EP or EH may only count in the numerator transitions of care that first count in the denominator– Receipt by the provider occurs when either the clinician receives/queries or the practice/facility at which the clinician works receives/queries the summary

of care

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Numerator/Denominator Calculations

• Key Points– EPs/EHs must use one of two methods to calculate

their denominator:» Minimal denominators provided by CMS in the

Stage 2 Final Rule» http://www.cms.gov/Regulations-and-Guidance/

Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_15_SummaryCare.pdf

» Minimal denominators PLUS criteria defined and consistently documented by the EP/EH such as all self referrals not just self referrals reported by the HIO

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Numerator/Denominator Calculations

• Counting Concepts– Unit of measure for ToC measure 1 and 2 is transition/referral and not individual patient– 1:1 relationship between transitions/referrals in the EP/EH’s denominator and

numerator. An EP/EH cannot count more than one pull/query in the numerator for just on TOC in the denominator

– All EPs/EHs contributing data to a patient’s CCDA may receive credit when that document is exchanged/pulled only if the transfer is in the EP/EHs denominator

» It is likely that an HIO will not have easy access to a particular EP or EH’s denominator unless the HIO is also the EHR vendor, and EHR vendor provides a list of denominator transitions or referrals to the HIO, or the EP or EH provides a list of denominator transitions or referrals to the HIO

– Approach to calculating the denominator for ToC measure 1 and 2 must be the same– The HIO must account for multiple “query/views” of a patient’s record and which

provider or organization viewed the record

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ToC Measure 2 Query Pull Method for EPs, EHs, and CAHs

Measure 2: The EP, EH or CAH that transitions or refers its 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

ToC Measure 2 Transport Methods

Electronically transmitted using CEHRT to a recipient

Numerator Denominator

Number of transitions of care in the denominator where a summary of care record was electronically transmitted using CEHRT or received by provider B via eHealth exchange. The organization can be a third-party or the sender’s own organization

Number of transitions of care and referrals during the CEHRT reporting period for which the EP, EH, or CAH’s inpatient or emergency department was the transferring or referring provider

Numerator Calculations

Recipient receives the summary of care record via exchange facilitated by an organization that is an eHealth Exchange participant

Option 1 EP/EH Calculates Option 2 HIO/HIE Calculates

HIO/eHealth provides: 1. List of patients for which the EP/EH contributed data2. Dates when the data was contributed (so the contribution can be associated with referrals/transitions in the denominator3. List of providers that queried the patients’records (data contributed by the EP/EH)4. The date of each query/view

HIO/eHealth needs the following information: 1. EP/EH’s denominator, however the EP/EH defines it2. Which patients the EP/EH contributed data for (data must be sent via CCDA summary document from CEHRT) 3. Which providers queried the patients’ records 4. The date of each query/view

Important Notes

1. EPs/EHs need to confirm that the date of the referral in the denominator predates the date of the query 2. An EP/EH’s approach to calculating the denominator for TOC measure #1 and #2 must be same3. EP/EH may only count transmissions in the numerator that are accessed by the intended provider 4. Receipt occurs when either the clinician or the practice/facility where they work receives/queries the ToC5. The unit of measure for TOC measure #1 and #2 is transition/referral and not individual patient6. CEHRT vendors must determine how to provide customers with transmission receipt assurance 7. Eps/EHs that contribute data to a CCDA may receive credit when that document is exchanged

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Numerator Denominator Deep Dive

• Deep Dive Numerator/Denominator Calculations– Technical Scenarios and Permutations of eHealth Exchange/Query Retrieve

» Push from sender to receiver through eHE/HIE/HISP (no N/D issue)» Push to eHE/HIE/HISP from single provider, only content contributor» Push to eHE/HIE/HISP from single provider – multiple contributors to C-CDA» Push to eHE/HIE/HISP – stored as single document» Push to eHE/HIE/HISP – stored as longitudinal record (multiple providers

contribute)» Query by recipient – no electronic notification» Query by recipient – electronic notification from HIE

– Requirements from CEHRT for denominator – Measure 1, Measure 2– Requirements from HIE to be able to calculate eHE/HIE/HISP numerator

contribution– Exchange of information between CEHRT and HIE/HIO required for Numerator and

Denominator Calculation

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MU 2 Numerator Denominator Discussion - Questions

1. How will a CEHRT distinguish a CCD that is tied to the ONC definition of a TOC. For CEHRTs that trigger a CCD to the local exchange based on some trigger event, how will the system determine that a CCD is part of the TOC denominator vs. other reasons (lab data, update registry, immunization, ED discharge without follow-up, etc.)

2. How will the CEHRT “count” the denominator based on the TOC definition as well as the time frame for reporting the measure

3. Option 1 – HIE will calculate numerator and denominator (CEHRT passing the denominator)a) How will the CEHRT export to an HIE/HIO the patient, sending provider, intended recipient, and date

stamp for referral, transition or discharge (or DOS) to an HIE?b) What format would be used to provide that to the HIE?c) How might the CEHRT time bound denominator information to be sent based on the providers preference

for their 90 day reporting period?d) The assumption is that if the CEHRT provides this information to the HIE, the HIE could then match to

“receipt/view/query” of TOC which would count as the numerator4. Option 2 – HIE will send CEHRT the numerator. CEHRT will calculate the measure and will already have

documented patient transitions in the denominatora) If an HIE/HIO sends to the CEHRT a numerator file, what will be needed at a minimum to count the

numerator – how will patient and provider matching happen?b) If more than one provider views the TOC as a recipient is there a mechanism to account for that?c) What does the CEHRT need for date/time stamp to match to the denominator reporting window?d) How will the CEHRT system determine if an EP/EH TOC denominator counts toward more than one

sending provider (i.e. in a multi specialty practice both the PCP and a specialist contributed to the CCD that will be sent to the receiver)

Wrap Up/Next Steps

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• Final comments– All attendees– Co-Chairs: Chuck Tryon and Adele Allison

• Next steps• Conclusion