Form SSA-680 Health IT Partner Assessment

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Overview

Partnering Process - Overview
1- Introductory Questions
2 - Clinical Documents
3 - Continuity of Care Document

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Sheet 1: Partnering Process - Overview

Social Security Administration Health IT Partner Assessment – Participating Facilities and Available Content Form					OMB No. 0960-XXXX, Approved 00/0000
Overview
Thank you for your interest in partnering with the Social Security Administration (SSA). Since 2008, we have been working to enable the electronic exchange of health information. We can improve the speed and consistency of disability determinations with the use of health information technology (health IT). Health IT enables us to reduce the amount of time we need to make a disability determination by allowing us to electronically request and receive health records. With health IT, we are able to receive health records within minutes or hours as compared to weeks or months in the traditional process. Health IT also allows us to analyze the data in health records electronically. We currently are exchanging health information electronically with several organizations and are working to bring on additional organizations moving forward.
1.0 Value Proposition
These Health IT innovations will improve service to the public, streamline processes, assist our state Disability Determination Services partners, and reduce our burden on the health care industry. As a partner in Social Security's health IT initiative, you can expect to attain benefits on the basis of several key value drivers. Below are some of the potential benefits of collaborating with Social Security.
Potential Benefits to Partners: • Reduced administrative costs and labor time for locating, printing, copying, and mailing paper records • Reduced uncompensated care as faster disability determinations give patients faster access to Medicare and Medicaid benefits • Automated payment from Social Security • Increased revenue by having the ability to respond to a higher number of Social Security requests for records • Improved patient satisfaction				Potential Benefits to the Public: • Faster and more consistent disability decisions • Quicker access to monthly cash benefits and financial peace-of-mind • Earlier access to medical insurance coverage • Fewer consultative examinations • Decreased burden to secure and provide medical records • Earlier access to other social service benefits
2.0 Process Overview
Before deciding to move forward with a health IT partnership, Social Security needs to understand whether your organization can electronically provide the substantive medical information that enables us to make disability determinations. The first step in this process is to tell us about your organization and its characteristics. Upon completing the Introductory Questions and Content Checklist contained within the following tabs, you should expect contact from SSA's New Partner Committee to review your responses and answer any questions you might have. Once the responses are reviewed, validated, and completed, Social Security will conduct careful analysis to determine if your organization is ready to begin a health IT partnership with SSA.
High-level Evaluation Process:				Overall Engagement Process:
1.1 Potential partner organization completes partner assessment form				2.1 Develop and review project plan
1.2 SSA New Partner Committee meets for initial review of evaluation templates				2.2 Demonstrate Clinical Document Architecture (CDA) capabilities and verify medical content
1.3 Committee meets with potential partner for initial review and follow-up questions				2.3 Analyze participating facility lists
1.4 Potential partner completes revisions and submits final form				2.4 Conduct interoperability testing (connectivity and end to end tests)
1.5 Committee assesses completed responses to determine readiness for potential partners				2.5 Complete production implementation
1.6 Committee decides on whether to proceed with partnership
1.7 Committee communicates results and next steps to partner organization
3.0 Document Overview
As mentioned in the Process Overview, we require completed responses to the Introductory Questions and Content Checklist templates found in this document. Each section contains a high level overview and detailed definitions. 1. The Introductory Questions a. are contained within a single tab b. contain definitions that help to clarify terminology across the entire workbook c. pose questions related to general characteristics, composition, and high-level technical capabilities related to your organization's health IT readiness 2. The Content Checklists a. are spread across two tabs: 2 - Clinical Documents and 3 - Continuity of Care Document b. is designed to provide a basic understanding of your organization’s available EHR content. We intend to evaluate your completed Content Checklist in terms of both potential accessibility of health information and the content value of your EHR for our disability determination process. Questions pertaining to each section will be addressed by the New Partner Committee as they arise. We suggest that you complete this template with an internal team that consists of representatives within your organization that span functional areas including project management, application development, and clinical health informatics.
4.0 Conclusion
Please note that your submission of this document will go through several rounds of review, and any questions that arise during the process of completing this document will be addressed by a representative from the New Partner Committee. Questions and completed documents should be submitted to ssa.hit.information@ssa.gov. Again, thank you for your interest in partnering with Social Security. We look forward to hearing from you soon.

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Sheet 2: 1- Introductory Questions

Social Security Administration Health IT Partner Assessment – Participating Facilities and Available Content Form

1.0 INTRODUCTION

The Social Security Administration (SSA) has implemented a health information technology (health IT) process with several large healthcare providers. With this health IT process, we have successfully demonstrated that we can electronically exchange health information with providers in a production setting. As the first step in determining your readiness to partner with SSA, please complete the general overview questions beginning with section 1.2 Identifying Your Entity as well as the Clinical and Continuity of Care Document Questionnaires found in tabs 2.0 and 3.0.

1.1 DEFINITIONS

1.1.1 Health Information Exchange (HIE) / Facility Identification: Any healthcare entity that will partner with SSA must provide a list of all participating facilities/provider groups within the partnering HIE. When your patient applies for disability, this information is used to determine which of the patient’s treating facilities reside within your HIE.

1.1.2 Electronic Health Record (EHR) System: The EHR is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR has the ability to generate a record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.

1.1.3 Beacon Communities: The Beacon Community Cooperative Agreement Program through the Office of the National Coordinator will provide funding to communities to build and strengthen their health IT infrastructure and exchange capabilities to demonstrate the vision of the future where hospitals, clinicians and patients are meaningful users of health IT, and together the community achieves measurable improvements in health care quality, safety, efficiency, and population health.

1.1.4 Virtual Lifetime Electronic Record (VLER): VLER is an initiative of the Department of Defense (DoD) and the Department of Veterans Affairs (VA) to create a unified lifetime electronic health record for Armed Services members. As a common access point for all patient records, VLER contains administrative, medical, and health benefits information throughout the life of a Service member, eliminating the need to bring paper copies of medical records from one medical facility to the next.

1.1.5 Disability Determination Services (DDS): Disability Determination Services are state agencies that review disability claims for the Social Security Administration.

1.1.6 Narrative Data in a Continuity of Care Document (CCD): A document or data in the narrative block of a CCD section regardless of whether information is also conveyed in CDA entries.

1.1.7 Coded Data in a CCD: Documents or data which are fully encoded into CDA header or entries.

1.1.8 Structured Standards Based Documents: A stand alone document that contains discrete data elements. A structured standards based document shall have narrative text and discretely coded data. Examples include documents such as Procedure Note, History and Physical, Discharge Summary, Continuity of Care Record, etc.

1.1.9 Unstructured Documents: A stand alone document that does not contain discrete data elements. Examples include natively formatted documents such as TIF, PDF, TXT, JPG, etc. Unstructured documents may also be encapsulated in a CDA wrapper (HITSP/C62 and HL7 Unstructured Docs). (CDA Definition: http://www.hl7.org/implement/standards/cda.cfm)

1.2 IDENTIFYING YOUR ENTITY

Organization or Group Name: _________________________________________________

Website URL: _________________________________________________

The following section allows you to identify the type of entity that best describes your organization. Please only select one type.

Entity Types

Health Information Exchange (HIE): Including Regional Health Information Organizations

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Hospital: Including hospitals, medical groups and/or networks

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Physician Group:

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Integrated Physician Network:

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Other: Please specify

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The following section allows you to identify the characteristics that best describe your organization. Select all that apply.

Entity Composition

Composition

Comments

Multi-Disciplinary Hospital

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Ambulatory Center

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Integrated Network

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Physician Group

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Rehabilitation Hospital

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Cancer Center

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Dialysis Center

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Children's Hospital

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Behavioral Health Facility

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Community Health Center

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ER Clinic

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Hospital Specialty Other

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Other: Please Specify

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If your organization contains separate organizations, facilities and/or provider groups, please provide a list of the primary organizations that account for the majority of volume for Medical Evidence of Record (MER) requests.

Participating Organizations, Providers and Facilities

Name

City

State

Physician / Organization Count

EHR Vendor(s) / Application

Estimated Annual SSA Requests

Questions

Comments

Describe your current electronic data exchange capabilities.

Describe your strategic plan / roadmap for interoperability.

Do you have an agreement to exchange medical data across the Nationwide Health Information Network with other Federal agencies? If so, please specify agency and program. (such as VLER, C-HIEP, ONC, State HIE, Beacon)

List all structured documents that can be interoperably transmitted to or with SSA. (e.g. HITSP C32, HL7 Operative Notes)

Is there anything else about your organization that SSA should understand when considering you as a future partner (e.g. special patient population characteristics, provider type uniqueness, experience in electronic health records, strategic goals).

1.3 PREPARED BY:

Primary Contact (if different from Preparer)

Title: _________________________________________________

Title: ______________________________________

Name: _____________________________________

Name: _____________________________________

Address: ___________________________________

Address: ___________________________________

City: _________________________

State: ___________

Zip: __________

City: _________________________

State: ___________

Zip: __________

Phone Number(s): __________________________________________

Phone Number(s): __________________________________________

E-mail: __________________________________________

E-mail: __________________________________________

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Sheet 3: 2 - Clinical Documents

Social Security Administration Health IT Partner Assessment – Participating Facilities and Available Content Form

2.0 Identifying Available Clinical Documents

The following section allows you to identify the types and formats of clinical documents that are currently generated within your organization. Please check all that apply.

For each report type, fill in the table according to the following instructions

CDA-Templated Document Type column

Please indicate in the CDA-Templated Document Type column any additional formats that your organization supports for a specific clinical document.

CDA-Templated Document: Narrative / Coded Data columns

Enter a 'Y' in either or both of the Narrative or Coded Data columns to indicate whether your organization generates documents that contain Narrative and/or Coded Data clinical content according to CDA specifications.

HITSP/C62, HL7 Unstruc Doc, TXT, PDF, DOC, RTF, TIF, JPG, PNG, GIF columns

Enter a 'Y' in each column where your organization generates a clinical document in the indicated format. Use the Other column to indicate formats that are not listed in the table.

* If you have indicated that you have a Summary of Care report in the CDA-Templated Document format column and indicate 'Y' in either or both the Narrative / Coded Data columns, please fill out the information in section 3 (worksheet 3 - Continuity of Care Document).

Report Type

CDA-Templated Document

HITSP/C62 HL7 Unstruc Doc

TXT

PDF

DOC

RTF

TIF

JPG

PNG

GIF

Other

Comments

Format

Narrative

Coded Data

Summary of Care*

HITSP/C32

Discharge Summary

Consultation

HITSP/C48, HITSP/C84

History & Physical

HITSP/C84

Lab

HITSP/C37

Pathology

Operative Notes

HITSP/C166

Doctor to Doctor

Inpatient Progess Notes

Outpatient Progress Notes

Emergency Room Notes

HITSP/C28

Procedure Notes

Audiometry/Audiology

Audiograms

Psychology Reports

Mental Status Evaluation

Neuropsychological Testing

Psychological Testing

Cardiac Reports

Angiogram

Cardiac Catheterization

Doppler Test

Electrocardiograph, electrocardiogram (EKG/ECG) result/interpretation

EKG/ECG Tracing Image

Echocardiogram result/interpretation

Stress Testing (exercise, pharma)

Holter monitor

Neurology

Electroencephalogram (EEG)

Electromyogram/nerve conduction (EMG)

Myelogram

Ophthalmology/Optometry

Visual Acuity

Visual Fields

Radiology (Interpretations Only; No Images)

CT

MRI

PET

X-Ray

Respiratory

DLCO Study

Pulmonary Function Study

Spirometry Test result/interpretation

Spirometry Tracing Image

Surgical Diagnostics

Bone Marrow (Biopsy/Aspiration)

Colonoscopy

Endoscopy

Additional Procedures

Ultrasound (exclude Doppler)

Genetic Testing

Physical Exam

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Sheet 4: 3 - Continuity of Care Document

Social Security Administration Health IT Partner Assessment – Participating Facilities and Available Content Form
3.0 Identifying Continuity of Care Document capability
Please fill out this worksheet if you have indicated that your organization has a Summary of Care report in the CDA-Templated Document format column and indicated 'Y' in either or both the Narrative / Coded Data columns in worksheet 2 - Clinical Documents.
For each row in sections 3.1 through 3.11, please indicate the availability and the format of the specific information in your EHR. - "Y" in any applicable columns if your organization has the information in the specific format; or - If your organization does not have information available, please indicate with a "Y" in the "Not Available" column. NOTE: Check all that apply. NOTE: Do not enter any information in cells shaded gray. Please see the Introductory Questions worksheet for definitions of Narrative and Coded Data. If a row is left blank, then we will assume that information is not available in an electronic format.
The following data elements are of particular value to the Social Security Administration for use in the disability determination process. Providing all or some of these elements may not guarantee conformance to any specific HIT content standard. It is the provider's responsibility to provide these data elements in the context of and in conformance with a recognized HIT content standard.
3.1 ENTITY IDENTIFICATION
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
HIE Name (if applicable)
Facility Name
OID (Object Identifier)
Street Address
City
State
Zip
Assigned Provider ID
Name of Affiliated Sites
3.2 PROBLEMS: All relevant clinical problems at the time the summary is generated.
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Condition Name
Diagnosis Code
Provider Name
Date - Start
Date - End
3.3 MEDICATION: A patient’s current medications and pertinent medication history.
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Product Name
Product Code
Dosage Details
Reason
Status, e.g., active, filled
Date - Start
Date - End
3.4 ENCOUNTERS: Any healthcare encounters pertinent to the patient’s current health status or historical health history. An encounter can be any documented hospitalization (acute, rehab, nursing facility, or long-term care), office or clinic visit, emergency room visit, home health visit, or any treatment or therapy (physical, occupational, respiratory, or other), or any interaction, even remote (non face-to-face), between the patient and the healthcare system or a healthcare provider.
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Date - Start
Date - End
Encounter Provider
Type/Activity
Facility Location
3.5 NOTES
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Admission Summaries/H&P
Emergency Room (ER)
Discharge Summaries
Consults (Inpatient and/or Outpatient)
Doc-to-Doc Letters
Neonatal
Operative Report
Outpatient
Office Notes
Clinic Notes
Mental/Behavioral Health Notes
Progress Notes
Physical/Occupational Therapy Notes
Other, e.g. telephone notes, medicaiotn notes
3.6 PROCEDURES: All interventional, surgical, diagnostic, or therapeutic procedures or treatments pertinent to the patient historically at the time the document is generated.
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Facility Location
Procedure Code
Treating Provider
Date
Procedure Type
Audiometry/audiology
--Audiograms
Cardiac
--Angiogram
--Cardiac Catheterization
--Doppler Test
--Electrocardiograph, electrocardiogram (ECG)
--Tracing image
--Echocardiogram
--Stress Testing (exercise, pharma)
--Holter monitor
Electroencephalogram (EEG)
Electromyogram/nerve conduction
Genetic Testing
Ophthalmology/Optometry
--Visual acuity
--Visual fields
Psychology Reports
--Mental Status Evaluation
--Neuropsychological Testing
--Psychological Testing
Radiology (Interpretations Only; No Images)
--CT
--MRI
--PET
--X-Ray
Myelogram
Respiratory
--DLCO Study
--Pulmonary Function Study
--Spirometry Test
--Tracing Image
Surgical Diagnostics
--Bone Marrow (Biopsy/Aspiration)
--Colonoscopy
--Endoscopy
Ultrasound (exclude Doppler)
3.7 PHYSICAL EXAMS
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Ambulation/balance
Apgar Score
--Color 10M Post Birth
--Heart Rate 10M Post Birth
--Muscle Tone 10M Post Birth
Burns
Edema/Inflammation/Swelling/ Tenderness
Growth Chart
Motor Function
Muscle Atrophy
Muscle Weakness/Strength
Range of Motion
Sensory Loss
Skin Lesions (Extent)
Speech
Weight Bearing Status
3.8 FUNCTIONAL STATUS
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Activities of Daily Living (ADL)
Minimum Data Set
Social Functioning (Capacity to interact independently, appropriately, effectively, and on a sustained basis with other individuals).
3.9 TREATMENT
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Antineoplastic Therapy
Blood Transfusions
Dialysis
3.10 LABS
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Lab Results
Pathology Reports
3.11 Support/Contact Information: individual(s) providing assistance, consult, counsel to patient
Electronic Content	CCD Delivery Method		Not Available	Comments
	Narrative	Coded Data
Support/Contact Name
Address
Phone Number
Relationship, e.g., sister
3.12 TERMINOLOGY
Terminology	Available	Not Available
LOINC
ICD 9-CM
ICD 10-PCS
ICD 10-CM
SNOMED CT
CPT4
International Classification of Function (ICF)
Other (Please Specify)
3.14 PREPARED BY:
Title: _________________________________________________
Name: _____________________________________
Address: ___________________________________
City: _________________________		State: ___________		Zip: __________
Phone Number(s): __________________________________________