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HIT Policy CommitteeHIT Policy CommitteeInformation Exchange Information Exchange WorkgroupWorkgroup
Micky Tripathi, Massachusetts eHealth Collaborative, ChairDavid Lansky, Pacific Business Group on Health, Co-Chair
March 15, 2011
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Agenda
Introduction 9:00-9:15
Overview of Stage 2 9:15-10:30
Review Stage 2 Objectives Related to HIE
10:30-12:00
Lunch 12:00-12:30
Continue Review Stage 2 Objectives Related to HIE
12:30-2:30
Quality Measures 2:30-3:00
Qualified Entity Concept, Additional Objectives
3:00-5:00
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Goal
• Prepare comments for MU WG in time for April 5th hearing where they will be reviewing public comments on MU Stage 2 proposal
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Process
• Proposed scope of our discussion today is to assess and provide comments on:
– Exchange related objectives– Exchange implications of quality measures – Qualified entity concept
• Need to be targeted and focused in crafting comments– What are the assumptions about exchange capacity availability for Stage 2?– Is this the right set of objectives?– Are any exchange objectives missing that could be supported by the current
capacity? – Can the ecosystem support the explicit or implied information exchange
requirements?
• Long term consideration: What changes in the ecosystem will be needed for Stage 3 exchange requirements? What incremental steps in Stage 2 are needed to put us on the right path?
• Flag ecosystem readiness questions for future consideration by IE WG
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State HIE Cooperative Agreement Program Objectives
• Rapidly mobilize information liquidity—basic messaging exchange—across the health care system to support stage one MU requirements:
• Receipt of structured lab results • Sharing patient care summaries across unaffiliated organizations• E-prescribing
• Address gaps, especially participation of less resourced exchange partners and data suppliers (small practices, critical access hospitals, independent labs, rural pharmacies)
• Develop openly available core infrastructure that lowers cost and complexity of exchange for many participants and allows for exchange across nodes (directories, authentication, eMPI)
• Create a phased approach to advanced exchange functions• Analytics and quality reporting• Patient matching and query• Public health reporting through exchange functionality• Distributed analytics• Patient access
• Market is rapidly evolving health information exchange solutions
Direct Overview
» Simple. Connects healthcare stakeholders through universal addressing using simple push of information.
» Secure. Users can easily verify messages are complete and not tampered with en route.
» Scalable. Enables Internet scale with no need for central network authority that must provide sophisticated services such as EMPI, distributed query/retrieve, or data storage.
» Standards-based. Built on well-established Internet standards, commonly used for secure e-mail communication; i.e.,. SMTP (or XDR) for transport, S/MIME for encryption, X.509 certificates for identity assurance
[email protected] [email protected]
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Use Cases
Direct Project facilitates the communication of many different kinds of content necessary to fulfill meaningful use requirements.
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Basic Principles
Direct Project Principles
»Universal addressing and transport»Identity assurance and encryption from sender to receiver»Open source to ease implementation
• The history of the Internet shows the power of permissively licensed open source in driving standardization, e.g., TCP/IP, HTTP
»Low barrier to entry for scalable, market-based solutions »Rapid and easy availability to a wide variety of participants. Direct Project’s BSD-licensed software stack enables:
• Client-side connectivity, for EHRs, EHR Modules, PHRs, etc.
• Server-side connectivity for “out of the box” HIOs and Health Information Service Providers (HISPs)
• Easily accessible high-quality code trivially available to developers, including high quality documentation
Implications
»Any legitimate healthcare participant with a need to push health information should be able to obtain the right products or services to send Direct messages.
»Direct available to participants by a variety of vendors and through a variety of mechanisms:
• Direct-enabled EHRs, LISs, HISs, PHRs
• Downloadable reference library • Web-based services• Email client plug-in
»Success metric for Direct: Ubiquitous penetration over the next year
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Current Status: Who has committed to implement Direct? (As of March 1, 2011)
» 40+ vendors have committed to roll-out Direct-enabled functionality, and ~20 states include Direct in their approved State HIE plans
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Exchange Infrastructure – Assumptions for Stage 2
• Wide-scale availability of directed exchange capabilities leveraging Direct (EHRs, lab systems, public health, HIE infrastructure)
• Rapid development of low-cost HISP options providers can use for directed exchange
• Identification of "qualified entities" who meet NwHIN governance privacy and interoperability requirements (to be defined)
• Openly available individual level provider directories at varying stages of implementation, do not cover the nation
• Pockets of exchange capacity supporting patient matching/query • Rapid growth of electronic lab exchange driven by (1) HIE program focus (2)
Reduced cost and complexity through increased standardization of content, vocabulary and transport. Small labs, critical access hospitals and small/rural providers least likely to participate
• Capability of public health infrastructure to receive data electronically varies
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HITECH Timeline (subject to change)
Apr-11 Dec-11
J ul-11 Oct-11
April 13, 2011
Health Information Technology Policy Committee (HITPC) meeting– MU WG reviews public comments on Stage 2 proposal
April 5, 2011Meaningful Use Workgroup (MU WG) reviews public comments
May 11, 2011HITPC Meeting – MU WG presents draft Stage 2recommendations to HITPC
June 2011HITPC Meeting – finalize Stage 2 recommendations to ONC
Dec-11HHS issues NPRM for Stage 2, opens 60-day public comment period
End of 2011
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HITECH Timeline (subject to change)
J an-12 J ul-14
Apr-12 J ul-12 Oct-12 J an-13 Apr-13 J ul-13 Oct-13 J an-14 Apr-14
May-13 - Jun-13Beacon Program ends
January 1, 2013Meaningful Use Stage 2
effective for Eligible Providers (current plan)
May-14 - Jun-14State HIE Cooperative Agreement Program
and Regional Extension Center Program end
October 1, 2012Meaningful Use Stage 2
effective for Eligible Hospitals/CAHs (current plan)
Jul-12 - Sep-12HHS publishes
final rule onStage 2
Feb - MarPublic comment period
closes on NPRM
/Summer 2012
Spring 2013
Spring 2014
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Priority Exchange-Related Objectives
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Key Questions to Consider for MU Objectives
• We will review exchange-related MU objectives, considering the following:– What exchange infrastructure is required to support the
objective? – Does the required infrastructure currently exist or will it be
available for Stage 2? (is the ecosystem ready)– Is this the right objective?– Is it the right level of stringency? (too challenging or not
rigorous enough)– Any objectives that should be added?
• In exceptional cases we can consider suggesting removal of an objective
MU Stage Two Objectives We Will Discuss Today
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Stage 1 Objectives Stage 1: Core or Menu
Stage 2Proposed Moving to Core
Stage 2 Proposed Increasing Threshold
E-prescribing (eRx) (EP) (40%) Core X
Report CQM electronically Core
Maintain active med list (80%) Core
Incorporate lab results as structured data (40%) Menu X
Provide electronic copy of discharge instructions (EH) at discharge (50%)
Core X
Perform test of HIE Core X
Perform medication reconciliation (50%) Menu X
Provide summary of care record (50%) Menu X
Submit immunization data Menu
Submit reportable lab data Menu X (EH) (add as menu for EP)
Submit syndromic surveillance data Menu X
Objectives that were in Stage One MU
MU Stage Two Objectives We Will Discuss Today (cont)
• List of care team members (including PCP) available for 10% of patients in EHR
• Record a longitudinal care plan for 20% of patients with high-priority health conditions
• Public Health Button for EH and EP: Mandatory test and submit if accepted. Submit notifiable conditions using a reportable public-health submission button. EHR can receive and present public health alerts or follow up requests.
• (EH) 80% of patients offered the ability to view and download via a web-based portal within 36 hours of discharge, relevant information contained in the record about EH
• EHRs have capability to exchange data with PHRs using standards-based health data exchange
• Offer capability to upload and incorporate patient-generated data (e.g., electronically collected patient survey data, biometric home monitoring data, patient suggestions of corrections to errors in the record) into EHRs and clinician workflow
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Proposed New Objectives
Incorporate Lab Results as Structured Data
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Incorporate lab results as structured data (40%)
Move current measure to core, but only where results are available
90% of lab results are stored as structured data in the EHR and are reconciled with structured lab orders, where results and structured orders available
Issues to consider– Ecosystem readiness – need to push to have this available widely!
• Readiness of small independent labs including critical access hospitals• Use of Direct/LOINC translation/value sets to ease implementation burden• HIE capacity
– Add sending lab results electronically and in structured form as a MU requirement for hospitals?
– How to define “where results are available”
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Provide Summary of Care Record
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Provide summary of care record (50%) Move to Core
Summary care record provided electronically for 80% of transitions and referrals
Issues to consider• Move requirement to share summary of care record electronically to Stage 2? (currently in stage 3)
• What enabling infrastructure is needed?‒ Will rely on (but does not require) provider directory and pockets of query based exchange‒ Availability of low-cost and easy-to-implement Direct options that can support small providers in
sharing care summaries
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E-prescribing
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
E-prescribing (EP) (40%)
50% of orders (outpatient and hospital discharge) transmitted as eRx if fits patient preference
90% of orders (outpatient and hospital discharge) transmitted as eRx if fits patient preference
If receiving pharmacy cannot accept eRx, automatically generating electronic fax to pharmacy OK
Current status:
• 26% of all office based physicians e-prescribe*• Approximately 18 percent of eligible prescriptions were prescribed electronically at the end of 2009*
Issues to consider•Should exemption for controlled substances continue?•Should two- factor authentication be included in certification?•Readiness of hospital e-prescribing?•What barriers need to be removed, other than pharmacy participation?
*Surescripts 2009 NATIONAL PROGRESS REPORT ON E-PRESCRIBING
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Perform Test of HIE
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Perform test of HIE
Connect to at least three external provider in “primary referral network” or establish an ongoing bidirectional connection to at least one health information exchange
Connect to at least 30% of external providers in “primary referral network” or establish an ongoing bidirectional connection to at least one health information exchange
Successful HIE will require development and use of infrastructure like entity-level provider directories (ELPD)
Issues to consider
• With HIE requirements built into other objectives (care coordination, public health) is a generic objective for HIE necessary?
• How should bi-directional be defined?
• What data needs to be exchanged?
• Later in the day we will discuss how health information exchange (qualified entity) should be defined
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Medication list and medication reconciliation
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Maintain active med list (80%) Continue Stage 1
80% medication lists are up-to-date
Expect to drive list to be up-to-date via medication reconciliation
Perform medication reconciliation (50%)
Medication reconciliation conducted at 80% of transitions by receiving provider (transitions from another setting of care, or from another provider of care, or the provider believes it is relevant)
Medication reconciliation conducted at 90% of transitions by receiving provider
Issues to consider• In stage one medication reconciliation described as human/manual process. Is
that still the state of world? • Require accessing/using fill history?
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List of care team members
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
(NEW)
List of care team members (including PCP) available for 10% of patients in EHR
List of care team members (including the PCP) available for 50% of patients via electronic exchange
Issues to consider
• Potential to use health information exchange (qualified entity) to achieve this objective, directly or enabled by core services
‒ For instance could use eMPI and claims data to map relationships between patients and providers
‒ What would be policies and issues in exposing this information to providers?
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Record a longitudinal care plan
Issues to consider
Should aim be a shared care plan? Doable for stage 3?• What information exchange models/platforms can support this objective?• How to handle versioning and “stewardship” of data as it’s shared?• How to address patient matching?
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
(NEW)
Record a longitudinal care plan for 20% of patients with high-priority health conditions
Longitudinal care plan available for electronic exchange for 50% of patients with high-priority health conditions
What elements should be included in a longitudinal care plan including: care team members; diagnoses; medications; allergies; goals of care; other elements?
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Patients can view and download information
Issues to consider• Could this objective be satisfied with “blue button” functionality or option to
routinely publish and subscribe patient information to PHR?
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
(NEW for EH)
80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human-readable and structured forms (HITSC to define).
80% of patients offered the ability to view and download via a web-based portal, within 36 hours of discharge, relevant information contained in the record about EH inpatient encounters. Data are available in human readable and structured forms (HITSC to define).
Inpatient summaries include: hospitalization admit and discharge date and location; reason for hospitalization; providers; problem list; medication lists; medication allergies; procedures; immunizations; vital signs at discharge; diagnostic test results (when available); discharge instructions; care transitions summary and plan; discharge summary (when available); gender, race, ethnicity, date of birth; preferred language; advance directives; smoking status. [we invite comments on the elements listed above]
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Electronic copy of discharge instructions to patients
Issues to consider– Potential to use health information exchange capabilities (qualified entity) to
provide electronic copy of discharge instructions
– Ideal Direct use case – send patient discharge instructions to Direct address
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Provide electronic copy of discharge instructions (EH) at discharge (50%)
Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 80% of patients (patients may elect to receive only a printed copy of the instructions)
Electronic discharge instructions for hospitals (which are given as the patient is leaving the hospital) are offered to at least 90% of patients in the common primary languages (patients may elect to receive only a printed copy of the instructions)
Electronic discharge instructions should include a statement of the patient’s condition, discharge medications, activities and diet, follow-up appointments, pending tests that require follow up, referrals, scheduled tests [we invite comments on the elements listed above]
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EHRs can exchange data with PHRs, incorporate patient-generated data
Issues to consider• Patient ID resolution and authentication• Publish and subscribe options to patients’ personal health tools/PHR• Use of Blue Button/Direct?• Need to define standards, transport, interfaces with patient devices
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
EHRs have capability to exchange data with PHRs using standards-based health data exchange
We are seeking comment on what steps will be needed in stage 2 to achieve this proposed stage 3 objective
Offer capability to upload and incorporate patient-generated data (e.g., electronically collected patient survey data, biometric home monitoring data, patient suggestions of corrections to errors in the record) into EHRs and clinician workflow
We are seeking comment on what steps will be needed in stage 2 to achieve this proposed stage 3 objective
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Immunization data reporting
Issues to consider• Standards/mechanisms for reporting are more established and in use compared to
other public health objectives• Public health is most prepared for this objectives, compared to others• What needs to happen now to support bi-directional IIS use in stage 3?
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Submit immunization data
EH and EP: Mandatory test. Some immunizations are submitted on an ongoing basis to Immunization Information System (IIS), if accepted
and as required by law
EH and EP: Mandatory test. Immunizations are submitted to IIS, if accepted and as required by law. During well child/adult visits, providers review IIS records via their EHR.
Stage 2 implies at least some data is submitted to IIS. EH and EP may choose not, for example, to send data through IIS to different states in Stage 2. The goal is to eventually review IIS-generated recommendations
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Syndromic surveillance reporting
Issues to consider• Not anticipated be to a huge implementation challenge for hospital reporting, but
standards/guidelines only recently established from ISDS • No standards yet in place for ambulatory setting
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 Comments
Submit syndromic surveillance data Move to core.
Mandatory test; submit if accepted
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Public health button
Aimed at reporting data from EHRs in addition to and in support of reportable lab results
Issues to consider, steps needed• What interfaces are needed?• Content (clinical data required varies by condition) – need standards and mechanisms for
extracting from EHR
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3 CommentsPublic Health Button for EH and EP: Mandatory test and submit if accepted. Submit notifiable conditions using a reportable public-health submission button. EHR can receive and present public health alerts or follow up requests.
We are seeking comment on what steps will be needed in stage 2 to achieve this proposed stage 3 objective
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Communicable disease reporting (ELR)
Issues to consider• No current capacity for EPs to report. Information for EP is being reported by
labs.• A few states can currently accept 2.5.1 messages (standard in stage one)
Meaningful Use: Stage 1 Final Rule (italics optional Stage 1) and Proposed Objectives for Stages 2 and 3
Stage 1 Final Rule Proposed Stage 2 Proposed Stage 3
Submit reportable lab data
EH: move Stage 1 to core
EP: lab reporting menu. For EPs, ensure that reportable lab results and conditions are submitted to public health agencies either directly or through their performing labs (if accepted and as required by law).
Mandatory test.
EH: Include complete contact information (e.g., patient address, phone and municipality) in 30% (EH) of reports. : submit reportable lab results and reportable conditions if accepted and as required by law.
EP: ensure that reportable lab results and reportable conditions are submitted to public health agencies either directly or through performing labs (if accepted and as required by law)
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Quality Measures
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Key Considerations for Quality Measures
• In Stage 2 need to ensure we don’t sub-optimize the approach when considering end goal
• To achieve community or person-based quality measurement we will need:– Computable data to support quality measurement– Data availability at the point of measurement– To prevent data silos from forming (e.g., policy requirements
on ACOs)– To be able to link patients’ data across sites of care
Additional Issues
• Health information exchange qualified entity concept
• Any additional objectives to propose
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Qualified Entity
• The objective to perform test of HIE discusses participating in at least one health information exchange (qualified entity) as one way to achieve the objective
• This idea could be linked to “qualified entities” concept under
NwHIN governance– Must meet conditions of trust and interoperability
• So, potential that participating in a qualified entity recognized by NwHIN could be used by providers to demonstrate a range of information-exchange related MU requirements
Several MU Objectives Could Potentially be Achieved Through a Qualified Entity
• Test of HIE
• Public health reporting
• Lab results
• Medication and fill history
• Sharing care summary
• Secure messaging
• Exchange data with PHRs
• Record advance directives
• Electronic copy of discharge instructions
• Quality reporting
• Upload patient-generated data
• Patients view and download data
• Longitudinal care plan
• List of care team members
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Qualified Entity – Issues to Consider
• Is this a good idea?• Scope that should be covered?• How should “participating” be defined?• A number of states have already or are considering establishing
requirements for qualified entities (Minnesota, New York etc).
• Should these state based definitions be accepted under Meaningful Use?
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Potential Additional Objectives
• Are there additional exchange-related objectives that we should consider?
– EH: Require hospital labs to electronically share lab results with providers?
• Would provide a big push to lab exchange and support providers in achieving MU
– EP: Require EPs to check medication fill history information?
– Others?
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Short Term Next Steps
• At March 24th IE WG meeting finalize comments on Stage 2 MU Objective for April 5th MU WG hearing.
• April 8th review revised ILPD recommendations and finalize Workgroup agenda moving forward.
Date Topic
March 15 • IE WG in-person meeting to discuss Stage 2 comments
March 28 • Finalize comments on Stage 2
April 5 • MU WG meeting to review public comments on Stage 2 recommendations
April 8 • Discuss and approval revised ILPD recommendations and discuss Workgroup agenda
April 13 • Present revised ILPD recommendation to HIT Policy Committee
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Longer Term Next Steps
• Outline what is needed to assure success of stage one and stage two meaningful use from an information exchange infrastructure and ecosystem standpoint
– Current status/achievement
– Issues and challenges: business, policy, regulatory, technology
– Most promising/high yield solutions, levers including:• Policy levers• Meaningful Use levers• Standards levers• State HIE Program levers
• Proposed workplan:– Lab interoperability: April
– Public health: May
– E-prescribing: June
– Transitions in care: July
– Quality reporting: August
– Consumer engagement: September
– HIE and HIX: October