1. HIT Standards Committee
Meeting
Wednesday, June 30, 2010
9:00 am ET

2. Agenda 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

3. 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

4. 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

5. 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

6. 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, ONC
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

7. 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

8. Outline
» The need for the S&I Framework
» S&I Framework and NIEM
» Process Overview
» Roles and Key Artifacts
» Coordination
6/30/2010

9. The Need for an S&I Framework
• 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.
6/30/2010

10. S&I ConOps Organizing Principles
• 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
6/30/2010

11. Mapping S&I Framework to NIEM
Scenario Map & Assemble &
Planning Model Document
Analyze Build & Publish &
Requirements
Analyze
Map and
Validate
Publish and
Implement
Implement
Implementation, testing and
Analyze Model
Requirement
s Requirement certification disciplines are
s
needed beyond NIEM
Add service and behavior
specification generation to
NIEM
11

12. S&I NIEM Process Outline
Biz scenarios identified
by: Publish IEPDs
• Health community to repository
• ONC Use Case Publish &
• Federal agencies Development Publish
Implement
Document in wiki Scenario
• Business scenario
• Use cases Planning Emergence Testing &
Pilot Certification
Elaborate tech
and business
requirements for Prioritize Continuous
exchange
Feedback
• Generate IEPDs
Identify relevant Implementation RI from UML model
standards and
Analyze Specifications • Package all
gaps
artifacts for
Requirements IEPDs
Assemble &
Harmonize Document
Standards Generate
implementable
Map & Model code from model
Develop Build & Validate
computable UML
model for content
and/or transactions
= Governance = NIEM IEPD
Decision = S&I Activity
12 Lifecycle Phase

13. Coordinating Iterative and Incremental S&I
Processes
• 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)
•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.
6/30/2010

14. S& I Overview of Roles and Controls
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”
6/30/2010

15. Prioritization and Backlog Lists
Strategic
Priorities
Operational
Priorities
“Day to Day”
Priorities within
each functional
team
6/30/2010

16. Stakeholder coordination
HITPC HIT SC
VLER VLER
NHIN CC NHIN TC
FHA FHA
6/30/2010

17. NHIN Direct Example
J J A S O N D J F M A M J J A S O N
S&I and HITSC NHIN Direct
Activities
Implementation Reference Pilot Demonstration
Specifications Implementation Projects
Standards
Development NHIN Inclusion
HIT Standards Committee Review
Activities
Evaluation
Use Case Development Harmonization of
Implementation Reference Certification
and Functional
Requirements
Core Concepts (NIEM
framework)
Specifications Implementation and Testing Other Standards
Governance
Evaluations
Tools and Services
(Use Case Development, Harmonization Tools, Vocabulary Browser, Value Set Repository, Testing Scripts, etc)
HITPC Activities
HITPC P&S Tiger Team Policy
Framework
HITPC + HITSC
Specification Policy Review

18. 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

19. 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

20. RFC 5322 Source HISP Destination HISP
Headers + DNS
Locate
Destination
(s)
SMTP +
MIME
(+XDM)
S/MIME S/MIME
Sign Verify
POP/IMAP +
SMTP + Reject TLS
MIME
S/MIME S/MIME
(+XDM) Encrypt Decrypt
SMTP +
S/MIME
SMTP +
TLS
SMTP Hold
(encrypted)
+ Content
S/MIM
E
SMTP +
Send Receive
TLS

21. 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

22. Agenda 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

23. 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
Maryjo.deering@hhs.gov

24. 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

25. 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.

26. 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.

27. 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?

28. 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?

29. 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)?

30. 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)

31. 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?

32. 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?

33. Discussion

34. Agenda 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

35. HIT Standards Committee
Privacy & Security Tiger Team Update
Deven McGraw, Co-Chair
Center for Democracy & Technology
Paul Egerman, Co-Chair
June 30, 2010

36. 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

37. 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

38. Proposed Schedule of Topics
June July August
• Organize Team • Continue Directed • Governance
• Address issues of Exchange • Final Report to
message handling • Develop policy Policy Committee
in Directed framework for other on August 19
Exchange HIO models
• Report to Policy • Address issues of:
Committee on June • Consumer
25 Choice/Consent
• Consumer Choice • Sensitive Data
Technology Hearing • Interstate
on 6/29 Exchange
• Report to Policy
Committee on July
21

39. 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.

40. 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)

41. 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.

42. 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.

43. 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.

44. Agenda 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

45. HIT Policy & Standards Committees
Enrollment Workgroup
Aneesh Chopra, Chair
Chief Technology Officer, OSTP
Sam Karp, Co-Chair
California Healthcare Foundation
June 30, 2010

46. Workgroup Members
Chair: Aneesh Chopra, Federal CTO
Co-Chair: Sam Karp, California Healthcare Foundation
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

47. 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.

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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.

54. 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

55. This Base Use Case Supports Several Eligibility and
Enrollment Scenarios in 2014 – Draft Under Discussion
Makes 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

56. Medicaid MAGI, MA,
Exchange, State systems
Diagram
Check Current
1 2 Enrollment:
Initial Check other systems 3
for existing coverage; first Obtain
Screening:
Applicant match using single identifier, Verification Info: IEVS
provides basic probabilistic formula, or Electronically verify
other method; then obtain identity, residency, VR
demographic info
enrollment info citizenship, household
size, income, IRS DMV
etc.
SSA DHS
4b Portal
makes
State
eligibility
decision Determine 4 systems
Eligibility:
Portal
Method
4a sends will depend
Enrollment eligibility on system 5
packet to capabilities.
Notification program Send eligibility info to
to Portal
other programs
Program
(human services, etc.)
makes
eligibility
decision
6
Send enrollment
information to plans

57. Agenda 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 member
10. Clinical Operations Workgroup: Electronic Document Standards for Discharge Summary &
Other Encounter Summaries
11. ONC Update: Temporary Certification Program
12. Public Comment
13. Adjourn

58. HIT Standards Committee
Quality Workgroup
Next Steps:
Quality Measures for 2013
Janet Corrigan, Chair
National Quality Forum
Floyd Eisenberg
National Quality Forum
June 30, 2010

59. 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

60. 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

61. 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

62. ONC Environmental Scan
Scan of 12 leading healthcare systems
Responses from 9 organizations: ONC Environmental Scan
• 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

63. ONC Environmental Scan Table 1 – 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.

64. ONC Environmental Scan Table 2 – Environmental Scan
Condition /
Cross-Cutting Area Performance Measure
Healthcare Associated Decrease Use of Urinary Indwelling Catheters in
Infections 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.

65. ONC Environmental Scan Table 3 – 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.

66. ONC Environmental Scan Table 4 – 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.

67. 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

68. 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

69. Agenda 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

70. HIT Standards Committee
Clinical Operations Workgroup
Workgroup Update
Jamie Ferguson
Kaiser Permanente
John Halamka
Harvard University
30 June, 2010

71. 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

72. Review: CCR and CCD
A CCD based document
CCD: A collection of templates representing core content for
healthcare summary documents with template content from CCR
Family History
Medications
Problems
Allergies
Social History
Vital Signs
Payer
Demographics
....
CDA: A foundation standard enabling the definition of templates
for a broad range of healthcare documents

73. Extending And Reusing Existing Templates In
Other Documents
A CDA based document
compatible with CCD
A CCD based document
CCD Template content from CCR
Chief Complaint
Diagnosis
Discharge
Transport
Mode of
Surgical Finding
New Section…
Discharge Diet
Family History
Medications
Problems
Allergies
Payer
Social History
Vital Signs
Demographics
....
CDA
Identified by the CCD document ID number
Identified by another identifier, e.g., an
ED Discharge document ID number

74. 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

75. 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

76. Next Steps
• Seek HIT Standards Committee input
• Continue Workgroup discussions to create future
recommendations to the full Committee

77. Agenda 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, ONC
12. Public Comment
13. Adjourn

78. Steve/Carol
HIT Standards Committee
Temporary Certification Program
Steve Posnack, ONC
Carol Bean, ONC
June 30, 2010

79. Adjourn
Meeting Adjourned