Supporting Meaningful Use
Stage 2 Transition of Care
Requirements
CEHRT & MU Relationship
Meaningful Use Stage 2 (MU2)
ONC: Standards, Implementation Specifications & Certification Criteria
(SI&CC) 2014 Edition
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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)
CMS: Medicare and Medicaid EHR Incentive Programs Stage 2
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•
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
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
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)
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
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
Valid Certification Scenarios for EHR Technology
(Sending with Direct)
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)
Scenario 1
Whatever EHR technology is presented for certification must
demonstrate compliance with both (i) and (ii) under (b)(2) to meet
the certification criterion.
STA/HISP function
Provider A
Provider B integrated into EHRs; no
1.EHR generates CCDA
2.EHR performs as STA and
sends Direct msg
separate certification
testing for HISP.
Direct (SMTP + S/MIME)
Complete EHR or EHR Module
certification issued.
Scenario 2
1.EHR sends “data” to HISP
2.HISP generates CCDA
3.HISP performs as STA and
sends Direct msg
HISP
Provider A
Any
Edge
Provider B
HISP certified
independently as EHR
Module.
Direct (SMTP +
S/MIME)
Protocol
EHR Module certification issued
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
EHR Affiliated HISP
Provider A
Provider B
Any
Edge
Direct (SMTP
+ S/MIME)
HISP certified as “relied
upon software” with the
EHR. Certification given
to the pair, not EHR and
HISP separately.
Protocol
What gets presented for certification
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.
Approach #1 -- Send with CEHRT Required Transport:
Using Direct
Scenario 1
STA/HISP function
Provider A
Provider B integrated into EHRs; no
1.EHR generates CCDA
2.EHR performs as STA and
sends Direct msg
separate certification
testing for HISP.
Direct (SMTP + S/MIME)
Complete EHR or EHR Module
certification issued.
Scenario 2
1.EHR sends “data” to HISP
2.HISP generates CCDA
3.HISP performs as STA and
sends Direct msg
HISP
Provider A
Any
Edge
Provider B
HISP certified
independently as EHR
Module.
Direct (SMTP +
S/MIME)
Protocol
EHR Module certification issued
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
EHR Affiliated HISP
Provider A
Provider B
Any
Edge
Direct (SMTP
+ S/MIME)
HISP certified as “relied
upon software” with the
EHR. Certification given
to the pair, not EHR and
HISP separately.
Protocol
CEHRT
Approach #2 -- Send with CEHRT Optional Transport:
SOAP + XD (Example)
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
Provider A
Provider B
SOAP +
In this scenario, the EHR
must be certified to
support both Direct
(required) and SOAP +
XDR/XDM (optional) as
transport standards.
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.
Approach #2 -- Send with CEHRT Optional Transport:
SOAP + XD via Intermediary (Example)
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
HISP
Provider A
Provider B
SOAP +
Direct (SMTP
+ S/MIME)
In this scenario, the EHR
must be certified to
support both Direct
(required) and SOAP +
XDR/XDM (optional) as
transport standards.
XDR/XDM
The HISP does not need
to be certified.
This meets the MU
requirement for using
CEHRT.
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.
Approach #3 – Send via NwHIN Exchange Participant
NwHIN Example
1.EHR generates CCDA
2.EHR sends CCDA to
NwHIN Exchange
Participant
3.NwHIN Exchange
Participant sends to
Provider B
Provider A
NwHIN Exchange Participant
(now eHealth Exchange)
Complete EHR or EHR
Provider B Module certification
issued.
NwHIN Exchange
participant does not get
certified.
CEHRT
CEHRT
Note: 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.
Key Points
•
HIEs providing HISP services have multiple options for
supporting providers in meeting the MU Stage 2 ToC
requirements:
a)
Allow EHRs to connect using SOAP + XDR/XDM (HISPs do not need
modular certification under this model to support MUS2)
b) Become NwHIN Exchange participant
c) Partner with an EHR vendor and get certified as pre-coordinated
bundle
d) Get modular certification for CCDA translation and Direct
•
HIEs should analyze the options and select one (or more)
that best serve the needs of their stakeholders/communities
Want to learn more?
•
State HIE Direct CoP Call
–
•
Monday, 11/19 @ 3PM Eastern
MU Stage 2 interoperability training modules coming soon
Reference
Key Terms / Acronyms
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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.