Helping Providers Meet Direct Requirements for Meaningful Use ...

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Dec 14, 2013 (4 years and 18 days ago)

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Presented by:

-

Claudia Williams
, Director, State HIE Program, ONC

-

Paul Tuten
, Senior Advisor, State HIE Program, ONC



Moderated by:

-

Kate Berry
, CEO, NeHC

December
19,
2012

Helping Providers Meet Direct
Requirements for Meaningful Use
Stage 2

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Presentation slides are now available on the NeHC
website!

http://www.nationalehealth.org/MU2DirectRequirements



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Supporting Meaningful Use
Stage 2 Transition of Care
Requirements


CEHRT & MU Relationship

Meaningful Use Stage 2 (MU2)

CMS: Medicare
and Medicaid EHR Incentive Programs
Stage 2


outlines incentive payments (
+$$$
) for early adoption


outlines payment adjustments(
-
$$$
) for late adoption/non
-
compliance

Reference
:

CMS Medicare and Medicaid Programs; Electronic Health Record Incentive
Program


Stage 2 Final Rule 495.6

ONC: Standards, Implementation Specifications
& Certification Criteria
(
SI&CC
)
2014 Edition


Specifies the
data
and standards requirements for
certified electronic health
record (EHR) technology (CEHRT) needed to achieve “meaningful use”

Reference:
ONC Health Information Technology : Standards, Implementation Specifications,
and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to
the Permanent Certification Program for Health Information Technology 170.314(b)(1)&(2)

MU2 Electronic Exchange Requirements


MU2 focuses on actual use cases of electronic
information exchange


Measure #1 requires
that a provider send a summary of care record for
more than 50%
of transitions of care and referrals
.



Measure #2 requires
that a provider electronically transmit a summary of
care
for
more than 10%
of transitions of care and
referrals



Measure #3 requires at
least one summary of care document sent
electronically to recipient with different EHR vendor or to CMS test
EHR

CEHRT & MU Relationship

Care Coordination / Transitions

Meaningful Use Stage 2 (MU2)


Care Coordination

CMS: Medicare
and Medicaid EHR Incentive Programs
Stage 2


Measure #2 :
Provide an electronic ‘‘summary
of care record for more than 10
percent of such transitions and
referrals” using one of the accepted transport
mechanisms specified in the rule.

Reference
:

CMS Medicare
and Medicaid
Programs; Electronic Health Record Incentive
Program


Stage 2 Final Rule 495.6

ONC: Standards, Implementation Specifications
& Certification Criteria
(
SI&CC
)
2014 Edition


Electronically
receive and incorporate

a transition of care/referral summary
Electronically
create
and transmit

a transition
of care/referral
summary

Reference
:
ONC Health Information Technology : Standards, Implementation Specifications,
and Certification Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to
the Permanent Certification Program for Health Information Technology 170.314(b)(1)&(2)

CEHRT Criterion 170.314(b)(2)



Transition of Care (Send)



In
order for a certification criterion to be met, all specific capabilities
expressed
as part of it need
to be
demonstrated.



For example, in 45
CFR 170.314(b)(2
) there are two:

(i)
Create
CCDA with requisite data specified for MU

(ii)
Enable
a user to electronically transmit
CCDA
in
accordance with:

(a)
Direct (
required
)

(b)
Direct
+
XDR/XDM (optional, not alternative)

(c)
SOAP
+
XDR/XDM (optional, not alternative)



Thus, whatever
EHR technology is presented for certification must
demonstrate compliance with both (
i
)
and

(ii) under (b)(2) to meet the
certification criterion
.



This also means that there’s
no certification for ‘transport only’
as part of
MUS2 / CEHRT 2014 Edition


What is Direct? Quick review…

HISP B

HISP A

Provider A

Provider B

Direct Backbone

(Encrypted SMTP)

Edge Protocol

(Encrypted)

Edge Protocol

(Encrypted)

The Direct specification defines the connectivity
between two security/trust agents (STAs)

Scenario 1

1.
EHR generates

CCDA

2.
EHR performs as STA and
sends Direct
msg



Complete EHR or EHR Module
certification issued.


STA/HISP

function
integrated into EHRs; no
separate certification
testing for HISP.

Scenario 2

1.
EHR sends “data” to HISP

2.
HISP generates

CCDA

3.
HISP performs as STA and
sends Direct
msg



EHR Module certification issued

HISP certified

independently as EHR
Module.


Scenario 3

1.
EHR generates

CCDA

2.
EHR sends CCDA to HISP

3.
HISP performs as STA and
sends Direct
msg


Complete EHR or EHR Module
certification issued

HISP certified as
“relied
upon software” with the
EHR. Certification given
to the pair, not EHR and
HISP separately.


Valid
Certification Scenarios for EHR Technology

(Sending with Direct
)

Provider A

Provider B

EHR Affiliated HISP

Provider A

HISP

Provider A

Direct (SMTP + S/MIME)

Provider B

Provider B

Direct (SMTP
+ S/MIME)

Direct (SMTP +
S/MIME)

Any
Edge


Protocol

Any
Edge


Protocol

What gets presented for certification

45 CFR 170.314(b)(2)

(i)
Create CCDA with requisite data specified for MU

(ii)
Enable a user to electronically transmit
ToC

in accordance with
Direct (or Direct +XDR/XDM; or SOAP + XDR/XDM)

Whatever EHR technology is presented for certification must
demonstrate compliance with both (
i
) and (ii) under (b)(2) to meet
the certification criterion.


MU Transition of Care



Measure #2:
The eligible provider,
eligible hospital or CAH that transitions or
refers their patient to another setting of care or provider of care provides a
summary of care record for more than 10 percent of such transitions and
referrals
either:



(
a) electronically transmitted using CEHRT to a
recipient,
or



(
b) where the recipient receives
the summary
of care record via exchange
facilitated by an organization that is a
NwHIN

Exchange participant or in a
manner that is consistent with
the governance
mechanism ONC
establishes for the nationwide health
information network.





Scenario 1

1.
EHR generates

CCDA

2.
EHR performs as STA and
sends Direct
msg



Complete EHR or EHR Module
certification issued.


STA/HISP

function
integrated into EHRs; no
separate certification
testing for HISP.

Scenario 2

1.
EHR sends “data” to HISP

2.
HISP generates

CCDA

3.
HISP performs as STA and
sends Direct
msg



EHR Module certification issued

HISP certified

independently as EHR
Module.


Scenario 3

1.
EHR generates

CCDA

2.
EHR sends CCDA to HISP

3.
HISP performs as STA and
sends Direct
msg


Complete EHR or EHR Module
certification issued

HISP certified as
“relied
upon software” with the
EHR. Certification given
to the pair, not EHR and
HISP separately.


Approach #1
--

Send with CEHRT Required Transport:
Using Direct

Provider A

Provider B

EHR Affiliated HISP

Provider A

HISP

Provider A

Direct (SMTP + S/MIME)

Provider B

Provider B

Direct (SMTP
+ S/MIME)

Direct (SMTP +
S/MIME)

Any
Edge


Protocol

Any
Edge


Protocol

CEHRT

Example #1

1.
EHR generates

CCDA

2.
EHR (certified to include
optional SOAP + XDR/XDM
transport) sends message
to Provider B using SOAP +
XDR/XDM

In this scenario, the EHR

must be certified to
support both Direct
(required) and SOAP +
XDR/XDM (optional) as
transport standards.




Approach
#2
--

Send with CEHRT
Optional Transport
:
SOAP + XD (Example)

Provider A

Provider B

SOAP +


XDR/XDM

CEHRT

Note:

This is one example of how a provider may use EHR technology that has been
certified to include optional transport standards. The CEHRT could support a different
optional transmission mechanism (e.g., Direct + XDR/XDM). Also, as with the required
Direct transport, the CEHRT has architectural flexibility to use relied upon software in
their solution, seek modular certification, etc.

Example #2

1.
EHR generates

CCDA

2.
EHR (certified to include
optional SOAP + XDR/XDM
transport) sends message
to Provider B (via HISP)
using SOAP + XD

3.
HISP repackages content
as Direct message and
sends to Provider B

In this scenario, the EHR

must be certified to
support both Direct
(required) and SOAP +
XDR/XDM (optional) as
transport standards.


The HISP does not need
to be certified.


This meets the MU
requirement for using
CEHRT.

Approach #2
--

Send with CEHRT
Optional Transport
:
SOAP + XD
via Intermediary (Example)

HISP

Provider A

Provider B

Direct (SMTP

+ S/MIME)

SOAP +


XDR/XDM

CEHRT



1.
Because Provider A is sending to Provider B using their CEHRT’s SOAP + XDR/XDM
transport option, the fact there’s a “HISP in the middle” is irrelevant with respect to Provider A
meeting MU requirements.


2.
This
allows any EHR vendor supporting the SOAP + XDR/XDM option to interoperate with
any HISP that also offers SOAP + XDR/XDM support.


3.
Under
this
approach,
HISPs do not have to be
certified


4.
If
EHRs implement SOAP/XD support
and
then partner with a
HISP (i.e., use the HISP as
relied upon software for certification),
they can also fulfill their Direct requirement
under
Scenario #3
with minimal (
or no)
additional development/technical work on their
part.

NwHIN

Example

1.
EHR generates

CCDA

2.
EHR sends CCDA to
NwHIN

Exchange
Participant

3.
NwHIN

Exchange
Participant sends to
Provider B

Complete EHR or EHR
Module certification
issued.


NwHIN

Exchange

participant does not get
certified.

Approach #3


Send via
NwHIN

Exchange Participant

Provider A

Provider B

CEHRT

NwHIN Exchange Participant

(now
eHealth

Exchange)

CEHRT

Note:

In addition to
NwHIN

Exchange, the regulation
also permits an EP, eligible
hospital, or CAH to count in
their numerator instances where
a summary care record
for transitions of care or referrals was received via electronic exchange facilitated in a
manner
consistent with
the governance mechanism ONC establishes for the
nationwide health information network. ONC has not yet established
a governance
mechanism for the nationwide health information network. Until ONC establishes
such a governance mechanism, this
specific option
will not be available.

Summary


CEHRT must fully address a criterion (i.e., create
and

send)


Must support the required transport standards (i.e., Direct)


May support optional transport standards (in addition to Direct)


In particular, SOAP + XDR/XDM provides additional flexibility



EHR technology vendors and HIEs / HISPs should carefully
consider the options for supporting providers and
select one
(or more)
that
best serves the needs of their stakeholders



Questions

Reference


Key Terms / Acronyms




SMTP (Simple Mail Transfer Protocol):
is an Internet standard for electronic mail
(e
-
mail) transmission across Internet Protocol (IP)
networks.


S/MIME (Secure/Multipurpose
Internet Mail
Extensions): an Internet
standard for
public key encryption and signing of MIME
data.


MIME
(Multipurpose Internet Mail Extensions):
an
Internet standard that extends
email
to
support other content types, including non
-
text attachments


SOAP (
Simple Object Access
Protocol)
: a protocol specification for exchanging
structured information in the implementation of
web services
in computer
networks


XDR /
XDM:
IHE standard for supporting XML
-
based detailed metadata along with
SMTP
-

or SOAP
-
based transport options. See
XDR/XDM for Direct

to learn more.


CCDA (Consolidated
Clinical Document
Architecture):
an XML
-
based markup
standard intended to specify the encoding, structure and semantics of clinical
documents for
exchange


XML (
eXtensible

Market Language): defines
a set of rules for encoding documents
in a format that is both human
-
readable and machine
-
readable


CEHRT Definition


(2) For FY and CY 2014 and subsequent years, the following:


EHR technology certified under the ONC HIT Certification Program to the
2014


Edition EHR certification criteria that has:


(
i
) The capabilities required to meet the Base EHR definition; and


(ii) All other capabilities that are necessary to meet the objectives and
associated measures under 42 CFR 495.6 and successfully report the
clinical quality measures selected by CMS in the form and manner
specified by CMS (or the States, as applicable) for the stage of meaningful
use that an eligible professional, eligible hospital, or critical access hospital
seeks to achieve.

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