HITPC - Information Exchange Work Group Meaningful Use Stage 3 Subgroup 1: Quality and Efficiency

1. HITPC - Information Exchange Work GroupMeaningful Use Stage 3 Subgroup 1: Quality and Efficiency Chair: Dave Goetz Members: Cris Ross, Chris Tashjian, Steve Stack

2. Agenda • LOI presentation and lab orders discussion • Controlled substance e-rx • Review Prior Authorization Language (if time allows)

3. IE Workgroup Timeline

4. Recommendation Options • The Subgroup is tasked with reviewing and developing prioritized recommendation in four key areas. The Subgroup has a number of options for addressing these areas including: • Stage 3 • Explore in RFC • Certification only • No recommendation • Push to Stage 4

5. John Feikema S&I Framework Coordinator LOI Overview 5

6. Laboratory Orders Interface (LOI) Initiative Coordinator: John Feikema 6 • Initiative Purpose: • The goal of the initiative is an IG for electronic ordering of laboratory tests in an ambulatory setting that can serve as a foundation for eventual use in in-patient and public health settings. Further, the design will incorporate vocabulary consistent with the above mentioned guides as well as support for use of the Electronic Directory of Service (eDOS) IG. • Standards Related: • Lab Results Interface • HL7 Version 2.5.1 Implementation Guide: Laboratory Results Interface for US Realm, Release 1 • Laboratory Orders Interface • Aligning the ELINCS Orders interface to LRI 2.5.1 • eDOS (electronic Directory of Services) • Aligning HL7 Laboratory Test Compendium Framework Implementation Guide Release 1 to LRI and LOI

7. Laboratory Results Interface Initiative 7 • The Laboratory Results Interface (LRI) Initiative, which kicked off in February of 2011, focused on standardizing results reporting to ambulatory primary care, in support of Meaningful Use objectives for decision support, quality reporting, transitions in care, and electronic copies of clinical summaries and Discharge Instructions. • The Initiative enables results reporting between a laboratory information system and an ambulatory EHR system in different organizational entities, including incorporation of lab results into EHRs as structured data. • Value: Standardizes results reporting to ambulatory primary care, in support of Meaningful Use objectives for decision support, quality reporting, and transitions in care.

8. Laboratory Orders Interface (LOI) Initiative 8 • The LOI Initiative, which kicked off in April of 2012, is focused on the creation of an Implementation Guide (IG) for the ambulatory setting that builds on the architecture and design of the California Health Care Foundation’s (CHCF) ELINCS Laboratory Orders and the Health Level Seven (HL7) Version 2.5.1 Implementation Guide: Laboratory Results Interface for US Realm, Release 1 (LRI IG).Further, the Initiative seeks to design an IG that can serve as a foundation for eventual use in acute care and public health and incorporate vocabulary consistent with the above mentioned guides as well as support for the HL7 Electronic Directory of Service (eDOS) IG. Additionally, tools will be developed to aid evaluation and adoption of messages compliant with the LOI IG generated by Electronic Health Records (EHR) Systems and Laboratory Information Systems (LIS). • Value: Defines the implementation guidance for the communication (i.e. message structure, data elements, vocabularies) of test orders from an EHR System to an LIS across the ambulatory setting.

9. Electronic Directory of Service (eDOS) Workgroup 9 • The Electronic Directory of Service (eDOS) workgroup effort aims to provide an electronic interchange of a laboratory’s directory of services in a structured format based on Health Level Seven’s (HL7) master file update found in Chapter 8 of version 2.5.1 or greater. The current implementation guide, developed by the members of the American Clinical Laboratory Association’s (ACLA) in conjunction with their Health Information Technology (HIT) Committee, is intended to provide all necessary information to help an Ordering Provider properly request laboratory tests consistent to aid patient care. • Value: Increases interoperability between Electronic Health Record (EHR) systems, Hospital Laboratory Information System (HLIS), Health Information Exchange (HIE) vendors, Laboratory Information systems (LIS), and laboratory providers through the development of a framework for the Laboratory Test Compendium and associated capability of electronic exchange of Directory of Services content.

10. LRI/LOI/eDOS:Current Status 10 LRI in the 2014 edition of the final rule LOI use case consensus achieved, harmonization in process eDOS use case consensus achieved Unified LRI/LOI/eDOS pilot program launched

11. Laboratory PilotsCommunity Options for Piloting Option One: Individual Initiative Pilots aka Pilots I • Point of Contact: Bob Dieterle • Details: Participants will pilot LRI LRI LOI eDOS Option Two: “Pilots II” • Point of Contact: Bob Dieterle & Patrick Loyd • Details: Participants will pilot LRI AND LOI with the option to additionally pilot eDOS LRI LOI eDOS Option Three: eDOS Only Pilots • Point of Contact: Patrick Loyd • Details: Participants will pilot eDOS LRI LOI eDOS 11

12. Laboratory Orders Interface (LOI) 12

13. Key Industry and Government Representation • Laboratory Orders Interface • Ken McCaslin – Quest Diagnostics, ACLA • Hans Buitendijk – Siemens Healthcare • JitinAsnanni – AthenaHealth • Cindy Johns – LabCorp • Glen Moy – CHCF • Pam Banning – 3M • Corey Spears – McKesson • Michael Fitzmaurice – AHRQ • Mary Kennedy – College of American Pathologists • Hai Nguyen – Mayo Clinic • Megan Sawchuk – CDC • Clement McDonald – NLM • Robert Snelick – NIST • Rebecca Goodwin – NIH 13

14. Electronic Prescribing of Controlled Substances • DEA has approved three certifying organizations • InfoGard Laboratories, Inc. • Drummond Group Inc. • iBeta LLC • Surescripts has enabled e-prescribing of controlled substances on its network 14

15. Electronic Prescribing of Controlled Substances 15 Source: Surescripts

16. Prior Authorization 1. The first order is to look to what might be required of EHRs that would facilitate prior authorizations, and then to look to providers to use where available. The certification requirements should build upon and hopefully reuse functionality that already exists or is being developed.2. The goal is to reduce unwanted variation in quality and cost and removing complexity and friction in the interaction between providers and payers in working towards that goal. The strategy is to identify the use cases where this interaction improvement could take place.3. The current interactions occur by fax, phone, portal and EDI. It is generally acknowledged by both providers and payers that fax exchanges are the least efficient method of interaction, and a focus on reduction of faxes could reduce the level of frustration on both sides. The highest number of interactions currently would be phone calls, which are often time consuming and labor intensive for both payers and providers. Uses of electronic exchange could reduce the number of calls, but phone calls will always be necessary for interaction over the more complex procedures with the most variation around efficacy and appropriateness. Next would be payer portals where providers may both inquire as to eligibility and coverage issues and also submit clinical and other information necessary for the most efficient determination, receipt of approvals, filing appeals of adverse decisions. Last in current utilization is the transaction sets around EDI. Some payers currently use these X12 transactions, mostly with hospital systems. There are serious efforts underway, led by the AMA, to consider how to use this existing set of interactions between payers and providers to improve these interactions. 16

17. Prior Authorization 4. Sub group 1 discussed these issues, and suggests that use cases for EHR certification can go from interaction with existing authorization systems through the transmission of clinical information for more complex decisions.  We recommend that: a.Where available, EHRs should be able to automatically check and make available to Meaningful Users as part of the clinical workflow those methods of interacting with payers that are already in widespread usage.  For example, for electronic prescribing, EHRs should be able to import formularies and medication histories, where available.  Where payers have secure portals for the purpose of receiving prior authorization requests, EHRs should be able to allow Meaningful Users to sign into those portals as part of the clinical workflow without having to leave their EHR.  Some payers currently have clinical questions on these portals, and clinicians can answer those to receive an automated approval.  This functionality should be encouraged for those approvals where the clinical pathways are clear.  b.Where this functionality exists in both EHRs and payer systems, providers should use this functionality in order to qualify as Meaningful Users, and payors should accept. c.As payers and providers work together to simplify and improve interactions around prior authorizations, they should be aware of how existing functionality in EHRs could be repurposed.  For example, CCDA could provide the clinical information that payers would need in order to be able to more efficiently reach decisions with a minimum of repetitive or lengthy interactions.  As noted above, there is work underway to see if other transaction sets can be repurposed or expanded to help automate routine transactions. 17

18. Prior Authorization Use Cases 1. Medication formulary compliance v.1: prescriber electronically prescribes, EMR reconciles against relevant formulary, if formulary-compliant, prescription transmitted to pharmacy2. Medication formulary compliance v.2: prescriber electronically prescribes, EMR reconciles against relevant formulary, if NOT formulary-compliant, prescription rejected, prescriber alerted to non-compliance, opportunity given via structured data prior-auth form to document medical necessity for non-formularly med, prior auth electronically and automatically granted in real-time if required prior auth requirements are fulfilled; this entire transaction could be done with structured data3. Procedure/Surgery prior authorization v.A: for those procedures/surgeries with clear and objective prior authorization requirements and a structured data prior authorization form is available, clinician fill out the prior authorization form using structured data fields and prior authorization can be granted electronically and in real-time by the payor.4. Procedure/Surgery prior authorization v.B: for those procedures/surgeries, for which prior authorization is non-standardized and is highly individualized, a standardized form is created that collects from the clinician text fields answering an agreed upon set of medical necessity questions, standardized form is sent electronically to insurer for review, insurer responds with Approval/Denial (with rationale if denied) using a standardized format text document back to clinician with either approval and/or denial with rationale.A CCD (or comparable) could be appended to any of the above for added context if/when desired by either party. 18