Paul Tang, ChairGeorge Hripcsak, Co-Chair

Meaningful Use Workgroup

January 6, 2014

Meaningful Use Workgroup Members

Chairs• Paul Tang , Palo Alto Medical Foundation• George Hripcsak, Columbia UniversityMembers• David Bates , Brigham and Women’s

Hospital• Christine Bechtel , National Partnership for

Women & Families• Neil Calman , The Institute for Family Health• Arthur Davidson, Denver Public Health

Department• Paul Egerman, Businessman/Entrepreneur• Marty Fattig, Nemaha County Hospital

Auburn, Nebraska • Leslie Kelly Hall, Healthwise• David Lansky, Pacific Business Group on

Health• Deven McGraw , Center for Democracy &

Technology

• J. Marc Overhage, Siemens Healthcare• Patricia Sengstack, Bon Secours Health

Systems• Charlene Underwood, Siemens• Michael Zaroukian, Sparrow Health

System• Amy Zimmerman, Rhode Island Office of

Health & Human ServicesFederal Ex officios• Tim Cromwell, Department of Veterans

Affairs• Joe Francis , Veterans Administration• Greg Pace, Social Security Administration• Martin Rice, HRSA• Robert Tagalicod, Centers for Medicare &

Medicaid Services, HHS

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Workplan

Date Meeting Tasks1/6/2014

9:30-11:30 ET• Standards feedback

• PGHD• Medication Adherence

• Open Notes• Affordable care • Health disparities

1/17/1411:00-1:00 ET

• Follow-up items• Review of recommendations

1/28/141:00-3:00 ET

• Follow-up items• Review of recommendations

2/4/14 • Present to HITPC

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Feedback from HITSC - PGHD

Engaging patients and families in their care: Patient Generated Health Data

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Stage 3 Functionality Goals

• Enabling active participation by patients and families to improve health and care

• Provide ability to contribute information in the record, including patient reported outcomes (PRO)

• Patient preferences recorded and used

Functionality Needed to Achieve Goals

• Eligible Providers and Hospitals provide the capability for patients to electronically submit patient-generated health information through structured or semi-structured questionnaires (e.g., screening questionnaires, intake forms, risk assessment, functional status), secure messaging or provider-selected devices using CEHRT. (Provider-selected devices pending consideration by HITSC)

• Recommended as a Menu item• Low threshold

Standards Recommendations

• ONC should consider the Direct transport standard for secure messaging and data from devices

• ONC should consider the HL7 Care Team Roster standard

• ONC should consider the HL7-CCDA for structured and unstructured questionnaires

• ONC should consider the Continua standard for data from devices

• We encourage standards that support mobile access to patient data and PGHD given the proliferation of mobile devices. However, we do not recommend mandating a specific standard at this time given that might stifle innovation.

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HITSC Discussion

• The key discussion was an evaluation of the standards maturity and the level of adoption of the standards suggested for patient generated data. Recommendations included Direct for data transport, CCDA for content capture, LOINC/SNOMED for vocabulary capture, and Continua implementation guides for devices.

• As a followup the Consumer Technology Workgroup will list examples of CCDA templates that can be used to support patient generated data use cases.

• Continua will provide a list of the named standards so that we can validate the maturity and adoption of Continua's recommendation.

• We will also ensure that the CCDA templates include the appropriate vocabularies that will enable incorporation of patient generated data into EHRs.

• http://geekdoctor.blogspot.com/2013/12/the-december-hit-standards-committee.html

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Medication AdherenceHITSC Clinical Quality Workgroup

Marjorie Rallins, Co-ChairDanny Rosenthal, Co-Chair

Questions presented to CQWG from MUWG

Updated Stage 3 Objective QuestionMedication adherence certification criteria: • Ability to accept data feed from PBM (Retrieve external medication fill

history for medication adherence monitoring)• Ability to identify important signals such as:

• identify data that patient is not taking a drug• patient is taking two kinds of the same drug (including detection

of abuse) or • multiple drugs that overlap

Certification criteria: EHR technology supports streamlined access to prescription drug monitoring programs (PDMP) data.• For example: Via a hyperlink or single sign-on for accessing the PDMP data Via automated integration into the patient’s medication history • Leveraging things like single sign on or functionality that could enable

the linkage between PDMPs and prescribers and EDs?

Clinical Quality: feedback on the readiness of standards will help determine whether this could be a certification criteria item for stage 3 or should be pushed out to a future stage.

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CQWG: Recommendations/Comments for Medication Adherence (I)

1. Suggest further clarification on the goals of MU for medication adherence and prescription drug monitoring. Once clarified, prioritize goals

2. The following standards could be recommended for medication adherence. Note, original intent of the standards were for administrative analysis. Clinical use may require further cleaning of the data

a. NCPDP SCRIPT Standardb. NCPDP Structured and Codified Sig Format (component to be used

with NCPDP SCRIPT Standard)c. RxNorm. EHR should be able to accept RxNorm codes

3. NDF-RT considered but limited to drug class identification

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Recommendations/Comments (II)

Other comments and recommendationsa. Signals can be identified but are not necessarily computable; b. Actions on signals are out of scope for this questionc. C-CDA medication list; reconciliation should be considered in the

context of medication adherenced. Various states accumulate data on controlled substances and make

that data available to providers that have no data integration with other systems

e. Alignment of goals medication adherence and prescription drug monitoring with other regulatory activity and other agencies (e.g., FDA is crucial)

f. MUWG should have direct communication with an NCPDP expert (e.g., Lynn Gilbertson, Vice President, Standards Development, NCPDP)

CQWG: Recommendations/Comments for Medication Adherence (II)

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CQWG: Recommendations/Comments for PDMP

• Many issues remain under consideration for prescription drug monitoring standards.

• As such, CQWG cannot recommendations at this time

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Open Notes

Follow-up from clinical documentation hearing

• To improve accuracy, to improve patient engagement, and to guard against fraud, EHRs should have the functionality to provide progress notes as part of MU objective for View, Download, and Transmit

• OpenNotes– http://www.myopennotes.org/– Recent NEJM article

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Affordable Care

Affordable care:Stage 3 Priorities

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• CDS support to avoid duplicative care

• CDS support to avoid unnecessary or inappropriate care

MU Outcome Goals

• Eliminate duplicative testing

• Use cost-effective diagnostic testing and treatment

• Minimize inappropriate care (overuse, underuse, and misuse)

• Formulary checks• Generics

Stage 3 Functionality Goals MU Outcome GoalsStage 1 + 2 Functional

Objectives

Affordable care:Clinical Decision Support

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Examples of Functionality Needed to Achieve Goals

• Demonstrate use of multiple CDS interventions that apply to quality measures in each of the six NQS domains. Recommended interventions include: – Preventive care– Chronic disease management (e.g., diabetes,

coronary artery disease) – Appropriateness of lab and radiology orders – Advanced medication-related decision support

(e.g., renal drug dosing) – Improving the accuracy/completeness of the

problem list– Drug-drug and drug-allergy interaction checks

• CEHRT should provide tools that enable the ability to provide these interventions

• Related work that can inform: S&I HealtheDecisions, HITSC Clinical Quality WG

Stage 3 Functionality Goals

• CDS support to avoid duplicative care

• CDS support to avoid unnecessary or inappropriate care

Reducing Health Disparities

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Reducing health disparities:Stage 3 Priorities

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• Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

MU Outcome Goals

• Eliminate gaps in quality of health and health care across race, ethnicity, and sexual orientation

• Language• Gender • Race• Ethnicity

Stage 3 Functionality Goals MU Outcome GoalsStage 1 + 2 Functional

Objectives

Reducing health disparities:Additional Patient Information

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Functionality Needed to Achieve Goals

• CEHRT provides the ability to capture– Patient preferred method of communication*– occupation and industry codes– Sexual orientation, gender identity (optional fields) – Disability status

o Differentiate between patient reported & medically determined

• Communication preferences will be applied to the clinical summary, reminders, and patient education objectives – Providers should have the ability to select options that are

technically feasible for them, these could include: Email, text, patient portal, telephone, regular mail

• Recommended as certification criteria only

Stage 3 Functionality Goals

• Patient conditions are treated appropriately (e.g. age, race, education, LGBT)

Reduction of Disparities – previous deeming recommendations

• Reduction of disparities in gap area• Identify areas where attesters should be

required to demonstrate they have reduced health care disparities in high-risk populations

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