SUMMARY OF KEY PROVISIONS OF ONC S NATIONWIDE INTEROPERABILITY ROADMAP VERSION 1.0

Transcription

1 SUMMARY OF KEY PROVISIONS OF ONC S NATIONWIDE INTEROPERABILITY ROADMAP VERSION 1.0 Cnnecting Health and Care fr the Natin: A Shared Natinwide Interperability Radmap Draft Versin 1.0 was released n January 30, 2015 by the Office f the Natinal Crdinatr fr Health IT (ONC). The Radmap is intended t identify critical actins that shuld be taken by key stakehlders t help advance interperability. Its key prvisins are summarized belw and in the pages that fllw. FUNDAMENTAL BUILDING BLOCKS OF THE ROADMAP The Radmap, as currently envisined, is based n a set f business and functinal requirements t achieve a learning health system. These requirements are rganized by five fundamental building blcks that supprt the business, plicies and technical needs f an interperable, natinwide infrastructure. ONC views these building blcks t be interdependent and that prgress must be incremental acrss all f them ver the next ten years. The crucial building blcks include A. Rules f engagement and gvernance B. Supprtive business, clinical, cultural and regulatry envirnments C. Privacy and security prtectins fr health infrmatin D. Certificatin and testing t supprt adptin and ptimizatin f health IT prducts and services E. Cre technical standards and functins A mre detailed descriptin f these building blcks fllws. RULES OF ENGAGEMENT AND GOVERNANCE A crucial cmpnent f interperability is a cmmn set f standards, services, plicies and practices that help facilitate natinwide electrnic health infrmatin exchange. The Radmap suggests that gvernance can nt nly help identify cmmn plicies, business practices and standards t enable interperability, but it can als help establish trust amng electrnic trading partners. Fr gvernance t be effective, the Radmap suggests that three key areas must be addressed plicy, peratins and technical standards. Belw is a detailed descriptin f these cre principles. POLICY Access t Persnal Health Infrmatin: Data hlders and entities facilitating interperability f health infrmatin shall, in accrdance with applicable law and individual preferences, exchange infrmatin, including with the individual t supprt patient care, care crdinatin and ther permitted purpses. Specifically N plicy, business, peratinal, r technical barriers that are nt required by law shuld be built t prevent infrmatin frm apprpriately flwing acrss gegraphic, health IT develper and rganizatinal bundaries in supprt f patient care. Where individuals clearly instruct a data hlder t release infrmatin abut them t thers, the data hlder shuld cmply with that directive. Data hlders and entities that facilitate interperability shuld nt cmpete n the availability f patient health data. Prmte cllabratin and avid instances where (even when permitted by law) differences in fees, plicies, services, peratins r cntracts wuld prevent individuals persnal health infrmatin frm being electrnically exchanged. Page 1 f 9

2 Respect Plicies f Other Exchange Partners: Data hlders and entities facilitating interperability f electrnic health infrmatin shuld nt establish plicies r practices in excess f law that limit the availability f electrnic health infrmatin by anther entity that is in cmpliance with applicable laws and these gvernance principles. Individual Chice: Data hlders and entities facilitating interperability f health infrmatin shuld grant individuals, cnsistent with existing law, the ability t exercise chice ver what persnal health infrmatin these rganizatins cllect frm them and hw the rganizatins use it and share it. An individual shall nt be denied access t health care services based n whether they have dcumented their chice regarding electrnic health infrmatin exchange. Individuals retain the right t nt disclse their infrmatin in the first instance. Data hlders and entities that facilitate the interperability f health IT shuld prvide clear and simple chices regarding what restrictins an individual can and cannt place n the cllectin, sharing, r use f that individual s health infrmatin. These chices shuld be presented at times and in ways that enable individuals t make meaningful decisins abut persnal health infrmatin cllectin, use and disclsure. These chices shuld be presented at an apprpriate level fr the literacy and language preference f the individual. Data hlders and entities that facilitate the interperability f electrnic health IT shuld enable these chices by prviding individuals with easily usable and accessible electrnic prcesses that reflect the scale, scpe and legal sensitivity f the persnal health infrmatin that data hlders cllect, use, r disclse as well as the legal sensitivity f the uses they make f the infrmatin. Transparency: Data hlders and entities facilitating electrnic exchange f health infrmatin shuld prvide easily understandable and accessible infrmatin abut the rganizatin s data practices. Specific examples include, but are nt limited t: Data hlders and entities shuld prvide clear descriptins f what persnal health infrmatin they cllect, why they need the data, hw they will use it, when they will delete it r de-identify it and whether and fr what purpses they may share such data. Data hlders and entities shuld prvide clear descriptins f decisin tls that may be used t match individual identifying infrmatin, share individually identifiable infrmatin, r withhld individual identifying infrmatin sharing. Data hlders and entities shuld prvide clear infrmatin t health infrmatin trading partners abut technical errr rates (e.g., fr imprper individual matching) and ther infrmatin abut infrmatin interperability that may have diverged frm expected practices. Security: Data hlders and entities facilitating interperability f health infrmatin shuld secure and ensure respnsible handling f persnal health infrmatin in line with ther examples f critical infrastructure. Specific examples include but are nt limited t: Data hlders and entities shuld maintain reasnable safeguards t cntrl risk, such as lss, unauthrized access, use, destructin, r mdificatin and imprper disclsure. Data hlders and entities shuld ensure that an individuals' persnal health infrmatin is cnsistently and accurately matched when electrnically exchanged. Data hlders and entities shuld take reasnable steps t ensure that persnal health infrmatin is cmplete, accurate and up-t-date t the extent necessary fr the intended purpse and has nt been altered r destryed in an unauthrized manner. Individual Access and Crrectin: Data hlders and entities facilitating exchange f health infrmatin shuld prvide individuals, cnsistent with applicable laws, a means t exchange and btain electrnic access t persnal health infrmatin and the ability t crrect such infrmatin in a timely manner Page 2 f 9

3 OPERATIONS that is apprpriate t the sensitivity f the data and the risk f adverse cnsequences t the individual if the data is inaccurate. Transparency: Entities facilitating interperability f health IT shuld perate with transparency and penness, including making publicly available infrmatin describing their electrnic exchange capacity and services. Inclusive Gvernance: Entities facilitating interperability f health IT shuld prmte inclusive participatin and adequate stakehlder representatin (especially amng individuals and patient advcates) in the develpment f data plicies and peratins plicies. Open Exchange: There shuld be neutrality in the exchange f persnal health infrmatin. An entity engaged in the exchange f electrnic health infrmatin shall treat all persnal health infrmatin exchange requests, services and effrts in rughly the same way and nt erect barriers t the authrized flw f infrmatin. Prvide pen access t exchange services, such as access t an rganizatin's prvider directry that wuld enable lcal, reginal and/r natinwide rganizatins and individuals t identify with whm they can electrnically exchange infrmatin and hw such exchange wuld have t be cmpleted, pursuant t applicable laws and regulatins. STANDARDS Data hlders and entities facilitating exchange f electrnic health infrmatin shuld ensure standards are priritized, develped and implemented t supprt the public interest, natinal pririties and the rights f individuals (e.g., health care delivery, privacy). Where available and apprpriate fr the desired exchange f health infrmatin federal vcabulary, cntent, transprt and security standards and assciated implementatin specificatins are used. Standards shuld supprt data prtability frm ne health IT prduct t anther. The develpment and implementatin f technical requirements shuld enable the adaptatin and incremental evlutin f health infrmatin exchange and technlgies supprting exchange t meet current and future needs f users as standards evlve. Standards develpment and adptin shuld nt unfairly prvide an advantage t ne sectr r ne rganizatin ver thers. SUPPORTIVE BUSINESS, CLINICAL, CULTURAL AND REGULATORY ENVIRONMENTS The Radmap states that fr in rder fr individuals and prviders t be able t send, receive, find and use critical health infrmatin acrss the care cntinuum, key stakehlders must advance plicy and funding levers t develp a business case and clinical demand fr interperability and electrnic health infrmatin exchange. FEDERAL GOVERNMENT HHS will pursue a natural lifecycle f plicies t drive interperability beginning with incentives, fllwed by payment adjustments and then cnditins f participatin in Medicare and Medicaid prgrams. In the next three years, HHS will lk t reinfrce interperability amng prviders participating in care crdinatin prgrams (like ACOs) thrugh measures f adptin f health IT amng prviders. DOD and OMB can prmte the use f measures f health IT adptin and interperability in a cnsistent fashin acrss cntracted payer rganizatins prvider netwrks. HHS can wrk with selected agencies t ensure funding streams fr capital investments fr health infrmatin systems including cnsistent requirements arund interperability standards. Page 3 f 9

4 STATES As part f managed care rganizatin requests fr prpsals (RFPs) and cntracts, states can require payers t ensure that prvider netwrks use interperable health IT r electrnically reprt data t supprt care crdinatin as a cnditin f participatin. States can als emphasize use f health IT and health infrmatin exchange as part f quality strategies fr managed care plans. Integratin f health infrmatin exchange and health IT int state Medicaid prgrams can be accmplished under demnstratin authrity at sectin 1115 f the Scial Security Act. States can als use the State Plan Amendment prcess t integrate health IT and health infrmatin exchange within their Medicaid state plans. Thrugh the Medicaid funding available under the HITECH Act, states can receive funding fr administrative activities related t cre health infrmatin exchange services (e.g., designing and develping a prvider directry, privacy and security applicatins and/r data warehuses), public health infrastructure, electrnic clinical quality measurement (ecqm) infrastructure and prvider nbarding. States can als use independent authrities in a variety f ways t drive interperability. PRIVATE PAYERS PURCHASERS Cmmercial payers have develped and deplyed a wide range f value-based payment prgrams within their prvider netwrks that ffer new pprtunities t fcus attentin n and generate demand fr interperability. Payers can make adptin f certified health IT systems r demnstratin f interperability a cnditin f participatin fr prviders that wish t take part in these prgrams. In markets with a mre advanced infrastructure fr health infrmatin exchange, such as an active health infrmatin rganizatin, payers culd cnsider partnering with a health infrmatin rganizatin and requiring participatin by prviders seeking t jin these prgrams. Payers culd als fcus n incentivizing cnsumers t chse prviders within their netwrks that have advanced IT-enabled capabilities arund care crdinatin. Cmmercial payers culd als explre adding health IT and interperability requirements t the factrs included as part f credentialing prcesses fr prviders in their netwrks. Alignment acrss payers arund value-based payment prgrams and reprting requirements can help prviders understand individuals ttal cst f care and reduce the administrative burden related t managing multiple value-based prgrams. Purchasers can selectively cntract with plans that demnstrate a cmmitment t the use f interperable health IT and health infrmatin exchange amng netwrk and nn-netwrk prviders. Purchasers can cmmit t spnsring benefit plans that encurage emplyees t chse prviders that are using interperable health IT and supprt individual access t electrnic health infrmatin. Purchasers, especially thse with a large ecnmic presence in a given market, can act as a pwerful frce t supprt state and cmmunity-based effrts t advance the use f interperable health IT by cllabrating with ther purchasers, prviders and cnsumers. INDIVIDUALS AS EMPOWERED, ACTIVE PARTNERS IN THEIR HEALTH & HEALTH CARE Greater fcus n incrprating patient-generated health data and ensuring the availability f tls fr individuals t use this infrmatin t manage their health and make mre infrmed health-related decisins. Page 4 f 9

5 Prviders, gvernment, payers and health IT develpers have a rle in supprting and empwering individuals t becme effective managers f their health and wellness where they live, wrk and play, using infrmatin and technlgy. CARE PROVIDERS PARTNERING WITH INDIVIUDALS TO DELIVER HIGH VALUE CARE Prviders shuld have the tls they need t supprt a cultural shift in the way they practice medicine and use technlgy that supprts the critical rle f infrmatin sharing. Expansin f data availability t include data frm a variety f relevant surces in the calculatin f electrnically specified clinical quality measures (ecqms) will be imprtant t guiding the transfrmatin f the delivery system t a learning health system. Clse integratin f CDS int health IT systems will enable the rapid disseminatin f new knwledge t supprt the use f best evidence in the care f all patients, including thse with multiple, cmplex r rare cnditins. Integratin and wide availability f this infrmatin will supprt distributed mdels f care management, cmprehensive medicatin management (CMM) and medicatin therapy management (MTM) acrss multiple healthcare disciplines and sites f care, such as cmmunity pharmacies. Cnsistent infrmatin n health care utcmes and transparency f health csts will: assist individuals in making care decisins; prviders in imprving care; and purchasers in mving frm paying fr vlume t paying fr value. This will require standards imprvements, plicy changes, crdinated gvernance and infrastructure investment. With the availability and apprpriate presentatin f hlistic, lngitudinal health infrmatin, accurate utcme measures, especially patient-reprted utcmes, will supprt innvatin f care mdels, allwing prviders t custmize wrkflws and supprt research. PRIVACY AND SECURITY PROTECTIONS FOR HEALTH INFORMATION The Radmap states that in rder fr effective participatin in and use f a learning health system, stakehlders must ensure that (1) a secure netwrk infrastructure is available, (2) an individual s privacy is prtected, (3) health infrmatin is nly accessed by thse whse identity has been verified and authenticated and (4) users nly have access t the infrmatin they are authrized t access. Belw is a detailed summary f each f these requirements. UBIQUITOUS, SECURE NETWORK INFRASTRUCTURE Cybersecurity & Encryptin: A learning health system s cybersecurity prgram includes but is nt limited t Cntracts, such as a Data Use Agreement, Memrandum f Understanding/Memrandum f Agreement (MOU/MOA), Intercnnectin Security Agreement (ISA), and Business Assciate Agreement (BAA). Cllectively, the bilateral dcuments and the individual rganizatin s plicy and cmpliance dcuments dcument the regulatry and ther requirements fr security cntrls, technical implementatin, as well as business t business requirements fr cnnecting between health IT systems; Crss-rganizatinal threat infrmatin sharing and mature incident respnse capabilities; Incident Management and Respnse plicies and prcedures in place and a respnse team identified within the rganizatin; Functinal cntents f all netwrk messages are fully encrypted; and, All data stred in any database cnnected t the netwrk (whether thrugh a cmpanin system, interface engine, r gateway) is fully encrypted. VERIFIABLE IDENTITY AND AUTHENTICATION OF ALL PARTICIPANTS Establish cmmn identity prfing practices at the pint f care; Page 5 f 9

6 Require multi-factr authenticatin fr all patient and prvider access t health IT systems in a way that aligns with what is required in ther industries; Leverage existing mbile technlgies and smart phnes t prvide efficient, effective paths fr patient r prvider identity authenticatin; and Integrate the RESTful appraches t authenticatin in anticipatin f the visin f tmrrw. CONSISTENT REPRESENTATION OF PERMISSION TO COLLECT, SHARE AND USE IDENTIFIABLE INFORMATION Adptin and effective implementatin f privacy prtectins is essential t establishing the public trust necessary fr brad scale interperability f health infrmatin. Reducing variatins in the current legal, regulatry and rganizatinal plicy envirnment related t privacy that is relevant t HIPAA will help facilitate the develpment f technical standards and technlgy that can adjudicate and hnr basic and granular chices natinwide in all care settings, while ensuring that special prtectins that apply as a result f deliberative legislative prcesses remain cnceptually in place. Hwever, individual privacy rights as specified in state and federal laws must nt be substantively erded. HHS is cmmitted t encuraging the develpment and use f rganizatinal plicy and technlgy t advance individuals rights t make chices abut the use and disclsure f their electrnic health infrmatin. HHS als supprts the develpment f standards and technlgy t facilitate an individual s ability t cntrl the disclsure f specific infrmatin that is cnsidered by many t be sensitive in nature. Methds t cnsistently capture, cmmunicate and autmate prcessing f individual chice will be essential as additinal systems and stakehlders are interperable. These same autmated prcesses are essential t supprt clinical research, ppulatin health and public health. Bth an individual s basic chice and granular chice will als need t persist as data is shared frm the pint f rigin t each subsequent system. Natin will need t make aggressive prgress t understand, align and harmnize laws and rganizatinal plicies s that individuals can mre fully understand hw data abut them is being used (cnsistent with FIPPs.) CONSISTENT REPRESENTATION OF AUTHORIZATION TO ACCESS HEALTH INFORMATION Specificatins fr an Authrizatin Framewrk must accunt fr the legal, regulatry and individual chice envirnment, as well as unambiguusly identify the types f learning health system data users and the scpe f their rles. As the health IT ecsystem matures t supprt an evlving natinwide learning health system, bth plicy and technlgy will need t supprt a grwing set f intended and authrized purpses fr use and prvide the infrmatin necessary t make clear determinatins t disclse electrnic health infrmatin. A learning health system must als prvide sufficient infrmatin t lg in and audit access s that disclsures can be accunted fr and audited. While authrizatin is nt the same as authenticatin, it critically depends n reliable mechanisms f authenticatin f individuals and systems invlved in infrmatin access. CERTIFICATION AND TESTING TO SUPPORT ADOPTION AND OPTIMIZATION OF HEALTH IT PRODUCTS AND SERVICES Certificatin and testing are crucial elements t ensuring cnfrmance t the technical standards necessary t achieve natinwide interperability. As the Radmap states, certificatin and testing are critical t guaranteeing the ptimizatin f Health IT prducts and services. Page 6 f 9

7 STAKEHOLDER ASSURANCE THAT HEALTH IT IS INTEROPERABLE Certificatin and testing prgrams will need t be administered by a variety f different entities bth inside and utside f gvernment, but it must be well-crdinated s as nt t create cnflicting r duplicative requirements fr industry stakehlders. Over time, there will be a need fr certificatin and testing prgrams fr prvider and nn-prvider systems such as netwrk technlgies and resurces, payer systems, ppulatin health resurces and systems emplyed fr patient engagement as all f these different technlgies becme part f a learning health system. Certificatin in supprt f a learning health system shuld be specific and fcused n the areas that have the greatest impact n interperability. As the market cntinues t demand interperability beynd rganizatinal bundaries, certificatin and testing prgrams can be a means t mre rapidly scale the cnsistent implementatin and use f a cmmn set f technical standards. Testing in additin t r independent f certificatin will play a critical rle in advancing interperability. A fcus n cntinuus testing, during health IT develpment, implementatin and pstimplementatin/use will require brad industry cmmitment t the develpment, maintenance and use f testing tls. Testing prgrams shuld als incrprate negative testing and exceptin handling cases t ensure systems are resilient acrss a brad range f real wrld interperability scenaris. Crdinated gvernance will have a rle in reinfrcing the use f a cmmn set f standards and testing prtcls, t assure that health IT can truly be interperable. CORE TECHNICAL STANDARDS AND FUNCTIONS The Radmap emphasizes that cre technical standards must be widely deplyed and advanced t enable natinwide interperability as well as a learning health system. T d s, the Radmap makes the fllwing recmmendatins described in detail belw. CONSISTENT DATA FORMATS AND SEMATICS It will be necessary fr the industry t cnverge and agree n use f the same cntent and vcabulary standards t satisfy each specific interperability purpse. Cntent standards shuld cntinue t accmmdate the exchange f structured and unstructured data, but develpers and end-users shuld design and subsequently implement systems with intentinal mvement and bias tward increased exchange f mre structured, standardized and discrete infrmatin. At minimum, we must agree t a standardized cmmn clinical data set that is cnsistently and reliably shared during transitins f care (and with individuals and their caregivers) t achieve the near-term gal f establishing a fundatin f interperability that can be expanded ver time. While it is unlikely that a single data frmat (at least structured as a dcument) will supprt all f the needs f a learning health system, every effrt shuld be made t minimize nt nly the number f data frmats, but t als have agreement n the use cases that each data frmat supprts. Industry will need t develp standards fr granular data elements that can be used in dcuments and mve tward ways f exchanging infrmatin that d nt require infrmatin t be in dcument frm. HL7 s Fast Healthcare Interperability Resurces (FHIR) effrt is ne effrt that is emerging and explring ways t accmmdate new methds f exchanging infrmatin. It will be increasingly necessary fr the industry t invest time in thughtfully planning the migratin and transitin frm ne standard t anther as well as frm ne versin f a standard t a newer versin. T supprt clinical care, research, quality measurement and clinical decisin supprt, a learning health system may need, fr sme envirnments and purpses, t shift frm static cde lists that define a cncept within a single applicatin r rganizatin t mre systematic, shared ways f representing Page 7 f 9

8 meaning. Industry shuld embrace the idea f making service calls t access the mst up-t-date vcabularies rather than trying t manage these vcabularies lcally in their systems. SECURE, STANDARD SERVICES A learning health system must cnverge n a limited set f APIs t supprt the services that are needed. Hwever, there is a delicate tensin: new features cntinue t be cnceptualized, new wrk flws are created and new APIs and standards are develped; at the same time, existing functinality cannt be easily r quickly abandned r replaced. While the Radmap will identify a limited set f APIs and standards that are needed t supprt a learning health system in the shrt term, crdinated gvernance will cntinue t identify, select and help transitin the industry t new APIs and standards whse functinality has been replaced r eclipsed. CONSISTENT, SECURE TRANSPORT TECHNIQUES Suite f transprt standards shuld be cnsistent with cre Internet technlgies that are pervasively deplyed. Secure transprt techniques will be necessary t supprt individual sharing f persnal health infrmatin, as well as patient-generated data. ACCURATE INDIVIDUAL DATA MATCHING Near-term need t fcus n patient identity matching fr ther learning health system prcesses t be fully supprted in the next ten years. Cnsequently, the three-year milestnes fcus primarily n imprving patient matching prcesses, standardizing data elements and develping best practices fr imprving data quality. Significant need t measure the accuracy f patient identity matching prcesses s systems can identify where imprvements must be made. Since universal perfrmance metrics d nt currently exist and there is little agreement in the industry n what shuld be measured, near-term milestnes fcus n gaining agreement in the industry n perfrmance metrics. Data quality must als be addressed. Accurate data cllectin during the registratin prcess is the first and ptentially mst imprtant cntributr t matching data later. Significant need fr the industry and frnt desk staff t establish and dcument best practices fr ensuring data quality at the pint f registratin. In 2013, ONC released the SAFER guide, which included best practices fr recrding patient demgraphic data. The industry can build upn these best practices as a starting pint. Little agreement in the industry n what shuld be measured in patient matching. Perfrmance metrics need t be universally defined with the expectatin that perfrmance threshlds can be established based n the care setting. Als, by defining the perfrmance metrics, an industry accepted level f accuracy culd be established. The perfrmance metrics need t cnsider nt nly the algrithm but als prcesses and data quality. Tls need t be develped that allw fr measurement by health systems and ambulatry practices. T develp these tls, surces f gld standard data (manually viewed linked recrds, reviewed by at least tw reviewers) will need t be established r a prcess needs t be established in which individual institutins can sample and empirically measure their match rates using cmmnly used infrmatin retrieval perfrmance metrics. Additinally, there will need t be a list f patient match scenaris that different rganizatins can cmpare against, (i.e., matching fr public health and Accuntable Care Organizatins (ACOs)) as they will have different perfrmance metrics than fr matching a clinical recrd fr care. Need in the near-term fr stakehlders in the care cntinuum (ther than hspital and ambulatry prviders) t adpt matching technlgy. Page 8 f 9

9 As perfrmance metrics and acceptable risk mdels are develped and tested, rganizatins will need t use the metrics t help refine them and ensure the natin is making prgress twards mre accurate individual data matching. RELIABLE RESOURCE LOCATION Due t its dynamic nature, resurce lcatin will likely have sme degree f decentralized administratin in rder t perate efficiently and remain accurate and up-t-date. Imprtant that natinwide directries cntinue t seek ut innvative ways in which t maintain the infrmatin. Prvides a means fr discvering the services that participants ffer and the APIs that can be used t lcate health infrmatin assciated with a patient, cnditin, r participant. Hwever, many aspects f resurce lcatin will be autmated t wrk with the ther functinalities described in the Radmap s users f health IT systems will nt have t d separate queries fr patients and their data. Since resurce lcatin prvides a user r system with the tls t access ther systems, it will be imprtant t cnsider security cntrls and a user's level f access based n their authenticatin t search the shared directry f participants and resurces. As the capabilities f a learning health system expand and mre participants jin and ffer data resurces and ther services, it will be increasingly imprtant t cnsider the API used t access it. There are a number f questins that must be addressed in the three- t six-year time frame, including: Hw des an individual r system place a query t discver participants f a learning health system r the services they ffer? Hw is API infrmatin passed back? Hw des ne knw the respnse is cmplete? Hw des an individual r system gain access t resurce lcatin? Hw is ne authenticated t access the system? Hw is infrmatin in resurce lcatin managed and updated and hw is the infrmatin curated t ensure accuracy? Resurce lcatin services will need t have the ability t lcate all f these resurces in a seamless way, including emerging directries f new participants and services. Fr any questins r cmments regarding this summary, please cntact Lauren Ellis Riplinger, Directr f Plicy & Gvernment Affairs, at the Health Data Cnsrtium at lellis@healthdatacnsrtium.rg. Page 9 f 9