Meaningful Use Workgroup New Pathways for Meaningful Use Stage 3

1. Meaningful Use Workgroup New Pathways for Meaningful Use Stage 3 April 9, 2013 Paul Tang, MDGeorge Hripcsak, MDChristine Bechtel

2. Agenda • Review of HITPC presentation and feedback • Consolidation and Deeming • Clinical Documentation • Comments/discussion of direction from HITPC and directional decisions (to be fleshed out in subgroups • Work plan review • Reconcile RFC comments where divergent public comments

3. Presentation to HITPC Meaningful Use Workgroup April 3, 2013

4. Stages of Meaningful UseImproving Outcomes Stage 3 2016-17 Stage 2 2014-15 Stage 1 2011-13

5. Stages of Meaningful UseImproving Outcomes Stage 3 2016-17 Stage 2 2014-15 Stage 1 2011-13

6. Original Principles for Stage 3 Recommendations • Supports new model of care (e.g., team-based, outcomes-oriented, population management) • Addresses national health priorities (e.g., NQS, prevention, Partnerships for Patients, Million Hearts) • Broad applicability (since MU is a floor) • Provider specialties (e.g., primary care, specialty care) • Patient health needs • Areas of the country • Not "topped out" or not already driven by market forces • Mature standards widely adopted or could be widely adopted by 2016 (for stage 3)

7. Lessons from Stages 1Implications for Stage 3 Stage 1 Experience • Substantial increase in adoption rates and effective use • Mandatory floor creating network effects • Thresholds consistently exceeded • Consistent use across the years • Reporting requirements have considerable costs and burden • Prescriptive, “forced march” impacts available resources for innovation or to address local priorities Implications for Stage 3 • Creating critical mass of users and data in electronic form • Rising tide is floating boats (e.g., setup for patient engagement, HIE) • Once MU functionality is implemented, it is used • Gains from stage 1 (and 2) will persist • Stage 3: Simplify and reduce reporting requirements • Stage 3: Rely more heavily on market pull (e.g., new payment incentives); promote innovative approaches ie., reward good behavior

8. Additional Goals for Stage 3 • Address key gaps (e.g., interoperability, patient engagement, reducing disparities) in EHR functionality that the market will not drive alone, but are essential for all providers: • to create level playing field • to create network effects • to fulfill need for a public good • Consolidate MU objectives where higher level objective implies compliance with subsumed process objectives • Consider alternative pathway where meeting performance and/or improvement thresholds deems satisfaction of subset of relevant MU functionality implicitly required to achieve performance/improvement

9. Consolidation Subgroup Christine Bechtel, Chair

10. Consolidation Summary • 43 MUWG objectives proposed in stage 3 RFC • Consolidated to 25 objectives • Assumptions • The full WG will consider RFC feedback and update criteria • All criteria will be included in certification • Focus on advanced uses • ex: recording data vs. use data • Give credit for MU objectives that should be standard of practice once passed stages 1 and 2 • Identify what needs to be “used” and certified

11. Types of Consolidation • Advanced within concept of another objective • Duplicative concepts • objective becomes certification only • Demonstrated use and can trust that it will continue

12. Advanced within Concept of Another Objective Demographics Added as an additional element Patient education, per patient preference Patient preferred means of communication (SGRP208) Reminders, per patient preference Clinical Summary, per patient preference Key: Maintained Objective Certification Criteria

13. Duplicative Concepts CDS (113) Interventions include preventative care for immunizations Immunization intervention (SGRP401B) Included in care summary (303) Structured lab results (SGRP114) Included in view, download, transmit (204A) Key: Maintained Objective Certification Criteria

14. Demonstrated Use • Patient lists and dashboards (SGRP115) • Needed for population management and quality measurement • How to measure use? • Existing external drivers that will drive use (new models of care) • PQRS, value based purchasing, ACOs

15. CPOE - Advanced within concept of another objective, duplicative concept, demonstrated use Needed to provide meds within care summary (303) CPOE for Medication Orders Needed to provide meds within VDT (204A) Needed for eRx formulary and generic substitutions Key: Maintained Objective Certification Criteria

16. Consolidation at a Glance

17. Consolidation Overview Quality, safety, reducing health disparities Engaging patients & families Improving care coordination Population & public health eRx – formulary EH: Lab results EP VDT ToC – Care summary Immunization registry Amendment CPOE - meds CPOE - referrals Adverse event* Test tracking Family Hx Amendment Prob, med, allg list CPOE - lab Advanced directive Synd Surveillance Family Hx Structured lab CDS Prob, med, allg list ELR Electronic notes Vitals Structured lab CDS for immun Smoking status Registries Pt list/dashboard Vitals Demographics Cancer registry Smoking status Reminders eRx transmission Specialty registry Demographics Comm preference Patient education HAI reports Comm preference EH: eMAR Reconciliation Case reports to PHA Inter prob list* Clinical summary Imaging results RxHx PDMP* Comm preference CPOE - rad CPOE - meds Secure Messaging Notify of health event Key: PGHD Care plan* Maintained Objective Identify clinical trials Referral loop Certification Criteria * Proposed for future stage of MU

18. Deeming Subgroup Paul Tang, Chair

19. Deeming Assumptions • Cannot reliably achieve good performance (or significantly improve) without effective use of HIT • Therefore: in order to promote innovation, reduce burden, and reward good performance, deemhigh performers (or significant improvers) in satisfaction of a subset of MU objectives as an optionalpathwayto qualifying for MU

20. Example Criteria for Deeming for EPs • Demonstrate high (top 30 %ile) or improved performance (20% reduction of gap between last year's performance and top quartile). Select two items from each of the categories below: • Prevention of high priority diseases (pick 2 from) • Breast cancer (mammography screening) • Colon cancer (colonoscopy screening) • Influenza (flu vax) • Pneumonia (pneumococcal vaccine) • Obesity (BMI screening and follow up) • Cardiovascular disease (LDL screen) • HTN (BP screen and follow up) • Control of high priority chronic health conditions (pick 2 from) • HTN (BP control or improvement) • Diabetes (A1c control) • Heart attack (LDL control) • Asthma (controller med) • CHF (ACEI or ARB meds) • MI (beta blocker)

21. Example Criteria for Deeming for EHs • Demonstrate high (top 30 %ile) or improved performance (20% reduction of gap between last year's performance and top quartile) for all of the below: • Patient safety (pick 2 from) • Clostridium difficile Infection (outcome measure) • Catheter-Associated Urinary Tract Infection (outcome measure) • Central Line-Associated Blood Stream Infection (outcome measure) • MRSA (outcome measure) • Specific Surgical Site Infection (SSI) Outcome Measure • Severe sepsis and septic shock: Management bundle • Late sepsis or meningitis in very low birth weight (VLBW) neonates (risk-adjusted) • Measure of pressure ulcers • Care coordination (pick 2 from) • Experience of care (from HCAHPS)? • Hospital-wide-all-cause unplanned readmission measure (HWR) • CTM-3, 3-item care transition

22. Additional Requirement • Disparities • Stratify all four population reports by disparity variables

23. Deemed MU Objectives Deemed in Satisfaction of: • CDS • eRx – formulary, generic subs • Reminders • Electronic notes • Test tracking • Clinical summary • Patient education • Reconcile problems, meds, allergies • *View, download, transmit (VDT), consider adding if stage 2 reports good uptake • *Secure patient messaging, consider adding if stage 2 reports good uptake Remaining Items: • Advance directive • eMAR • Imaging results • EH: provide lab results • Patient generated data • *VDT • *Secure patient messaging • Care summary • Care plan • Referral loop • Notification of health event • Immunization registry • ELR • Case reports to PHA • Syndromic surveillance • Reporting to 2 registries • Adverse event reporting

24. Additional Considerations • Propose performance reporting period to be 6 months vs. 1-year MU reporting period to give providers a chance to deem yet still have time to resort to functional objectives qualification if not meeting deeming thresholds • Specialists may have fewer options for deeming as determined by available NQF QMs.  If not able to report on at least 4 performance measures, then may not be eligible for the deeming pathway

25. HITPC Comments • Fazard • While it makes sense to use outcome measures, there may be measures that fall short of total outcomes, but are still closer to outcomes than functional measures. Examples: closing the referral loop, medication safety (functional measures around CPOE), patient experience (maybe pt ed is consolidated). Measures that relate to the functionality, that push further than the functional measure. • Need to tie deeming measures to the functional measures that they relate to • Supportive in general. Encouraged to be even bolder related to consolidation - deeming with a focus on justification for why it is appropriate to HIT. There is room for more reflection • Terry Cullen/Fazard/Christine • Publish constraints within recommendations in terms of what would qualify for measures. Strategically involve the boards? This is an HIT program related to outcomes – innovation related to HIT? • How big of a door will be open? ACOs, PCMH deeming? CAHPS, could be useful for providers (accessible through HIT program). Expectations that HIT incentives be spent on HIT and not duplicate other quality incentive programs. Potential to explore HIT CAHPS model – more valuable for the provider to know if the display of information is helpful for patients, hold accountable for what directly relates to MU (group not individual level). • Gayle • Participants in the PQRS program are able to deem 2014 CQMs, is there a possibility to do the same for functional measures? • Robert Tagalicod • Would be ideal to align multiple programs and report once for a number of initiatives. The simpler the better. PQRS is a good starting point. Recommended working with Kate Goodrich. • Are there unintended consequence? What level and balance is needed? • Terry Cullen • Slide 20 (within this deck) - none of the other measures are included in core. • Slide 21 (within this deck) – none of the measures are on 2014 measure list (might be hard to improve if all new measures).

26. HITPC Comments - Specialists • Marc Probst • Ensure not skewing to one provider group. • Paul response, followed the national priorities. Supportive. • Chris • The role of the patient registries going forward? Reporting to a professional registry could be consolidated, way for using reports. Collaboration with specialty societies. Specialty societies are using registries too. • Judy Faulkner • Are there more things for pediatrics? • Gayle • To develop some of the categories for deeming – reach out to specialty societies to come up with recommendations and put together a package for deeming? • David Lansky • Invite specialists to propose measures which would lend themselves for deeming. Challenge is to define criteria for what measures would qualify that they leverage IT infrastructure, information flow and management. Continue to encourage vendors to create more flexible means for reporting. Measures proposed can help vendors move towards more flexible reporting platforms and enable standardization. Opportunity for measures to be used widely for public purposes, not just local narrow interests. Paul: raise the incentives for participation – reasons why outcome measures are important. Add to incentive. Christine: timing issues • Art Davidson • Need to find a way for specialists to participate in the deeming process. Patient reported outcomes in data to registries, how does that affect the way that the registry is used. • Neil Calman • Too prescriptive for specialists, need to give people an opportunity to innovate in this space. Think about ways to do this for what is important to the specialty. Need to get outside of the top 10 list. Measures are being developed from those who are innovating in a field, creative things in specialty areas – how to recognize within MU? • PT response: limited set of measures, focused on outcome measures that demonstrate control. • CB response: specialists could do consolidated approach and innovative pathway (create a measure and provide specifications to CMS to fill the gaps).

27. Clinical Documentation Presentation to HITPC

28. Clinical Documentation HearingFebruary 14, 2013 • The Future State of Clinical Data Capture and Documentation, AMIA • Role of Clinical Documentation for Clinicians • Role of Clinical Documentation for Care Coordination across the Health Team • Role of Clinical Documentation for Secondary Uses • Role of Clinical Documentation for Legal Purposes

29. Hearing Summary (I) • Clinical documentation serves multiple stakeholders for primary and secondary uses.  • Preoccupation of billinguses may interfere with clinical use of the documentation.  Legal requirements ("if it is not documented, it did not happen") also drive documentation behaviors • Productivity tools developed (including, templates, cut/paste, copy forward, macros, etc.).   Overuse or inappropriate use of these productivity tools has resulted in a concern about accuracy of the documentation and has made it difficult to find the important information • Little quantitative, available evidence on accuracy of documentation or how to assess for good documentation • Anecdotes about poor documentation • No clear method associated with high quality documentation => don't prescribe just one method or prevent other methods

30. Hearing Summary (II) • Quality of note not necessarily associated with quality of care • Voice recognition is efficient, but does not work for everyone • Natural language processing may be useful to get structured concepts out of free text • In order to balance the richness contained in free text with the value of coded information, may need to use hybrid of both text and structure.  Voice recognition + natural language processing + guideline-based structured templates may be used • Sharing notes with patients for viewing may help improve accuracy of notes => decrease fraud • Very hard to capture medical record in a dynamic EHR; cannot reduce to paper printout • Some excessive or inappropriate documentation is due to misunderstanding of E&M coding criteria • Ensure that vendors have security provisions that comply with requirements of "legal medical record" (e.g., data integrity, data provenance)

31. Recommendations (I) • Move clinical documentation menu item to core in stage 3 • HTIPC: Need to distinguish the differences in the types of documentation (EPs and EHs). • Do not prescribe or prohibit method of clinical documentation.  Guide appropriate use through education and policies • Help reader assess accuracy and find relevant changes by making the originating source of sections of clinical documents transparent.  Analogous to "track changes" in MS Word™ • HITPC: This should only relate to progress note, not the progress note copied or pulled in • Default view of documents in the medical record and those transmitted to other EHRs is a "clean copy" (i.e. not showing tracked changes).  The reader can easily click a button and view the tracked-changes version. 

32. Recommendations (II) • To improve accuracy, to improve patient engagement, and to guard against fraud (HITPC: careful with this word), EHRs should have the functionality to provide progress notes as part of MU objective for View, Download, and Transmit – • It is being done at the VA as part of bluebutton (positive experience, provider education needed – more sensitive about what they write), hold off on adding as a use requirement for MU? • Maintaining the functionality component and as we go through RFC, haven’t been specific about how. Differentiate between EP and EH? • Further innovation and research required to collect and meaningfully display information (possibly using graphical views), rather than just text • Increase education about E&M coding criteria; better yet, as payment reform emphasizes outcome over transactions, seek to change E&M coding criteria to reduce over- reliance on specific language in clinical documentation • Propose that HITSC review what standards are needed to ensure that CEHRTmaintains legal medical record content for disclosure purposes (e.g. what was accessed during the encounter and what gets printed out as the legal medical record?) • what was in the record as of a date? Remind the standards committee to review testimony. Chad’s remarks in transcript. Standards are important • New recommendation, Fazard: Productivity tools that don’t have a true function? Tools for upcoding – example of something that encourages inappropriate use of documentation. • Neil: Anti-certification requirement? No clinical benefit. CMS guidance is based upon medical necessity.

33. MU Workgroup – Next Steps • Workplan • Finalize consolidation and deeming proposals (use scheduled subgroup time for consolidation and deeming subgroup meeting) • April 30 – MU WG • Finalize consolidation and deeming approach • Review of objectives with divergent public comments • May 14 – MU WG? • May 28 – MU WG • Subgroups present reconciled RFC comments with consolidated MU objectives to MU WG

34. Consolidation Follow-up

35. Consolidation - VDT

36. Consolidation – Care Summary

37. Proposed Full Workgroup - RFC Discussion Items • Demographics - 104 • CDS – 113 • Electronic notes - 120 • VDT – 204A • PGHD – 204B • Care Summary - 303 • Care Plan – 304

38. Demographics – SGRP104 (I)

39. Demographics - SGRP104 (II)

40. Demographics - SGRP104 (III)

41. Demographics - SGRP104 (IV)HITSC Feedback • Although a high level of demographic data recording has been achieved, discontinuing the requirement could diminish collection of foundational data. Sensitive data such as sexual orientation and disability status should be omitted.  • No other sector would consider 80% to be optimal performance on an important quality measure, nor should healthcare. • Agree with the retirement of the topped out measures (Original demographic measures) • Agree with the addition of the new updated demographic measures • Structured data will be captured and not codified data at this time • What is the definition of Disability Status? Federal definition or patient identification, or otherwise • Question on how sexual orientation will or can be codified • Introduce as a general comment about Disability status being included as long as it can be captured • Date of disability status and inclusion of functional status should be included • Note: CMS has established HCPCS and modifier coding requirements for reporting functional status and degree of impairment for therapy services claims, and explicitly requires them to be documented into the medical record. Any CMS requirement for that kind of information for meaningful use Stage 3 should take that into account and leverage it at least where the two requirements overlap – not impose additional requirement. The CMS claims requirement impacts all manners of therapy services providers including hospitals and physicians

42. Background Slides

43. Stage 2 – Option 2 for reporting CQMs • Submit and satisfactorily report CQMs under the PQRS's EHR Reporting Option. • Under this option, Medicare EPs who participate in both the PQRS and the Medicare EHR Incentive Program will satisfy the CQM reporting component of meaningful use if they submit and satisfactorily report PQRS CQMs under the PQRS's EHR reporting option using CEHRT. • EPs choosing to report under this option for purposes of the Medicare EHR Incentive Program will be subject to the reporting periods established for the PQRS EHR reporting option, which may be different from their EHR reporting period for the meaningful use objectives and measures. For example, in CY 2014, an EP who is beyond his or her first year of meaningful use will have a 3-month quarter EHR reporting period for the meaningful use objectives and measures, but the reporting periods for the PQRS EHR reporting option that fall within CY 2014 would apply for purposes of reporting CQMs. • EPs who are in their first year of demonstrating meaningful use in the year immediately preceding a payment adjustment year cannot choose this Option 2 for reporting CQMs for the EHR Incentive Program. For purposes of avoiding a payment adjustment, they must submit their CQM data by attestation no later than October 1 of such preceding year. • Regardless of whether an EP chooses Option 1 or Option 2 for CQM reporting, all EPs must also report the meaningful use objectives and measures through attestation, as well as meet all other meaningful use requirements. We acknowledge that under the PQRS, only Medicare patient information is submitted. In general, our preference is to measure quality at the all patient level, based on samples of all patient data (that is, patients that meet the denominator criteria of each reported CQM). We believe this provides a better assessment of overall care quality rendered by EPs. Medicare and Medicaid EHR Incentive Program Final Rule p. 54057

44. Clinical Data Registry • SATISFACTORY REPORTING MEASURES THROUGH PARTICIPATION IN A QUALIFIED CLINICAL DATA REGISTRY.— For 2014 and subsequent years, the Secretary shall treat an eligible professional as satisfactorily submitting data on quality measures under subparagraph (A) if, in lieu of reporting measures under subsection (k)(2)(C), the eligible professional is satisfactorily participating, as determined by the Secretary, in a qualified clinical data registry (as described in subparagraph (E)) for the year. • http://www.gpo.gov/fdsys/pkg/BILLS-112hr8enr/pdf/BILLS-112hr8enr.pdf