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S&I FRAMEWORK PROPOSED

INITIATIVE SUMMARIES
December 10, 2010

Dr. Douglas Fridsma, Office


of Interoperability and
Standards
Executive Summary

» The Standards and Interoperability (S&I) Framework represents a


unique approach to evolve a new model of health information exchange
» What is needed to achieve this future are specific initiatives that can be
harnessed into health information exchange initiatives to guide the
design and development of a fully connected health information
infrastructure that will enhance efficiency, quality and effectiveness in
healthcare delivery.
» The information exchange foundation envisioned through the S&I
Framework would leverage existing and new investments in
technology, take advantage of health IT innovations, and identify
opportunities for new investments through the management of health
information exchange initiatives within a portfolio
» This presentation is a summary of the initiatives under
consideration, for review and selection by ONC leadership, in
consultation with appropriate steering bodies and advisory
groups.
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Clinical Summary

The exchange of Clinical Summaries is hampered by the lack of unambiguous common


definitions of what data elements must at a minimum be exchanged, how they must be
encoded, and how those common semantic elements map to MU specified formats (C32/CCD
Challenge and CCR). Further, the CCD and CCR standards are overly complex and hinder simple
information exchange. Finally, the lack of a robust toolset to aid in development and
validation of conformant Clinical Summaries is a major impediment to the widespread
adoption of the standards.
Collaborate with stakeholders and SDOs to create a minimum baseline data set for the clinical
Scope
summary including use of unstructured text and coded data elements that allow for provider adoption
Statement
in accordance with Stages 1-3 of meaningful use requirements.
• Enable Clinical Summary validation services to be available such as if an organization passes
validation, they have a high degree of confidence that any other organization passing the same
validation has a 99.9% opportunity to understand the same clinical summary specification
Target
• Reduce template development time through new tools developed through the S&I Framework and
Outcomes
public/private activities (such as Open Health Tools) by a factor of 1.5x. Reduce time to create a
new minimal unstructured summary and structured summaries based on the CCD/CCR by 10% in
2011 and by 25% in 2013
Meaningful Use Exchange key clinical information among providers of care and with patients and other authorized
Alignment entities electronically
• Consultations and Transfers of Care, • NHIN Direct User Stories (see notes for more):
medication summaries and public health • Primary care provider refers patient to
case reporting (ONC/AHIC) specialist including summary care record
Related Use • Endocrinology Referral (HIMSS) • Primary care provider refers patient to hospital
Cases/Stories • Dermatology Referral (HIMSS) including summary care record
• Specialist sends summary care information
back to referring provider
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Templated Clinical Documents

In addition to clinical summaries, there are other structured and unstructured documents
produced and exchanged in delivering patient care and providing information to other trusted
organizations for the purpose of patient empowerment, public health, quality reporting,
research and financial and administrative purposes. Currently there are multiple
Challenge implementation guides, referenced standards, and terminologies published by different
sources as paper documents with extensive redirection to other paper documents. This
makes unambiguous implementations and validation very difficult. There is a clear need for a
set of simple to use tools to create and validate clinical documents that can be constrained
for different business purposes.

Collaborate with stakeholders and SDOs to create computable implementation guide and validation
Scope
tools for clinical documents including standard headers, sections and data elements that can be
Statement
constrained by templates to meet specific information exchange and interoperability requirements.
• Enable Clinical Summary validation services to be available such as if an organization passes
validation, they have a high degree of confidence that any other organization passing the same
validation has a 99.9% opportunity to understand the same clinical summary specification whether
as unstructured data or structured and encoded data.
Key Outcomes
• Reduce template development time through new tools developed through the S&I Framework and
public/private activities (such as Open Health Tools) by a factor of 1.5x. Reduce time to create a
new unstructured and structured documents based on the HL7 CDA by 10% in 2011 and by 25%
in 2013

Exchange key clinical information among providers of care and with patients and other authorized
Meaningful Use
entities electronically based on level of system capability, i.e., human readable, unstructured text or
Alignment
full interoperable structured data
Related Use • Use cases and coordinated requirements to support direct care and secondary use will be
Cases/Stories developed as input to sections and data entries

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Lab Interface Improvement

There is a lack of harmonized specifications standards and code sets to enable the exchange
of lab results. The cost and time to initiate new electronic laboratory results interfaces
hampers broad adoption of such interfaces. The field by field details of HL7 v2 implementation
Challenge
guides used by clinical labs and EHRs vary, creating a need for mapping or configuration per
interface, and the prevalence of core subsets of LOINC codes for common tests and analyses
also varies, causing downstream issues in decision support and quality reporting.

Limited to address this challenge for the subset of lab reporting to primary care (internal medicine,
Scope Statement
family practice, pediatrics)

• Achieve cost savings of up to 90% due to lab interface development improvements by 2015
Target Outcomes
• Reduce total lab interface implementation time by up to 20% by 2013

Meaningful Use Incorporate lab results into EHR as structured data


Alignment

• EHR Lab Scenarios (ONC/AHIC)


Related Use • Electronic Health Record (Laboratory
• Laboratory sends lab results to ordering provider
Cases/Stories Result Reporting) (ONC/AHIC)
(NHIN Direct)

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Medication Reconciliation Improvement

Medication reconciliation is a critical clinical workflow step that is often manual, time-
consuming and error prone. When medication and medication allergy and adverse reaction
data are electronically available from multiple sources (e.g., e-prescribing hubs, care
Challenge summaries sent on transitions of care, HIEs) it should be possible to partially automate
comparisons in medication lists and flag potential changes, deletions, and additions, but
there is no clear guidance on how this should be done, and the lack of guidance has
hampered implementation of this function in clinical IT.

Medication reconciliation improvement would be scoped to focus on improving medication


Scope
reconciliation tools, with the medications templates and entries undergoing further refinement as
Statement
ambiguities are addressed.

• Develop a new standardized medication reconciliation toolset that lowers total costs of medication
reconciliation by 10-20% from current costs by 2013
Target
• Develop tools to improve medication reconciliation execution time by up to 25% from current
Outcomes
response times by 2013
• Increase adoption of medication reconciliation tools up to 25% by 2013.

Meaningful Use Perform medication reconciliation at relevant encounters and each transition of care and referral
Alignment

Related Use • Medication Management (ONC/AHIC) • Pharmacist sends medication therapy management
Cases/Stories • Medication Management (NHIN) consult to primary care provider (NHIN Direct)

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Provider Directories

There is no consistent practice or infrastructure across the industry to support the


development and maintenance of provider directories. There is also no universal availability of
provider information to locate providers. Without clear guidance as to how to set up a directory
in a way that provides consistent information and promotes interoperability, EHRs and
Challenge
directories will have to deal with different directory instances that provide overlapping
information on the same entity. In addition, there will be no clear guidance on how to
incorporate interoperable endpoints (e.g. Direct Addresses, HIO SOAP endpoints) in
directories.

Scope This specification would focus on developing a specification to allow third parties to build a provider
Statement directory that is interoperable with other provider directories

• Develop a provider directory specification to allow for rapid development of federated provider
directories that can communicate provider information with initial adoption projected at 10% by
Target
2013.
Outcomes
• Develop a content specification for provider directory data elements with a commensurate increase
in response time of 25-50%
Exchange key clinical information among providers of care and patient authorized entities
Meaningful Use
electronically
Alignment

Related Use • Healthcare Provider Directory (IHE) • Entity Level Provider Directory (ONC HITPC
Cases/Stories Information Exchange Workgroup)

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Syndromic Surveillance

The overall adoption rate for syndromic surveillance is extremely low, yet meaningful use
requirements demand an increased level of surveillance reporting. There is a direct need for a
simplified way of reporting standardized data to appropriate public health authorities that will
Challenge
enable meaningful use requirements associated with surveillance to be fulfilled. It is
debatable as to whether providers can meet existing and future surveillance requirements
with the current implementation guidance available.

Develop a syndromic surveillance service specification to be used by vendors to deploy a


standardized syndromic surveillance service within their infrastructure

Scope NOTE: This initiative would complement the work conducted by ISDS and CDC to develop Stage 1
Statement meaningful use recommendations for syndromic surveillance. The ISDS recommendations are
available for public comment and review at :

http://www.syndromic.org/uploads/files/ISDSRecommendation-PROVISIONAL_vFINAL.pdf

Target • Increase syndromic surveillance reporting by 10% by 2013


Outcomes • Increase syndromic surveillance data collection response times for at least 2 conditions by 20%

Meaningful Use
Provide electronic syndromic surveillance data to public health agencies
Alignment

• Public Health Case Reporting (ONC/AHIC) • Laboratory reports test results for some
Related Use
• Hospital or provider send chief complaint data to specific conditions to public health (NHIN
Cases/Stories
public health (NHIN Direct) Direct)

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Quality Measures

There is no clear linkage and guidance between defined standards and vocabularies and the
quality measures required by CMS. A root cause of this challenge is the lack of good, easy to
use tooling, modeling, and mapping between semantic health concepts and quality
Challenge measures. The lack of a defined linkage creates downstream problems in mapping between
data received via interoperability (e.g., care summaries, electronic labs, medication history) and
the associated quality reports leading both to additional cost incurred by providers and to poor
quality data received by CMS and other agencies.

Scope Focus on quality reporting format specification to help meet Stage 1 meaningful use requirements, with
Statement initial scope highlighting the most critical quality measures needed.

• Develop a quality measure development standard for the 44 Stage 1 Clinical Quality Measures by
Target
2012
Outcomes
• Promote adoption of quality measure specification by 25% of eligible providers by 2013.

Meaningful Use Report ambulatory quality measures to CMS or the States


Alignment
• HIMSS Use Cases
• Quality (ONC/AHIC)
• Public Health Quality Monitoring using
• Quality Use Case Requirements (NHIN)
eMeasure
• NHIN Direct User Stories:
• Ambulatory Quality BMI eMeasure Utilization
• Provider or hospital reports quality
• Hospital Quality eMeasure Utilization
Related Use measures to CMS
• Quality ACE ARB eMeasure Utilization
Cases/Stories • Provider or hospital reports quality
measures to State
• Provider or hospital sends update to
regional or national quality registry

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Population Health Query

Meaningful use places additional demands on providers to provide and report public health
information. Traditional centralized models for public health data management have proven to
be costly, difficult to maintain, a inflexible to across population health conditions. To date,
various distributed query models have been implemented to facilitate public health situational
Challenge
awareness, quality monitoring, and research. A standardized query approach is needed to help
determine how clinical providers, hospital systems and public health will share and report
information important for public health situational awareness, clinical decision support, and
quality monitoring and prevention.

Develop detailed specifications focused on enabling distributed query mechanisms to aggregate data
Scope Statement
from multiple public health data sources into a single view

• Development of a common query standard for all population health data sources, which can be
reused by all population health query systems by 2012
Target Outcomes
• Reduce total population health query costs by at least 20%
• More than 25% of total unique providers using population health query standard by 2013

Meaningful Use
None
Alignment

Related Use
None
Cases/Stories

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Clinical Decision Support

Clinical decision support is a key function of EHR systems that is expected to improve care. In
Stage 1 of the meaningful use requirements, provider and hospital EHR systems must execute
clinical decision rules and alerts. There will be a need to standardize these rules and alerts
Challenge across EHRs using interoperable templates. There also will be value in enabling interoperability
between an EHR system and a CDS provider, e.g., to notify a provider that a patient or panel of
patients require a test. Without a set of standards to guide development, rule development will
be localized, costly, and non-standardized.

Scope Development of a standard content specification for implementation and exchanging clinical decision
Statement support rules and alerts across various EHR platforms

• Develop a common standardized format for submitting patient data to CDS service providers that is
adopted by up to 20% of providers by 2013.
Target • Develop standardized format for submitting and generating CDS rules that is adopted by 20% of CDS
Outcomes vendors by 2013.
• Increase total deployment cost savings for clinical decision support service capabilities by 25%
• Generate a total increase in clinical decision support usage of 10%

Meaningful Use Implement Clinical Decision Support Rules


Alignment

Related Use • Medical Home: Problem Lists & Practice-Based Registries (ONC/AHIC)
Cases/Stories • Care of the Stroke Patient in the Acute Care Setting (HIMSS)

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Blue Button

The Blue Button, should it become ubiquitous on health institutions’ patient portals (or for
smaller practices, simply on their website), payer-based PHRs, employer-based PHRs (often
just a PHR provided by payer), and even regional or state-wide HIEs, the effort that it would
Challenge take for an average consumer to gather their data to create a longitudinal record could be
simplified significantly. In order for the blue button to work, though, there is a need to develop
a common standard for downloadable information (a common standard for the downloaded
text files) so that a text file can be processed as patient readable.

The focus would be on developing a standard content specification for how the text file would be
structured to make it readable for patients, and ensuring the structure could be mapped and/or
Scope Statement
transformed to the CCD (so that documents using those standards could be transformed into the
common text file format).

• Develop a common format for representing the blue button text file that is adopted by VA and CMS
in 2011.
Target Outcomes • Increase in blue button deployment to 10 additional organizations in 2012.
• Develop the capability to map a blue button standardized text file to C32 summary documents by
2013.

Meaningful Use
Provide clinical summaries to patients
Alignment

Related Use
None
Cases/Stories

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Green Button

Providers often need to transition from one EHR system to another. Such transitions occur
when providers purchase new EHRs or EHR modules or move practices. There is no
Challenge
standardized mechanism to allow data transfer to occur in EHR system transitions, creating
a less dynamic market for EHR systems by encouraging lock-in.

Develop clear standard format for how data from one EHR can be transferred to another EHR
Scope Statement
using a green button specification

• Achieve cost reduction of at least 25% compared to paper transfer options by 2012.
Target Outcomes
• Promote VLER adoption of green button standard by 2013.

Meaningful Use Exchange key clinical information among providers of care and patient authorized entities
Alignment electronically

Related Use
None
Cases/Stories

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Value Set Development

For a given meaningful use requirement needing a value set, experts would need to define the
value sets appropriate to the specific requirement with due consideration of harmonization with
similar and existing solutions. The infrastructure and format for maintaining the actual value
sets and making them available as needed would also require specification. This would include
Challenge
issues of intellectual property and versioning. Stakeholders would have to agree to use or map
value sets from master(s) code sets like SNOMED rather than maintaining domain specific
codes. Without this value set development flow in place, the localized developed of value sets is
likely to continue, leading to less value set adoption.

There is a specific need for standardized value sets in areas such as:
Scope • Lab Orders – critical for meaningful use
Statement • Reportable Conditions
• Lab Results – for the most frequently reported tests

• Initial value sets ready to support meaningful use by end of 2011


Target
• Align 2011 developed value sets to existing vocabularies and vocabulary mappings by 2012.
Outcomes
• Reduce value set development response time by 50% by 2013

Meaningful Use
Foundational to Meaningful Use
Alignment

Related Use
None
Cases/Stories

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