Beacon Community ProgramBuild and Strengthen – Improve – Test innovation

Beacon-EHR Vendor Full Affinity GroupSeptember 20, 2013

• Roll call – Lynda Rowe• Affinity Group Next Steps – How to Sustain the Group After the Beacon Period

Closes – Chuck Tryon– Leadership– Facilitation– ONC/CMS Participation– Goals

• MU 2 ToC Query/Retrieve Pertinent Questions for ONC/CMS and EHR/HIE Vendors Review – Chuck Tryon/Lynda Rowe– Are these the right questions to move forward?– What are the best next steps to move forward?– What is the ideal forum for these discussions?

• Beacon Pilot Updates – Lynda Rowe/Beacon Communities• Wrap Up/Next Steps – Chuck Tryon/Adele Allison

Today’s Goals

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MU 2 ToC Numerator Denominator Questions for ONC/CMS• 1. Will the CHPL list out what certifications and types of transports each Vendor is certified in?

– Paul Tuten –Yes• 2. In the following scenario, how do we count the referral: Provider A refers a patient to

provider B, provider B receives the referral order but cannot accept the patient for any number of reasons. The patient is referred then to provider C by provider A, provider C receives and accepts the referral, and ultimately treats the patient. Does this referral count twice in the numerator and denominator for provider A since each referral was sent and received in the specified manner, even though the patient was not seen by provider B?

• 3. Would a referral count that was sent from Provider A to a specific provider (B), but provider B was not able to treat the patient, so the referral was forwarded (by provider B) to another provider (C) which is within the HIE network count in provider A’s numerator? – In other words, if a patient is referred to a specific doctor by their PCP but choose to go

to another specialist, who is part of the HIE, and that specialist pulls the most up to date information from the HIE, does this ToC still count in the numerator of the referring PCP?

• 4. Can the types of transfers for ToC be better defined? Meaning, do transfers such as from an ICU to an inpatient hospital bed count in the ToC measures? A transition from a PCP to a physical therapist?

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MU 2 ToC Numerator Denominator Questions for EHR/HIE Vendors

• 1. What is the specific data available which can be used for numerator/denominator calculations?

• 2. Who will do the numerator/denominator calculation, and when will this calculation occur?

• 3. When does a ToC order get calculated in the numerator? When it is placed, or when the ToC is sent to an HIE/another party?

• 4. What can your specific EHR/HIE software produce in respect to an audit log? Can you produce an excel spreadsheet listing the ToCs that occurred and when they occurred? Can you intake an excel spreadsheet listing the ToCs and when they occurred?

• 5. How do you identify the providers internally? NPID? Proprietary Solution? Tax ID?– How can this identification system be used to help track ToCs made by each

specific EP or EH?• 6. How do you identify patients for which a ToC was created?• 7. How do you define who the recipient of a ToC is, and what counts as a ToC as

related to MU 2 measures?

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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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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