Monday, February 2, 2015

ONC Annual Meeting

The ONC Annual Meeting is February 2-3, 2015. It is being broadcast live HERE.

National Coordinator and Acting Assistant Secretary for Health Dr. Karen DeSalvo's opening remarks and HHS Secretary Burwell's comments are below:

Dr. DeSalvo:
Last year, when I stood before this ONC Annual Meeting I was just a few days into my tenure as National Coordinator, I was literally fresh off the farm. I shared with you my perspectives as a daughter, as a doctor being as a public health leader and what we had done in post Katrina New Orleans learning how health IT would make a difference in care and public health. I had just purchased an EHR for a hospital we were constructing and have been through three implementations of a health record in the clinical care environment in the outpatient setting and still using EHR's in the practice of medicine. That day I said we would look at how health IT would be a key ingredient in reforming our nation's healthcare system, including focusing on how it would support payment reform and how payment reform would support health IT, I said we would break down barriers and silos that were holding in data and focus on interoperability and save lives to improve the public health. I told you we would risen to everyone's ideas about how to rairpz the floor for health and health information in this nation. I want to remind you all of what we've accomplished in this last year at ONC and HHS with our federal partners, with our private sector collaborators, and with many of you in this room. It's truly been an all hands on deck effort and the work is just beginning. 
I want to start with what we did on the internal side of the house at ONC. We talked last year about how we were making a pivot at the ten year mark of the office of the National Coordinator, moving off the high-tech era where we had been catalyzing the marketplace to adopt and adapt to electronic health records and health IT and that it was time for us to borrow from the best of our past, the best of our present and look to the future so we could reshape ourselves into one that would be as efficient and effective as possible and low us to focus on interoperability. We have many fresh new faces in the office of the National Coordinator, many of whom I hope you get to meet in the next couple days and we lost some members of our family who have gone on to bigger and better things and some of them are here today with us, so I hope you all will have a chance to reconnect with them. We sought to be better partners, we wanted to make sure we were understanding the realities on the ground, what health IT meant for the work flow in the clinical environment. We listened to what you all were saying about the implementation of meaningful stage 2 and in partnership with CMS moved ahead with adding flexibility last spring to provide additional exemptions for hardship and to see that we were providing flexibility in which of the health IT products clinicians and hospitals could use. We recently announced we were also providing flexibility in upcoming rulemaking around 365-day reporting rule. And as we look to stage 3, we are learning and listening from what has happened in the success stories and in the challenges on the ground about developing meaningful use and are looking to develop a program that is straightforward and flexible, focused on outcomes and on interoperability. We opened our certification process to one that would allow for strategic improvement in partnership with clinicians and developers and others and it is an ongoing effort and we invite you to participate in that process. We wanted to convene conversations that would invite best ideas, best practices, and not keep us siloed in our own ideas inside the Humphrey Building and beyond. We reorganized the work groups and our federal advisory committees and the volunteers who worked tirelessly in those efforts are to be commended as well as the thoughtfulness that they gave as we underwent change for this new era. I want to thank a minute to thank Paul Tang and John Halamka, you can't imagine how many hours they give, bringing forward information from the front lines, and the advisory committees are helping us. 
We reported out on the progress of the digitization of the care experience for people in this country in our report to Congress. It's really been a dramatic advancement as many of you all know because you're living it every day. We have the vast majority of hospitals using electronic health records and the majority of physicians and clinicians as well. And in many places it's not just in clinical care environment but you know there are pockets of real excitement where health information technology is advancing clinical care and science and quality improvement and safety and the public health places like intermountain showing us the way and are leaders in the field. 
We work to reset our federal priorities to see that we would meet the expectations going forward. This was a process that involved more than 35 federal partners, not only the HHS family, CMSr Office of Civil Rights, but also well beyond, VA, DOD, FTC, amongst many others, it was a chance for us to really as a federal partner to you all sit down and say where is the world going, and we saw that that world was going to a place where we had to attend to health well beyond the healthcare system using tools for health information technology, including but beyond the electronic health record and that we needed to understand what levers we had to bring to bear to see that that advancement continued well beyond the meaningful use program. 
And I had the chance to get out of the beltway many times and have the chance to learn what is going on the front lines with many people working to implement electronic health records and learning to adjust to a digitization of healthcare and the health experience. We had the chance to host 15 listening sessions across the country where I had the opportunity to get underscored for me and for many of the team members how different this nation is and how we are not one size fits all that, we must learn to meet communities where they are. There's variability in where we are in the health IT spectrum but also this challenges that are being faced. I asked people in those listening sessions to tell me what was working, what was not, what were the priorities, how could we help as the federal government and how could we get out of the way much. The Robert Wood Johnson foundation also hosted five listening sessions across the country, inviting in more atypical folks and organizations into health IT conversations, urban planners and public health and consumers and economic development organizations so we could see how health data might improve health, might inform a culture of health going forward. I want to thank them for that time and I look forward to hearing more about that report. The variability is something like this. In Tennessee where I was last week they're talking a lot about payment reform, they're thinking through how the opportunity for payment reform enables and supports interoperability but they're also very concerned about within an organization interoperability between their developed products so the emergency room and the outpatient setting and the inpatient setting may all use different electronic health records and those systems are not interoperable. It's not even a matter of interoperability between organizations. In places like Minnesota they're thinking about how to integrate public health in a more seamless fashion than they have already shown to be successful and in ver monltd their leaders in behavioral death data, not only the adoption of electronic health records in that care environment but integrating it into their interoperability framework. In Alabama though a lot of work has been done, for many rural physicians in that community, access to broadband is a fundamental challenge preventing them from advancing health IT. In Silicon Valley I heard about ideas for innovation in digital platforms that wrap around people and not institutions, they are almost forgetting that there's an electronic health record and thinking of this next generation of digital data that we all have to plan for. All of this work in IT whether it's about adoption or interoperability or the use of the data is just a means to the end, it's about the use. It's about seeing that we can realize The secretary's vision of smarter care, healthier spending and healthier people. You'll hear more about that in the next couple days and I hope you saw what we announced last week as a part of the broader vision but I want you to understand that Secretary Burwell as you'll hear from her clearly understands how important and essential health IT is to achieving not just better care but better health if we want to really have better care, we need better data models than we are working with today. We spent 2014 working on a path to do that, to find a way to unlock data so it could be put to use, not just for delivery system reforms but for all the purposes that you want every day or are engage in every day. We want to see that it's an all-in equation and that we have a chance to have more seamless interoperability so it's not an afterthought or an additional bit of workload. We know that it is time to see this return on investment and we know that the clock is ticking. In June we released a vig report to interoperability, a call to the table to ask all of you to come forward and work with us on a pathway to see that we could achieve a learning health system in ten years. We called out that we thought the critical pathways would involve certification, privacy, governance, standards, and the right business and regulatory environment. We asked folks specific comments about that broad vision and to work with us in the intervening months through a variety of mechanisms to have as much feedback as possible, to understand best practices in the community and all those areas to see what the realistic opportunities were to achieve real term near term impact. 
And just last Friday, are we put out our report the nationwide interoperability roadmap and the interoperability standards advisory which is the result of that collective action, that conversation, that input we've had from you and others well beyond. It reflects the frankly collective intelligence of the health IT community and calls for areas where we have common ground that will allow us to advance and move forward. 
In the end our roadmap described three broad clinical pathways to address that we believe will get us to a learning health system in ten years and work backwards to meaningful interoperability to catch the clinical environment in the shorter term. We believe we must start by setting clear standards that everyone can follow and build upon iteratively over time. Second, there needs to be a trusted environment in which data is collected, shared and used, one in which the privacy expectations of the consumer are respected and followed, one in which data is secure, one in which we understand the rules of the road, one in which there is a defined pathway forward, a defined set of business practices, one in which the people sitting around the table making decisions about how to use the data are people like you, people you trust, people who understand what is actually happening out in the clinical environment and well beyond in the community. We are clear in our role in this document and we believe that we have an opportunity as the federal government to achieve interoperability based upon the set of levers that we have laid out. 
Let me tell you a couple things in the document. We'll have time later today to walk through the interoperability roadmap and plenty of chances well beyond that. Let me start by saying that success looks like in three years that there's a common clinical dataset that can move with patients, with consumers, as they move through the healthcare system available for doctors when they need that information to save a life or to make a clinical decision and that can be used as the fundamental building blocks for quult improvement, quality reporting and better patient safety in the healthcare system. A couple words about standards. We actually pulled a page from the playbook of the prior administration in publishing a list of standards, and ya'll have been around for a while know that this was a notion that Secretary Levitt and his team had of putting out the best available standards and pointing to them with a set of motivators. 
What we expect for you all to see in this is that these are what we believe are the best available and widely used standers, that they're the foundation that will allow us to have the interoperability for this common clinical dataset in the short run. We know it's going to require improvement of consistency and things like the CDA but we also know that we need to move towards a more restful approach, that we need to see that we can mature standards like fire which we encourage the private sector to do because we know we want a more nimble and scalable architecture. The standards advisory is out for public comment. It's owr first deliverable from the roadmap so we encourage you to look at that, give us feedback, you can bother Steve Posnak about that and we want this to be the dictionary that we can all begin -- the dictionary that we can all begin to use. 
For certification I mentioned earlier that we've laid it out and we believe it can stand to be improved. The team has been working actively on that for months and already has some new testing methods but we believe there's opportunity for us to continue to make it work better out in the real clinical environment so that when the product comes out of the shrink-wrap, it's doing what we all want it to do. With respect to incentives, as part of the secretary's delivery system reform initiative last week we made an announcement at HHS that we would move very aggressively to set goals around alternative payment models. We said that we would, as HHS, using our Medicare program r by 2018 have 50% of Medicare payments be an alternative payment model and work backwards to 30% in 2016. The significance of this to interoperability is this is but one of many sets of motivators we have at our disposal in the federal government that can help point to the standards that will drive interoperability and encourage behaviors out in the marketplace to drive interoperability and we're cawmg on the private sector to come along, they'll be participating in a learning and action network to have conversations about alternative payment models and how we can continue to advance, and we're also calling on state government to use their levers, whether that's the Medicaid program or other opportunities to advance interoperability. 
And finally, in the trusted environment space, a snapshot of the things there, we will plan to set out some clear rules of the road, they're in the document. We would like to see that those varied and emerging health information exchanges and interoperability orgs move to using -- organizations move to using the same set of rules of the road, the same set of business practices, same set of standards so that the consumer knows what to expect from their data and a way that we can recognize those entities that are trusted and hold them accountable. 
In the privacy and security space, this is an area where we don't necessarily need to do more except be more clear. This is our chance to work with The office of Civil Rights and let r everyone know what HIPAA does and does not prevent and work with states at aligning their security policies at a state level. Better harmony will help the data move. You'll hear more on that later and I look forward to have the opportunity to have Q & A and continue to see the feedback we're getting, but we are calling on you all, this is not something that the federal government should do alone, can do alone, we must have partnership in this. This is too important for our country, it's too important for all the use cases. There are ways and opportunities for the private sector, for consumers, for payers, for states to lean forward, to look at this document, this roadmap, this path forward of who needs to do what by when and say I can take that, I want to lead in that area and I want to partner with others. It has to be inclusive and we have to meet deadlines because the country is impatient, as are all of you when you show up in the clinical environment. 
So it has been a busy year and next year is about execution. We have to implement on ideas called out in the strategic plan, on ideas called out in the interoperability roadmap to make sure that we meet our marks and have maximum impact. Looking back ten years at what David Brailer wrote and said about connecting care for the nation and as we think again to connecting care for the nation, I think about who might stand on this stage in ten years as the National Coordinator and reflect back on this challenge of interoperability that we are facing today, and I would hope that it would have been solved and where we would be in ten years is continuing to have the opportunity to innovate with health IT but doing it in a way that is more seamless and meaningful for everybody out there, to see that health information technology has changed healthcare in a way that Eric Topal calls out in his new book that the patients that have a Smartphone, Proxy Doctor that can allow them to test their own labs and monitor their vital signs and as a doctor, know they're still going to come and see us, but health IT is magic inso much as it's enable being our work flow and not it the way of work flow, that's helping us to have the right clinical information to make a choice about the person in front of us, to understand how we're doing about managing population and to seamlessly have evidence at our fingertips to make the best evidence-based decisions, where science is going and we're being rapidly pulled along through efforts like the precision medicine initiative the president announced Friday is a world in which your genetic makeup dictates the meds that you get even for common disease and the dose that you receive, in a way that isn't the kind of guessing that I've been doing for 20 years about which hypertension med is really the right one for the person. This is a world in which public health has the data available in realtime to be able to save lives, to improve the public health, to respond to disaster. 
And so I thank you all for the work that you have done in this last year. I thank you all for your input about this vision of a learning health system. I thank you all for pushing us when we needed to be pushed, and I look forward to continuing that conversation. We have a chance to raise the floor for everybody in this country. We have a chance to see that everyone, no matter where they live, no matter the color of their skin, no matter the type of insurance they have or don't have, no matter the kind of healthcare system in which they receive care, can take full advantage of health IT in the way that only the best models are doing right now in this country. This is our chance to work together to see that we can bring everybody along to that learning health system. 
So for the next two days we're going to talk about some of the work that's in hand and hear from you all to get some feedback and questions. We're also going to have the chance to hear from some visionary leaders and thinkers who have been in this space for some time. Later on today I'll have the opportunity to have a fire side chat with Senator Daschle and Frist. Tomorrow afternoon Elliot fisher will join us to understand how health IT is really going to move the dial on delivery of care. Tomorrow my boss Secretary Burwell will be here to share with us how she sees health IT A's critical for advancing healthcare delivery and beyond. What I'm really excited about -- don't tell my boss I said that -- is the five national coordinators being on this stage, it's a joy and pleasure for me to have them as mentors can colleague as we are taking this journey into the next decade and I look forward to their thoughts about where we are today and where we'll be going. In addition to you aof them, Angela will share her personal story from her family and we have many other thoughtful people who have come from across the country to tell us how health IT is working and what we can all do in the path ahead. So thank you all again for being here. Thank you to the team for making it so. Thank you to the speakers who have traveled to be a part of this day. We look forward to the ongoing conversations today and beyond. And so with that, I'm going to turn it over to Dr. Andy Gettinger, a new are member of the family, he'll come to the podium and introduce our next panel on big data and health information to improve population and public health. Thank you all very much.        

Secretary Burwell:
Good morning. And Karen, thank you for that introduction. I want to start actually by recognizing Karen and expressing appreciation for Karen and not only for her role in the Office of the National Coordinator of Health IT but also for the great work that she's been doing on delivery system reform, together with Dr. Patrick Conway, it's all part of of a whole. This is my first Annual Meeting since I became Secretary, and I did not want to mips the opportunity to tell you all how committed we are as an administration to partnering with you. I've spoken about improving our nation's health delivery system isn't my very first days as Secretary, and what I've said is that I believe whether you're a consumer, a provider, a business, a health plan, or a taxpayer, it's within all of our common interests to build a healthcare system that is better, smarter, and healthier, a system that delivers better care, spends our healthcare dollars more wisely, and makes our communities healthier. The good news is that for all of the differences of opinion in this town when it comes to healthcare policy, there's one area where we have near-unanimous agreement, and that's that the system that's been in place for the last 50 years has underdelivered on the issues of access, quality and affordability. You could almost sum it up in one sentence and that is the prices we paid far outweighed the progress that we've made. Over the last several years, however, we started making significant progress on access, affordability and quality. And some of that is thanks very much and in part progress from the Affordable Care Act. The question now is how do we build on this progress? How do we take it to the next level? How do we provide better care, achieve smarter spending, and have healthier patients? It's my belief that the key to doing this is finding better ways as a country to deliver care, pay providers, and distribute information. 
Last week we announced historic goals around moving Medicare payments from rewarding volume to rewarding value. We set a goal that 30% of Medicare provider payments would be alternative payments by 2016 and that that number would be 50% by 2018. Today I want to announce some steps forward that we're taking to achieve a better, more efficient healthcare system with healthier patients. To do that, we need to ensure that the information is available to both consumers and their doctors. To help inform and empower decision-making, and support practice improvement. We've made significant progress digitizing the care experience of Americans, especially when it comes to the implementation of the HITECH act. Now it's time for us to free up that data, which had previously been trapped and unavailable for use. So patients and providers can have access to their health information when and where they need it across the continuum care. Last Friday we announced a shared nationwide interoperability roadmap, for the private and public sectors to unlock data and maximize cr. Information sharing and interoperability over the next ten years. First it promotes the use of common industry standards, for information sharing technologies to interact with one another. Second, it outlines incentives that would encourage public and private use of these standards and supportive business practices. And third, it proposes to build trust and confidence in the new health IT infrastructure by defining the rules of engagement, including expectations around the privacy, security and use of electronic health data. The goal is to get in place where we have a successful learning health system, where exciting advances like precision medicine can actually be the norm. The roadmap explains how we can get there over the next ten years, and ONC delivers on a critical first step in this process by publishing a companion list of standards available in its 2015 interoperability standards advisory. 
I want to thank ONC and the robust community of stakeholders who provided input both for your hard work in developing this roadmap but also for your commitment to implementing it now as we go forward. I also want to share with you another step that we're taking to move the ball forward on interoperability and information sharing. Today we're announcing the availability of a $28 million in grant funding to advance interoperability. Having been at OMB, that's always a very important line around the money. This two-year grant program will ask awardees to demonstrate innovative community-based solutions to advance standardized, secure and interoperable movement of health information across organizations, vendors, and geographic boundaries. 
Finally, it's important to remember the real reason that we're doing this work, because if we succeed in our efforts around interoperability and delivery system reform, it means that a patient who is admitted to a hospital or referred to a specialist will be more likely to get the right tests and medications because her doctors are doing a better job of coordinating with each other. It means that businesses, large, medium and small, including their workers, will benefit as we continue to slow the growth in healthcare costs, freeing them to reinveps the dollars they save in higher quality care for their employees or other things. It means a cancer patient can continue his chemotherapy regime even after a hurricane evacuation because his information will be available when and where he needs it. Finally, it means our friends and neighbors, even though they may not know what the word interoperability means, will have access to the kind of cost and quality information they need to make the decisions for the care they want to receive. To do this, we need your energy, your commitment and your partnership. And together, I believe we can and we will build a delivery system that's better, smarter, and healthier for all Americans. Thank you all for having me today.

Tuesday, January 6, 2015

FHIR and the Future of Interoperability

There is growing interest in the health care information technology community in an emerging data exchange technology known as FHIR (pronounced “fire”). Last year we held a webinar on the topic with Dr. John Halamka, CIO of Beth Israel Deaconess Medical Center; Keith Boone, Standards Geek at GE Healthcare; Janet Campbell, Software Developer at Epic; and Arien Malec, VP, Data Platform and Acquisition Tools at RelayHealth. Now I am following up with another great webinar (register for free HERE) with a great panel including Dr. Michael Hodgkins, CMIO of American Medical Association (AMA); Dr. Doug Fridsma, MD, CEO American Medical Informatics Association (AMIA); Dr. Charles Jaffe, CEO Health Level Seven (HL7); Jeffery Smith, Senior Director of Federal Affairs, College of Healthcare Information Management Executives (CHIME); and Mario Hyland, Senior Vice President, Inc. You won't want to miss this...

FHIR, or Fast Health Interoperability Resources, is a proposed interoperability standard developed by the health care IT standards body known as HL7. Health Level Seven International (HL7) is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing and retrieval of electronic health information.

Stakeholders from across the HIT ecosystem are actively exploring, experimenting and testing FHIR. Part of the enthusiasm surrounding FHIR is due to the elegant simplicity of the technology.

FHIR is attractive primarily because it is based on a truly modern web services approach (and one used by companies such as Yahoo, Facebook and Google). This approach makes it easier for systems to exchange very specific, well-defined pieces of information, rather than entire documents.

Such specific pieces of information might be as simple as a patient’s gender or marital status. Today in HIT, the common standard is one based on what is known as C-CDA, or Consolidated Clinical Document Architecture. And unfortunately, C-CDA is designed to transfer entire documents, rather than a single piece of data or a simple list.

This means that today, when a physician requests just one piece of information about a patient, the system often needs to transfer multiple documents to fulfill the request. This process can often be inefficient, because a physician may have to search through many pages of information to find just one piece of needed data.

FHIR, on the other hand, makes it simple for anyone to receive only, and specifically, the piece of information requested. FIHR also allows access to smaller or “granular” data elements that are not included in some clinical documents.

In sum, the proposed FIHR-based standard will make exchanging health care information faster and much more efficient.

The major technology change embodied in FIHR is a fundamental move away from a document-centric approach to a data-level access approach using application programming interfaces or APIs. Specifically, FHIR features a concept called “Resources,” meaning a very basic set of structured data.

For example, a resource could be defined as a medication list, a problem list or lab results. Already in today’s system, standard coding sets such as Logical Observation Identifiers Names and Codes (LOINC) for lab results, or RxNorm for medications, allow software applications to exchange just the data that is needed and present it in a highly meaningful way to clinicians or consumers. What FHIR offers is tools for developers to assemble and present many much smaller data elements to enhance the context or meaning of the information.

The consumer aspect is critical because the same technology can be used for patient engagement. FHIR will allow developers to access and use personal health care information to create innovative new apps. An app might be created to remind patients to take certain medications at the right time, for instance. The open Internet standards utilized by FHIR will make a personal health care “account” work much like any other secure app.

Read the rest of this post co-authored by Jean Doeringsfeld, COO of Wisconsin Statewide Health Information Network (WISHIN) on Government Health IT

Wednesday, December 31, 2014

[UPDATED] Unique Patient Identifiers and Congressional Appropriations

Unfortunately, I have discovered that the prohibition is still in effect. 

The language is slightly different than I am used to searching for but is included in the legislation HERE and copied below:
Sec. 510. None of the funds made available in this Act may be used to promulgate or adopt any final standard under section 1173(b) of the Social Security Act providing for, or providing for the assignment of, a unique health identifier for an individual (except in an individual's capacity as an employer or a health care provider), until legislation is enacted specifically approving the standard.
In March 2013 I submitted a petition to the White House suggesting that the President should ask Congress to no longer prohibit HHS from establishing standards for a unique patient identifier. Sadly, it did not get the required number of signatories (and could have been just ignored in any event) and is now removed from the WhiteHouse site, but the issue now suddenly seems to have been resolved, at least for the time being. 

In 1993 under President Clinton's health plan, the government would have issued "health security cards" to all Americans certifying their right to medical care, and the plans for a unique patient identifier were put in place. While the health reform did not make it into law at that time in 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA) [Public Law 104-191].  HIPAA included administrative simplification provisions that required HHS to “adopt national standards for electronic health care transactions” and “a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system” [PL 104-191]. HHS has since adopted unique identifiers for employers, health care providers, and is now in the process of adopting a unique health plan identifier, but has not adopted a standard unique identifier for individuals. 

On October 21, 1998, the 105th Congress passed Public Law 105-277 (an omnibus appropriations act for fiscal year 1999) that prohibited HHS from spending any funds to “promulgate or adopt any final standard…providing for, or providing for the assignment of, a unique health identifier for an individual…until legislation is enacted specifically approving the standard [Title V, Section 516 of PL 105-277].” 

For the past 15 years, despite calls from experts at RAND Corporation and the Healthcare Information and Management Systems Society (HIMSS), identifying the potential administrative cost savings and safety benefits associated with a unique patient identifier, Congress has maintained this prohibition. It appears there is no such prohibition in the Continuing Resolution Omnibus Appropriations Bill recently signed into law. (hat tip to Carl Bergman at EHRSelector)

While a unique patient identifier is no silver bullet it seems prudent for Congress to permit HHS to pursue its implementation, especially if such an identifier could increase administrative efficiencies and prevent medical errors due to incorrectly linked medical records. 

Wednesday, December 3, 2014

Health IT Sections in Proposed Rule to Update the Medicare Shared Savings Program

On December 1, 2014, CMS released an NPRM updating policies under the Medicare Shared Savings Program (MSSP). The proposed rule outlines proposed changes and seeks feedback in key program areas, including some health IT components. Comments are due February 6, 2015. The proposed rule is available here. The sections dealing with health IT are below.

8. Required Process to Coordinate Care

a. Overview

Section 1899(b)(2)(G) of the Act requires an ACO to "define processes to … coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies." In the November 2011 final rule (76 FR 67829 through 67830), we established requirements under § 425.112(b)(4) that ACOs define their care coordination processes across and among primary care physicians, specialists, and acute and postacute providers. As part of this requirement, an ACO must define its methods and processes to coordinate care throughout an episode of care and during its transitions. In its application to participate in the Shared Savings Program, the ACO must submit a description of its individualized care program, along with a sample care plan, and explain how this program is used to promote improved outcomes for, at a minimum, its high-risk and multiple chronic condition patients. In addition, an ACO’s application must describe target populations that would benefit from individualized care plans.

In developing these policies for the November 2011 final rule (76 FR 67819), we received comments acknowledging that requiring ACOs to define processes to promote coordination of care is vital to the success of the Shared Savings Program. Commenters stressed the importance of health information exchanges in coordination of care activities and recommended that CMS allow ACOs the flexibility to use any standards-based electronic care coordination tools that meet their needs. Other commenters suggested that the proposed rule anticipated a level of functional health information exchange and technology adoption that may be too aggressive.

As stated in § 425.204(c)(1)(ii), applicants to the Shared Savings Program must provide a description, or documents sufficient to describe, how the ACO will implement the required processes and patient-centeredness criteria under § 425.112, including descriptions of the remedial processes and penalties (including the potential for expulsion) that will apply if an ACO participant or an ACO provider/supplier fails to comply with and implement these processes. Under § 425.112(b), an ACO must establish processes to accomplish the following: promote evidence-based medicine; promote patient engagement; develop an infrastructure to internally report on quality and cost metrics required for monitoring and feedback; and coordinate care across and among primary care physicians, specialists and acute and postacute providers and suppliers.

In addition to the processes described previously, we believe it is important for applicants to explain how they will develop the health information technology tools and infrastructure to accomplish care coordination across and among physicians and providers Adoption of health information technology is important for supporting care coordination by ACO participants and other providers outside the ACO in the following ways: secure, private sharing of patient information; reporting on quality data and aggregating data across providers and sites to track quality measures; and deploying clinical decision support tools that provide access to alerts and evidence based-guidelines. As ACOs establish more mature processes for risk management, information technology infrastructure allows ACOs and providers to conduct robust financial management of beneficiary populations, deliver cost and quality feedback reporting to individual providers, and streamline the administration of risk based contracts across multiple payers. We believe that requiring ACOs to address health information technology infrastructure in their application to the Shared Savings program would support more careful planning and increased focus on this issue.

b. Accelerating Health Information Technology

HHS believes all patients, their families, and their healthcare providers should have consistent and timely access to their health information in a standardized format that can be securely exchanged between the patient, providers, and others involved in the patient’s care. (HHS August 2013 Statement, “Principles and Strategies for Accelerating Health Information Exchange”) HHS is committed to accelerating health information exchange (HIE) through the use of EHRs and other types of health information technology (HIT) across the broader care continuum through a number of initiatives including: (1) alignment of incentives and payment adjustments to encourage provider adoption and optimization of HIT and HIE services through Medicare and Medicaid payment policies; (2) adoption of common standards and certification requirements for interoperable HIT; (3) support for privacy and security of patient information across all HIE-focused initiatives; and (4) governance of health information networks. These initiatives are designed to encourage HIE among health care providers, including professionals and hospitals eligible for the Medicare and Medicaid EHR Incentive Programs and those who are not eligible for the EHR Incentive programs as well as those providers that are participating in the Medicare Shared Savings Program as an ACO and those that are not, and are designed to improve care delivery and coordination across the entire care continuum. For example, the Transition of Care Measure #2 in Stage 2 of the Medicare and Medicaid EHR Incentive Programs requires HIE to share summary records for at least 10 percent of care transitions.

We believe that HIE and the use of certified EHRs can effectively and efficiently help ACOs and participating providers improve internal care delivery practices, support management of patient care across the continuum, and support the reporting of electronically specified clinical quality measures (eCQMs).

c. Proposed Revisions

We continue to believe that ACOs should coordinate care between all types of providers and across all services, and that the secure, electronic exchange of health information across all providers in a community is of the utmost importance for both effective care coordination activities and the success of the Shared Savings Program. We understand that ACOs will differ in their ability to adopt the appropriate health information exchange technologies, but we continue to underscore the importance of robust health information exchange tools in effective care coordination.

ACOs have reported how important access to real time data is for providers to improve care coordination across all sites of care, including outpatient, acute, and postacute sites of care. We believe that providers across the continuum of care are essential partners to physicians in the management of patient care. ACOs participating in the program indicate that they are actively developing the necessary infrastructure and have been encouraging the use of technologies that enable real time data sharing among and between sites of care. We believe having a process and plan in place to coordinate a beneficiary’s care by electronically sharing health information improves care, and that this helps all clinicians involved in the care of a patient to securely access the necessary health information in a timely manner. It also can also be used to engage beneficiaries in their own care. We further believe that Shared Savings Program applicants should provide, as part of the application, their plans for improving care coordination by developing, encouraging, and using enabling technologies and electronic health records to make health information electronically available to all practitioners involved in a beneficiary’s care.

Therefore, we propose to add a new requirement to the eligibility requirements under §425.112(b)(4)(ii)(C) which would require an ACO to describe in its application how it will encourage and promote the use of enabling technologies for improving care coordination for beneficiaries. Such enabling technologies and services may include electronic health records and other health IT tools (such as population health management and data aggregation and analytic tools), telehealth services (including remote patient monitoring), health information exchange services, or other electronic tools to engage patients in their care. We also propose to add a new provision at § 425.112(b)(4)(ii)(D) to require the applicant to describe how the ACO intends to partner with long-term and postacute care providers to improve care coordination for the ACO’s assigned beneficiaries.

Finally, we propose to add a provision under § 425.112(b)(4)(ii)(E) to require that an ACO define and submit major milestones or performance targets it will use in each performance year to assess the progress of its ACO participants in implementing the elements required under § 425.112(b)(4). For instance, providers would be required to submit milestones and targets such as: projected dates for implementation of an electronic quality reporting infrastructure for participants; the number of providers expected to be connected to health information exchange services by year; or the projected dates for implementing elements of their care coordination approach, such as alert notifications on emergency department and hospital visits or e-care plan tools for virtual care teams. We believe this information would allow us to better understand and support ACOs’ plans to put into place the systems and processes needed to deliver high quality care to beneficiaries.

We also note that ACOs have flexibility to use telehealth services as they deem appropriate for their efforts to improve care and avoid unnecessary costs. Some ACOs have already reported that they are actively using telehealth services to improve care for their beneficiaries. We welcome information from ACOs and other stakeholders about the use of such technologies. We seek comment on the specific services and functions of this technology that might be appropriately adopted by ACOs. For example, does the use of telehealth services and other technologies necessitate any additional protections for beneficiaries? Are these technologies necessary for care coordination or could other methods be used for care coordination? If a particular technology is necessary, under what circumstances?