hitsc 2010 06-30 slides
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TRANSCRIPT
HIT Standards Committee
Meeting
Wednesday, June 30, 2010
9:00 am ET
Call to Order
1. Call to Order– Judy Sparrow, Office of the National Coordinator for Health
Information Technology
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
Opening Remarks
1. Call to Order
2. Opening Remarks – David Blumenthal, MD, MPP, National Coordinator for Health
Information Technology
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
Review of Agenda
1. Call to Order
2. Opening Remarks
3. Review of the Agenda – Jonathan Perlin, Chair
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
John Halamka
1. Call to Order
2. Opening Remarks
3. Review of the Agenda – John Halamka, ONC
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
ONC Update: NHIN Direct; Framework; Concept of Operations
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications;
Standards & Interoperability Framework;
Concept of Operations – Arien Malec, ONC
– Doug Fridsma, ONC5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge Summary &
Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
Standards & Interoperability
Framework ConOps Overview:How to operationally deliver on the vision of the framework
HHS – ONC
June 30, 2010
Doug Fridsma
Acting Director, Office of Interoperability and Standards
ONC
7
Outline
» The need for the S&I Framework
» S&I Framework and NIEM
» Process Overview
» Roles and Key Artifacts
» Coordination
6/30/2010
The Need for an S&I Framework
6/30/2010
• Managing the Lifecycle : There needs to be a controlled way to
manage all the activities within the standards and interoperability
activities from identification of a needed capability to implementation and
operations
• Reuse: Standards development and harmonization efforts need to
accommodate multiple stakeholders and business scenarios so as to
ensure reuse across many communities.
• Semantic Discipline: The work products need to be developed in a
way to ensure computability and traceability throughout the entire
lifecycle.
S&I ConOps Organizing Principles
6/30/2010
• Representative Participation:
• ONC Strategic Plan affirms that this diversity is purposeful and should be encouraged.
• Framework needs to elicit capabilities and verify specifications, standards and guidelines across
a broad range of stakeholders and communities.
• Transparency and Openness:
• Need to established trust in the framework processes.
• Transparency and Openness of activities and work products will engender trust in the process.
•Responsive:
• Wide-scale, multi-community interoperability efforts can suffer agility due to scale.
• The framework must ensure timely attention in addressing emerging issues while remaining
flexible enough to accommodate planned activities.
•Accountability:
•While all work is collaborative, the framework must assign accountable roles for delivery of key
artifacts.
•Measureable and Planned Results:
• One objective of the framework is to build the factory that can achieve milestones and make
predictable progress in producing standards and specification.
• The framework should measure schedules, level of effort, and other metrics in establishing and
improving framework processes
Mapping S&I Framework to NIEM
11
Analyze
Requirement
s
Map and
Model
Publish and
Implement
Add service and behavior
specification generation to
NIEM
Implementation, testing and
certification disciplines are
needed beyond NIEM
Scenario
Planning
Analyze
Requirement
s
Map &
Model
Analyze
RequirementsBuild &
Validate
Assemble &
Document
Publish &
Implement
Implementation
Specifications
Use Case
Development
S&I NIEM Process Outline
12
Scenario
Planning
Analyze
Requirements
Prioritize
Biz scenarios identified
by:
• Health community
• ONC
• Federal agencies
Document in wiki
• Business scenario
• Use cases
Elaborate tech
and business
requirements for
exchange
Map & ModelDevelop
computable UML
model for content
and/or transactions
RI
Build & Validate
Generate
implementable
code from model
Emergence
Pilot
Assemble &
Document
• Generate IEPDs
from UML model
• Package all
artifacts for
IEPDs
Harmonize
Standards
Testing &
Certification
Publish &
ImplementPublish
= Governance
Decision= S&I Activity
= NIEM IEPD
Lifecycle Phase
Continuous
Feedback
Publish IEPDs
to repository
Identify relevant
standards and
gaps
Coordinating Iterative and Incremental S&I
Processes
6/30/2010
•Artifacts: To support the requirement of computable and traceable resultant artifacts, the S&I
framework needs ensure the content and structure of the artifacts within the process are well defined
and provide continuity within the activities and the tools.
•Roles: Clear “ownership” of significant artifacts and activities must be assigned to ensure coordination,
lack of duplication and discontinuity throughout the process. An example of this is the Use Case
Stewart, but there are additional roles throughout the process.
•Control Points: At points in an iterative and incremental process, prioritization, validation or approval
of artifacts is required to ensure quality and alignment with goals. These points, and the approval
entities need to be well defined for the framework to operate smoothly.
• Not a “waterfall” Process: Developing and harmonizing
standards and service specifications across diverse
communities necessitates concurrent, agile activities, not
waterfall processes
•Need for Structured Coordination: To manage coordination
of the concurrent activities within the framework , we need well
defined:
• Artifacts
• Roles
• Decisions (Control Points)
S& I Overview of Roles and Controls
6/30/2010
Core artifacts
are versioned
and controlled
Artifacts are
“packaged”
and released
Each artifacts
has a
responsible
role
Artifacts and
releases have
prioritization
and approval
points, or
“controls”
Prioritization and Backlog Lists
6/30/2010
Strategic
Priorities
Operational
Priorities
“Day to Day”
Priorities within
each functional
team
Stakeholder coordination
6/30/2010
HITPC
VLER
NHIN CC
FHA
HIT SC
VLER
NHIN TC
FHA
S&
I and H
ITS
C
Activitie
s
NH
IN D
irect
Activitie
s
J J A S O N D J F M A M J J A S O N
Tools and Services
(Use Case Development, Harmonization Tools, Vocabulary Browser, Value Set Repository, Testing Scripts, etc)
Use Case Developmentand FunctionalRequirements
Standards Development
Certificationand Testing
Harmonization ofCore Concepts (NIEM
framework)
Implementation Specifications
Reference Implementation
Implementation Specifications
Pilot Demonstration Projects
Reference Implementation
HIT
PC
Activitie
s
HITPC P&S Tiger Team Policy
Framework
HITPC + HITSC
Specification Policy Review
HIT Standards Committee ReviewNHIN Inclusion
Evaluation
Other Standards
Governance
Evaluations
NHIN Direct Example
NHIN Direct Project Consensus Proposal
» Currently in consensus process
• Implementation group contains 60+ organizations representing
– Providers (small, large)
– Federal partners, State and Regional HIOs
– EHR, PHR, HIE and national network organizations serving a
variety of markets
» Lessons learned:
• Strong support for services that “meet providers where they are”
and offer an upward migration path to comprehensive
interoperability
• Strong support for IHE profiled SOAP services by EHR and HIE
technology vendors of all sizes and target markets
• Existing health care standards need work to be policy neutral for
these uses
6/30/2010
NHIN Direct Project Consensus Proposal
» Supports SMTP + S/MIME as the minimum backbone
protocol
• Universal addressing
• Secure transport of health information
• Separation of address metadata from content metadata
» Endorses use of strong content metadata
» Supports XDR for existing and future NHIN Exchange
participants
» Encourages development of exchanges that support both
SMTP and a modified XDR specification to support a
bridge to NHIN Exchange
6/30/2010
Source HISP Destination HISPRFC 5322
Headers + DNS
Reject
SMTP +
S/MIME
SMTP +
MIME
(+XDM)
Send
Locate
Destination
(s)
SMTP +
MIME
(+XDM)
POP/IMAP +
TLS
SMTP +
TLS
Receive
SMTP
+
S/MIM
E
S/MIME
Encrypt
S/MIME
Sign
SMTP +
TLS
Hold (encrypted)
Content
S/MIME
Verify
S/MIME
Decrypt
Where Next?
» Continued collaboration with HIT Policy Committee and HIT Standards
Committee
• Vetting of the consensus specifications against policy guidelines
• Continued development of privacy and security policy framework
» Detailed project work on:
• Documentation and Testing
• Security and Risk Analysis
• Open Source Reference Implementation
• Early Implementation Geographies
» Work with IHE to modify XDR specification to better meet policy
guidelines and usage needs
6/30/2010
NHIN Governance
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance– Mary Jo Deering, ONC
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
HIT Standards Committee Meeting
Nationwide Health Information Network
Governance
June 30, 2010
Mary Jo Deering, PhD
ONC, Office of Policy and Planning
NHIN Policy and Governance
Current Request For FACA Committee Input
• Help us frame initial request for public input on
nationwide health information network governance:
what issues and questions should be included?
– HITPC June 25, 2010: Guidance on governance for
NHIN policies and services
– HITSC June 30, 2010: Guidance on governance for
NHIN standards
• The slides that follow reflect our experiences and
preliminary analysis
• We have identified possible questions whose answers
will shape the NPRM
• We will be seeking additional input from the HITSC and
HITPC in September to develop the NPRM
Background and Purpose of Rule Making
• HITECH directed the National Coordinator to “establish a
governance mechanism for the nationwide health
information network.”
– To be accomplished by rulemaking
• Rulemaking would establish foundational policies and
structures which would:
– Engender trust
– Assure effectiveness
– Meet or exceed consumer expectations
– facilitate use of the nationwide health information network
• Recognize that some governance is in place (e.g., HIPAA
Privacy and Security Rules); identify where complementary
governance mechanisms are necessary for evolving
nationwide health information network.
Scope of Rulemaking for Nationwide Health
Information Network Governance
Identify Governance Requirements in Domains of the HIE Trust Framework
• Agreed Upon Business, Policy and Legal Requirements: All
participants will abide by an agreed upon a set of rules, including (but not
necessarily limited to) compliance with applicable law and act in a way
that protects the privacy and security of the information and is in
accordance with consumer/patient expectations.
• Transparent Oversight : Oversight of the exchange activities to assure
compliance. Oversight should be as transparent as possible.
• Enforcement and Accountability: Each participant must accept
responsibility for its exchange activities and answer for adverse
consequences.
• Identity Assurance: All participants need to be confident they are
exchanging information with whom they intend and that this is verified as
part of the information exchange activities.
• Technical Requirements: All participants agree to comply with some
minimum technical requirements necessary for the exchange to occur
reliably and securely.
Scope of Governance
• Should participation or compliance with nationwide
health information network standards, services and
policies (or a subset) be:
– Optional
– Preferred – “seal of approval”/nationwide health information
network brand
– Mandatory
• How and where should governance apply?
• What are appropriate levers of governance?
– When should they be applied?
– Under what conditions?
Business, Policy And Legal Requirements And
Expectations – Key Issues
• When should patient consent be required and for what?
– Populate RLS
– Disclose/reuse PHI
– More granular (e.g. particular data elements)
• What requirements are necessary to assure data
integrity and quality?
• Should requirements (for consent, data use, etc.) vary
by exchange model?
– Exchange participants (query and lookup)
– Directed secure routing (known endpoints)
• How should we specify appropriate purposes for using,
exchanging and reusing data and minimize data
required for transactions?
Transparent Oversight – Key Issues
• Is there a role for federal and/or state oversight to
monitor and address abusive market behaviors?
• Is there a need for a federal mechanism of oversight
over information exchange organizations?
• What are the appropriate federal and state roles?
• How can transparency and open processes be assured
for setting nationwide health information network
policies and technical requirements?
• How can transparency, oversight and accountability be
assured for the nationwide health information network
(e.g., auditing and alert capabilities, patient access,
correction, redress)?
Enforcement and Accountability – Key Issues
• Should there be a certification or accreditation program
for intermediaries (e.g., HISPs) or participants (e.g.,
Exchange)? If so:
– Key roles for certifying / accrediting body
– Certification / accreditation requirements
– Limits of certification / accreditation
• What other types of enforcement and accountability
measures should be considered?
– Regulatory requirements
– Contractual mechanisms (with federal government, between
participants)
Identity Assurance – Key Issues
• Should there be identity assurance requirements for:
– Provider access to clinical information systems/data?
– Patient/consumer access?
– For participation in nationwide health information network
transactions?
• Should there be mechanisms to validate identity
assurance processes and mechanisms, e.g.,
certification or accreditation?
Technical Requirements – Key Issues
• Do we need additional testing and oversight to assure
participant conformance with nationwide health
information network technical requirements? Potential
mechanisms:
– Threshold for exchanging with federal agencies/government
contracts
– Certification/meaningful use
– Government identifying best practices
• What level of interoperability in the nationwide health
information network is required to meet policy goals?
Discussion
Tiger Team Update
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update– Deven McGraw, Chair
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
HIT Standards Committee
Privacy & Security Tiger Team Update
Deven McGraw, Co-Chair
Center for Democracy & Technology
Paul Egerman, Co-Chair
June 30, 2010
Broad Charge
• The Office of the National Coordinator for Health Information
Technology (ONC) formed a Privacy & Security Tiger Team
under the auspices of the HIT Policy Committee to address
privacy and security issues related to health information
exchange that must be resolved over the summer.
• Members of the Tiger Team are comprised of individuals from
the HIT Policy Committee and the HIT Standards Committee
as well as National Committee on Vital and Health Statistics
Tiger Team Members
• Deven McGraw, Center for Democracy & Technology, Co-Chair
• Paul Egerman, Co-Chair
• Dixie Baker, SAIC
• Christine Bechtel, National Partnership for Women & Families
• Rachel Block, NYS Department of Health
• Neil Calman, The Institute for Family Health
• Carol Diamond, Markle Foundation
• Judy Faulkner, EPIC Systems Corp.
• Gayle Harrell, Consumer Representative/Florida
• John Houston, University of Pittsburgh Medical Center; NCVHS
• David Lansky, Pacific Business Group on Health
• David McCallie, Cerner Corp.
• Wes Rishel, Gartner
• Micky Tripathi, Massachusetts eHealth Collaborative
• Latanya Sweeney, Carnegie Mellon University
Proposed Schedule of Topics
June
• Organize Team
• Address issues of message handling in Directed Exchange
• Report to Policy Committee on June 25
• Consumer Choice Technology Hearing on 6/29
July
• Continue Directed Exchange
• Develop policy framework for other HIO models
• Address issues of:
• Consumer Choice/Consent
• Sensitive Data
• Interstate Exchange
• Report to Policy Committee on July 21
August
• Governance
• Final Report to Policy Committee on August 19
Message Handling in Directed Exchange
• What are the policy guardrails for message handling in Directed
Exchange?
• Who is responsible for establishing “trust” when messages are
sent?
– The terms “message handling” and “directed exchange” refer to transporting
patient data from one known provider to another where both providers are
directly involved in the care of the patient who is the subject of the information.
We assume communication channels are encrypted.
Categories of Message Handling
To frame the discussion, message handling has been classified into four categories:
A. No intermediary involved (exchange is direct from message originator to message recipient)
B. Intermediary only performs routing and has no access to unencrypted PHI (message body is encrypted and intermediary does not access unencrypted patient identification data)
C. Intermediary has access to unencrypted PHI (i.e., patient is identifiable) - but does not change the data in the message body)
D. Intermediary opens message and changes the message body (format and/or data)
Recommendations
• Unencrypted PHI exposure to an intermediary in any amount raises privacy concerns.
• Fewer privacy concerns for directed exchange are found in models A and B above, where no unencrypted PHI is exposed.
• Models C and D involve intermediary access to unencrypted PHI, introducing privacy and safety concerns related to the intermediary’s ability to view and/or modify data. Clear policies are needed to limit retention of PHI and restrict its use and re-use.
• Our team may make further privacy policy recommendations concerning retention and reuse of data, Model D also should be required to make commitments regarding accuracy and quality of data transformation.
• Intermediaries who collect and retain audit trails of messages that include unencrypted PHI should also be subject to policy constraints.
• Intermediaries that support Models C and D require contractual arrangements with the message originators in the form of Business Associate agreements that set forth applicable policies and commitments and obligations.
Establishing Exchange Credentials
We also addressed the question of whether establishing exchange “credentials” should be centralized or decentralized (i.e., who holds the “trust”?)
• The responsibility for maintaining the privacy and security of a patient's record rests with the patient's providers. For functions like issuing digital credentials or verifying provider identity, providers may delegate that authority to authorized credentialing service providers.
• To provide physicians and hospitals (and the public) with some reassurance that this credentialing responsibility is being delegated to a “trustworthy” organization, the federal government (ONC) has a role in establishing and enforcing clear requirements and policies about the credentialing process, which must include a requirement to validate the identity of the organization or individual requesting a credential.
• State governments can, at their option, also provide additional rules for these authorized credentialing service providers.
Discussion Regarding “NHIN Direct” Project
• The basic technical model for NHIN Direct should not involve intermediary access to unencrypted PHI (i.e., models A and B above).
• HHS should develop regulations, guidance and/or best practices to promote greater transparency to patients about direct electronic exchange of health information.
– Regional Extension centers should also play a role in helping providers to be transparent to patients about direct electronic exchange using this model.
Enrollment W G Update
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update– Aneesh Chopra, Chair
– Sam Karp, Co-Chair
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge
Summary & Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
Aneesh Chopra, Chair
Chief Technology Officer, OSTP
Sam Karp, Co-Chair
California Healthcare Foundation
June 30, 2010
HIT Policy & Standards Committees
Enrollment Workgroup
Workgroup Members
Members: Ex Officio/Federal:
• Cris Ross SureScripts Sharon Parrott, O/S, HHS
• James Borland Social Security Administration Nancy DeLew, HHS
• Jessica Shahin U.S. Department of Agriculture Penny Thompson, CMS/HHS
• Stacy Dean Center on Budget & Policy Priorities Henry Chao, CMS/HHS
• Steve Fletcher CIO, Utah Gary Glickman, OMB
• Reed V. Tuckson UnitedHealth Group John Galloway, OMB
• Ronan Rooney Curam David Hale, NIH
• Rob Restuccia Community Catalyst Paul Swanenberg, SSA
• Ruth Kennedy Louisiana Medicaid Department David Hansell, Administration for
• Ray Baxter Kaiser Permanente Children & Families, HHS
• Deborah Bachrach Consultant Julie Rushin, IRS
• Paul Egerman Businessman Farzad Mostashari, ONC
• Gopal Khanna CIO, Minnesota Doug Fridsma, ONC
• Bill Oates CIO, City of Boston Claudia Williams, ONC
• Anne Castro Blue Cross/Blue Shield South Carolina
• Oren Michels Mashery
• Wilfried Schobeiri InTake1
• Bryan Sivak CTO, Washington, DC
• Terri Shaw Children’s Partnership
• Elizabeth Royal SEIU
• Sallie Milam West Virginia, Chief Privacy Officer
• Dave Molchany Deputy County Executive, Fairfax County
Chair: Aneesh Chopra, Federal CTO
Co-Chair: Sam Karp, California Healthcare Foundation
Section 1561 of Affordable Care Act
1561. HIT Enrollment, Standards and Protocols. Not
later than 180 days after the enactment, the Secretary,
in consultation with the HIT Policy and Standards
Committees, shall develop interoperable and secure
standards and protocols that facilitate enrollment in
Federal and State health and human services
programs through methods that include providing
individuals and authorized 3rd parties notification of
eligibility and verification of eligibility.
Enrollment Workgroup Charge
• Inventory of standards in use, identification of gap,
recommendations for candidate standards for federal
and state health and human service programs in
following areas:
– Electronic matching across state and Federal data
– Retrieval and submission of electronic
documentation for verification
– Reuse of eligibility information
– Capability for individuals to maintain eligibility
information online
– Notification of eligibility
Potential Deliverables
1. Inventory of standards-based data exchange in use
today to enroll in health and human services
2. Candidate standards for data elements and
messaging
3. Proposed process to fill in gaps to rapidly turn
"requirements" into working prototypes/live
implementations to deliver world class eligibility and
enrollment services
Potential Candidate Standards
• Core data elements • Name, address, residence, income, citizenship, etc.
• Messaging • Checking eligibility and enrollment
• Consumer matching across systems
• Retrieving and sending “packages” of verification information including income, employment, citizenship
• Communicating enrollment information
• Privacy and security • Secure transport
• Authentication
Standards Requirements
We need to conceptualize standards that might be useful
and work across a variety of use cases or architectures
which might include:• Front end user-facing consumer portal* to conduct initial eligibility
checks and obtain and forward verification information
• Comprehensive eligibility system for Health and Human Services
programs
• State or Federal exchange portals
* online, mail and telephone based systems
Draft Policy Principles - Reprise
Standards and technologies must support and be in service to our policy goals:
• Consumer at the center
• Make enrollment process less burdensome; simplify eligibility process and make it seamless
• Enter/obtain information once, reuse for other purposes
• Make it easier for consumers to move between programs
• Focus on 2014 world
Draft Standards Principles - Reprise
• Keep it simple - Think big, but start small. Recommend standards as minimal as required to support necessary policy objective/business need, and then build as you go.
– Don’t rip and replace existing interfaces that are working (e.g., with SSA etc.)
– Advance adoption of common standards where proven through use (e.g., 270/271).
• Don’t let “perfect” be the enemy of “good enough” Go for the 80 percent that everyone can agree on.
– Opportunity to standardize the core, shared data elements across programs.
– Cannot represent every desired data element.
• Keep the implementation cost as low as possible – May be possible to designate a basic set of services and interfaces that can be
built once and used by or incorporated by states.
– Opportunity to accelerate move to web services
• Do not try to create a one-size-fits-all standard that add burden or complexity to the simple use cases
– Opportunity to describe data elements and messaging standards that would be needed regardless of the architecture or precise business rules selected.
Base Use Case – Draft – Under Discussion
Consumer-facing web portal that allows applicants to:
» Identify available services for which they might be eligible
» Conduct initial screening and enrollment checks
» Retrieve electronic verification information from outside sources
» Determine eligibility or forward eligibility “packet” (screening information and verification information) to programs for final determination
» Store and re-use eligibility information
This Base Use Case Supports Several Eligibility and
Enrollment Scenarios in 2014 – Draft Under DiscussionMakes recommendations more flexible, durable and useful
» Scenario One: Exchange portal• Screening, verification and eligibility for 2014 MAGI-eligible group: Medicaid,
CHIP and exchange • Send/receive applicant information “packets” with Medicaid
» Scenario Two: Medicaid/TANF/SNAP portal• Screening, verification and eligibility for residual Medicaid, TANF, and SNAP. • Send/receive applicant information “packets” with exchange• Re-use eligibility information to screen for other programs
» Scenario Three: Combined portal• All of Medicaid, CHIP, Exchange; other combinations
Diagram
Send eligibility info to
other programs
(human services, etc.)
Obtain
Verification Info: Electronically verify
identity, residency,
citizenship, household
size, income,
etc.
Check Current
Enrollment:
Check other systems
for existing coverage; first
match using single identifier,
probabilistic formula, or
other method; then obtain
enrollment info
Initial
Screening:
Applicant
provides basic
demographic info
Determine
Eligibility: Method
will depend
on system
capabilities.
IRS
DHS
State
systems
IEVS
DMV
VR
23
Medicaid MAGI, MA,
Exchange, State systems
1
5
Program
makes
eligibility
decision
4
Portal
makes
eligibility
decision
4b
Portal
sends
eligibility
packet to
program
4a
Enrollment
Notification
to Portal
SSA
Send enrollment
information to plans
6
Clinical Quality W G Update
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework; Concept of
Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on
Survey– Janet Corrigan, Chair
– Floyd Eisenberg, Workgroup member10. Clinical Operations Workgroup: Electronic Document Standards for Discharge Summary &
Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
HIT Standards Committee
Quality Workgroup
Next Steps:
Quality Measures for 2013
Janet Corrigan, ChairNational Quality Forum
Floyd Eisenberg
National Quality Forum
June 30, 2010
Clinical Quality Workgroup Members
• Janet Corrigan, Chair, National Quality Forum
• Floyd Eisenberg, National Quality Forum
• John Derr, Golden Living, LLC
• Judy Murphy, Aurora Health
• Marc Overhage, Regenstrief
• Rick Stephens, Boeing
• James Walker, Geisinger
• Jack Corley, HITSP
• John Halamka, Harvard Medical School
• Walter Suarez, Kaiser Permanente
Presentation at a Glance
• Update on Retooling of Potential 2011 MU Measures
• Results of the ONC Environmental Scan of Leading
Health Systems
• Overview of NQF Fast Track Project
Measure Retooling Update
Measure Retooling Update
• 44 Ambulatory Measures
• Use the Quality Data Set to identify data elements
• Apply logic in human readable format
• Provide lists of codes (value sets) for each data element
ONC Environmental Scan
Scan of 12 leading healthcare systems
Responses from 9 organizations:
• American Board of Family Medicine
• Geisinger Health System
• Mayo Clinic
• Kaiser Permanente
• Aurora Healthcare
• Tenet Healthcare
• Interim Healthcare
• PointRight
• National Association of Home Care and Hospice
ONC Environmental Scan
Table 1 – Environmental ScanONC Environmental Scan
Condition /
Cross-Cutting Area Performance Measure*
Diabetes HbA1c<7%
Diabetic Screen for Peripheral Neuropathy
Monitoring HbA1c and LDL in Patients with Diabetes
Tobacco use in Diabetic Patients
Preventive Services Breast Cancer Screening
Colon Cancer Screening Rate
Cervical Cancer Screening Rates
Flu Vaccination
Obesity Weight Management
Hypertension High Blood Pressure
* Yellow highlighting indicates the measure or a comparable measure is included in the
set delivered to HHS.
Table 2 – Environmental ScanONC Environmental Scan
Condition /
Cross-Cutting Area Performance Measure
Healthcare Associated
Infections
Decrease Use of Urinary Indwelling Catheters in
Patients 65 and Older
SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within
24 Hours After Surgery End Time
SCIP-Inf-9 Postoperative Urinary Catheter Removal on
Post-op Day 1 or 2
Safety Events Total Falls per 1,000 Patient Days
Appropriate Use of High Risk Medications
High-Risk Pressure Ulcer Prevention and Chronic Care
Medication Management Medication Compliance
* Yellow highlighting indicates the measure or a comparable measure is included in the
set delivered to HHS.
Table 3 – Environmental ScanONC Environmental Scan
Condition /
Cross-Cutting Area Performance Measure
Patient experience HCAHPS Survey Scores
Staffing Nursing Staffing Ratio
Nursing Turnover Rates
Skilled Nursing Chronic Care (CC) Percent of residents who have
moderate to severe pain.
Physical Restraints-Chronic Care (CC) Percent of
residents with daily physical restraints.
Care Transition Re-hospitalization measures
Stratification of disposition based on discharge
assessment
* Yellow highlighting indicates the measure or a comparable measure is included in the
set delivered to HHS.
Table 4 – Environmental ScanONC Environmental Scan
Condition /
Cross-Cutting Area Performance Measure
Home Care Acute Care Hospitalization after Home Health
Episodes of Care
Improvement in Management of Oral Medications
Stabilization in Self Grooming
Stabilization in Light Meal Preparation
* Yellow highlighting indicates the measure or a comparable measure is included in the
set delivered to HHS.
NQF Fast Track Project – Two Objectives
1. Identify “types of measures” that might be appropriate for
2013 with input from:
• ONC Environmental scan of health systems
• Comments on Potential MU11 Measures
• Beacon Communities List of Measures
• Gretsky Group
• Other
2. Identify pathways to generate the desired types of
measures within the requisite time frame:
• Appropriate measures available
• “Similar” measures available that might be adapted
• Measures would need to be developed de novo
Next Step
• NQF Report due July 2010
• Intended to
o Inform Policy Committee’s September discussions
aimed at identifying types of MU measures for 2013
o Identify time-sensitive measure development work
that must get underway very quickly
o Input to Standards Committee’s Fall work aimed at
identifying specific measures available to satisfy
Policy Committee’s recommended measure types
Clinical Operations W G
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework;
Concept of Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10.Clinical Operations Workgroup: Electronic
Document Standards for Discharge
Summary & Other Encounter Summaries– Jamie Ferguson, Chair
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn
Agenda
HIT Standards Committee
Clinical Operations Workgroup
Workgroup Update
Jamie Ferguson
Kaiser Permanente
John Halamka
Harvard University
30 June, 2010
Problem Statement
• Implementers of CCR and CCD for transfers of care
also need other standard document types, e.g.,:
– Inpatient Discharge Summary
– ED Discharge Summary
• These documents may contain specialized content not
found in CCR or CCD, e.g.,:
– Discharge Diet
– Surgery Description
– Surgical Operation Note Findings
– Estimated Blood Loss
– Chief Complaint
Review: CCR and CCD
Medications
Allergies
Social History
Dem
ographics
Payer
. . . . V
ital Signs
Problem
s
A CCD based document
CCD: A collection of templates representing core content for
healthcare summary documents with template content from CCR
Family H
istoryCDA: A foundation standard enabling the definition of templates
for a broad range of healthcare documents
Extending And Reusing Existing Templates In
Other Documents
Medications
Allergies
Social History
Dem
ographics
Payer
. . . .
Vital Signs
Chief C
omplaint
Discharge
Diagnosis
Problem
s
A CCD based document
A CDA based document
compatible with CCDM
ode of
Transport
Ne
w S
ectio
n…
Template content from CCR
Family H
istory
Surgical Finding
Dis
ch
arg
e D
iet
CDA
CCD
Identified by the CCD document ID number
Identified by another identifier, e.g., an
ED Discharge document ID number
Discussion points
• We plan to make recommendations to the Standards Harmonization entity as outlined in the Concept of Operations plan
• General direction of WG: Recommend that the process should standardize templated CDA sections to build upon and extend what was done in CCR and CCD
• WG direction is consistent with NIST direction for testing
Discussion points, continued
• Must enable more documents and reuse existing work
• May also recommend this direction for attachments
• Identification of complete documents assembled from templates: – A few complete documents might have complete document IDs,
e.g., discharge summaries, ambulance services, etc.
– Otherwise, a general method for identification should be devised• Embedded or concatenated identifiers would avoid enumerating a
combinatorial explosion of complete documents assembled from templates
• Coordination of templates with value set standards– E.g.,: value sets for hospital readmission measures could be
coordinated with discharge summary template standards
Next Steps
• Seek HIT Standards Committee input
• Continue Workgroup discussions to create future recommendations to the full Committee
ONC Update: Temp Certification Program
1. Call to Order
2. Opening Remarks
3. Review of the Agenda
4. ONC Update: NHIN Direct Specifications; Standards & Interoperability Framework; Concept of
Operations
5. NHIN Governance
6. Lunch
7. Privacy & Security Tiger Team Update
8. Enrollment Workgroup Update
9. Clinical Quality Workgroup Update on Survey
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge Summary &
Other Encounter Summaries
11.ONC Update: Temporary Certification
Program– Steve Posnack, ONC
– Carol Bean, ONC12. Public Comment
13. Adjourn
Agenda
Temporary Certification Program
Steve Posnack, ONC
Carol Bean, ONC
June 30, 2010
Steve/Carol
HIT Standards Committee
Adjourn
Meeting Adjourned