Longitudinal Coordination of Care Pilots WG

1. Longitudinal Coordination of Care Pilots WG Monday, July 7, 2014

2. Meeting Etiquette Remember: If you are not speaking, please keep your phone on mute Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded • Another reason to keep your phone on mute when not speaking Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. • Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Panelists

3. ReminderJoin the LCC WG & Complete Pilot Survey • http://wiki.siframework.org/Longitudinal+CC+WG+Committed+Member+Guidance • http://wiki.siframework.org/LCC+Pilots+WG ** If your contact information has recently changed, please send your updated information to Becky Angeles at becky.angeles@esacinc.com

4. Agenda

5. Pilot Work Group Purpose and Goals • Purpose • Provide tools and guidance for managing and evaluating LCC pilot Projects • Create a forum to share lessons learned and best practices • Provide subject matter expertise • Leverage existing and new partnerships • Goals • Bring awareness on available national standards for HIE and care coordination • Real world evaluation of parts of most recent HL7 C-CDA Revisions Implementation Guide (IG) • Validation of ToC and Care Plan/HHPoC datasets

6. Meeting Reminders S&I Framework Hosted Meetings: http://wiki.siframework.org/Longitudinal+Coordination+of+Care LCC Pilot WG meetings are every other Monday from 11:00– 12:00 pm Eastern • Focus on validation and testing of LCC Standards for Transitions of Care & Care Plan exchange HL7 Structured Documents WG Meetings Thursdays from 10:00 – 12:00pm Eastern • WebEx: https://global.gotowebinar.com/register/144336339 • Dial In: 770-657-9270; Access Code: 310940 • A pre-publication draft of CCDA R2.0 specification was distributed to the SDWG list serv on July 3rd: (http://www.hl7.org/Special/committees/structure/docs.cfm?). • If you are a negative balloter, please review and reply with any comments by July 11. • Currently discussing CCDA R2.0 Template OID versioning issue.

7. HL7 Patient Care WG Meeting Reminders Coordination of Care Services Specification Project • Provide SOA capabilities/models to support coordination of patient care across the continuum • Reconciling May 2014 Ballot Cycle Comments • Current working documents found here: http://wiki.hl7.org/index.php?title=Coordination_of_Care_Services_Specification_Project • Tuesdays from 5:00 – 6:00pm ET • Meeting Information: • Web Meeting URL: https://meetings.webex.com/collabs/meetings/join?uuid=M55ZKYUA35CE2U3J4SV41XMZR3-3MNZ • Meeting Number: 193 323 052 • Phone: 770-657-9270, Participant Code: 071582

8. HL7 Patient Care WG Meeting Reminders, cont’d... Care Plan Project • Reconciling May 2014 Ballot Cycle Comments for the updated Care Plan DAM and story boards. • Current working documents found here: http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012 • Every other Wednesday from 4:00 – 5:30pm ET • Next meeting is July 16th • Meeting Information: • Web Meeting URL: https://intermountainmeetings.webex.com/intermountainmeetings/j.php?J=621920971 • Phone: 770-657-9270, Participant Code: 943377

9. HL7 Patient Care WG Meeting Reminders, cont’d... Health Concern Topic • Developing Health Concern DAM for September HL7 Ballot Cycle • Current working documents found here: http://wiki.hl7.org/index.php?title=Health_Concern • Thursdays from 4:00 – 5:00pm ET • Next meeting scheduled for July 10th • Meeting Information: • Web URL: https://meetings.webex.com/collabs/#/meetings/joinbynumber • Meeting Number: 233 955 026 • Phone: 770-657-9270, Participant Code: 943377

10. HL7 Patient Care WG Meeting Reminders, cont’d... Patient Care FHIR Resources and Profiles • Reviewing/Finalizing storyboards for the HL7 Sept WGM FHIR Clinical Connectathon • Developing FHIR Resource for Referral and Transition/Transfer of Care • Current working documents found here: http://wiki.hl7.org/index.php?title=FHIR_Patient_Care_Resources • Thursdays from 5:00 – 6:30pm ET • Next meeting scheduled for July 10th • Meeting Information: • Web URL: www.webex.com • Meeting Number: 198 139 396 • Phone: 770-657-9270, Participant Code: 943377

11. HIMSS Health Story Roundtable Why attend? • Advocate and build support for the Health Story Project • Collaborate and network with Health Story Project supporters • Engage with industry leaders in monthly meetings • Participation is open to any HIMSS Members at no additional cost Meets monthly on the 1st Monday from 4pm-5pm ET. Next meeting scheduled for July 7th • Meeting Information: • Web URL: Click here to view agenda and download the calendar invitation (this link will also work to join the meeting) • Meeting Number: 927 311 214 • Meeting Password: meeting • To receive a call back, provide your phone number when you join the meeting, or call the number below and enter the access code. • Call-in toll-free number (US/Canada): 1-866-469-3239 • Call-in toll number (US/Canada): 1-650-429-3300

12. FACA Meeting Reminders (see end of deck for updates) HIT Policy Committee Meaningful Use WG Next meeting scheduled for July 15th from 10:00am – 12:00pm ET http://www.healthit.gov/facas/calendar/2014/07/15/policy-meaningful-use-workgroup HIT Standards Committee Next meeting scheduled for July 16thfrom 9:00am – 3:00pm ET http://www.healthit.gov/facas/calendar/2014/07/16/hit-standards-committee HIT Policy Committee Next meeting scheduled for July 8thfrom 9:00am – 1:15pm ET http://www.healthit.gov/FACAS/calendar/2014/07/08/hit-policy-committee HIT Quality Measures Vendor Tiger Team Cancelled until further notice HIT Policy CommitteeAccountable Care WG Workgroup has been retired as of 05/29/14 meeting

13. LCC Pilot WG Timeline: Aug 2013 – Sept 2014 LCC Pilot Proposal Review LCC Pilot Monitoring & Evaluation LCC Pilot WG LCC Pilot Wrap-Up HL7 Ballot & Reconciliation HL7 Ballot HL7 C-CDA IG Revisions LCC Pilot WG Launch Revisions for HL7 CCDA IG Complete HL7 Ballot Publication HL7 Fall Ballot Close IMPACT Go-Live LCC Pilot Test Spec. Complete Milestones LCC Pilots Close GSI Health Go-Live NY Care Coordination Go-Live

14. Upcoming LCC Pilots Meeting Presentations Upcoming presentations: • July 21st: • Care at Hand Presentation / Demo • August 4th: • Lantana HIMSS Health Story Presentation & SEE Tool Demo (tentative) • IMPACT Updates (tentative) • TBD: • GSI Health Pilots Follow-up • VHA Care Plan FHIR Introduction

15. National Quality Forum Measure Gaps Care Coordination Report Lauralei Dorian, NQF ldorian@qualityforum.org

16. Priority-Setting for Healthcare Performance Measurement: Care Coordination Lauralei Dorian

17. Care CoordinationCommittee Members

18. Project Overview

19. Care Coordination Project Objectives • Guided by a multistakeholder committee, the project will consider and prioritize opportunities to measure care coordination in the context of a broad “health neighborhood.” • The project considered coordination between safety-net providers of primary care and providers of community and social services that impact health. • The work is intended to broaden the current scope of care coordination performance measurement to account for the influence of social determinants such as housing, transportation, and the environment.

20. Care Coordination Project Objectives, Continued • Interoperable data systems that link health and human services information could provide rich new sources for performance measurement; the project will explore this potential as well as challenges associated with sharing data for the purposes of care coordination. • The project will identify existing measures and measure concepts that could successfully measure care coordination in targeted areas. • A final report will provide recommendations on high-leverage opportunities and next steps for measure development, endorsement, and use.

21. Definition of Care Coordination “Care coordination is the deliberate synchronization of activities and information to improve health outcomes by ensuring that care recipients’ and families’ needs and preferences for healthcare and community services are met over time.” • Developed based on AHRQ Care Coordination Measures Atlas, the NQF Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination, and committee feedback.

22. Related Efforts in Care Coordination and Measurement: NQF Consensus Development Process • 2006: Care Coordination Framework identified five domains essential to the future measurement of care coordination: • Healthcare home • Proactive plan of care and follow-up • Communication • Information systems • Transitions or handoffs • 2010: Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination • 2013-current: Care Coordination 3-Phase Measure Evaluation Project

23. Care Coordination Conceptual Framework

24. Committee Recommendations: Priority Measure Domains

25. Comprehensive Assessment Subdomains • Document care recipient’s current supports and assets • Assess function • Assess social needs • Assess behavioral health needs • Assess medication management needs • Assess health literacy • Measure care recipient/family level of activation/engagement • Capture preferences and goals • Estimate health risk level and customize care coordination approach appropriately • Continuous holistic monitoring

26. Shared Accountability Subdomains • Plan of care documents all members of the care team, including community providers • Plan of care assigns responsibilities for meeting care recipients’ goals and care team members accept them

27. Linkages/Synchronization Subdomains • Shared documentation and understanding of care coordination goals by clinical providers, community providers and care recipient/family • Appropriate community services identified and contacted based on needs assessment • Care recipient/family successfully engages with and utilizes community services • Bi-directional communication to facilitate coordination • Frequent and accurate communication to solve problems

28. Progression Toward Goals Subdomains • Resolution of unmet needs, as documented in ongoing assessment • Services congruent with person-centered goals and preferences • Maximized health outcomes and functional status • Reduce care recipient risk through interventions • Increased care recipient/family level of activation

29. HIT Needed to Support Paradigm Shift • The increasing use of HIT can support a paradigm shift in care coordination, ultimately yielding substantial improvements in health care delivery. Currently, significant HIT efforts are underway: • AHRQ is currently gathering information from the field on what is needed to enable electronic quality measurement, particularly testing criteria for Meaningful Use Stage 3. • ONC’s priorities include promoting more consistent use of data fields within care plans, matching data capture through electronic health records with actual clinical workflows, and the use of clinical decision support. ONC plans to effectively design and implement HIT workflows across provider types.

30. Data Standards to Support Care Coordination and Plan of Care • In order for data standards to enable interoperability, specification of a minimum data set around the care team roster is needed. The HL7 Clinical Document Architecture (CDA) supports the representation of the care team and allows for relationships between all care team members to be captured. This specifically includes: • Electronic contact information for each team member, the professional role of each provider, and the familial and legal relationship of family care team members to the care recipient. • HL7 CDA also allows for relationships between those care team members and other data elements and activities in the care plan.

31. Front-Line Perspective on Interoperability: Alliance of Chicago • Alliance of Chicago encourages the use of technology to coordinate services in ways that effectively reduce burden: • EHR’s with longitudinal records and clinical decision support that includes prompts for non-clinical, community-based elements, prompts for information about a care recipient’s visit, and reminders to review previous entries to determine necessary follow ups. • EHR’s are also connected to a comprehensive and up-to-date list of community resources generated by University of Chicago students • Data linkage with the Centers for Disease Control and Prevention (CDC) alerts providers when there is a public health concern or disease outbreak in the community that may be relevant to the individual seeking care

32. Additional Committee Recommendations: Priorities for Care Coordination and Performance Measurement • Priority measure domains reflect the need for person-centered, accountable care. • Innovation is desired, but stronger evidence of effective care coordination practices is fundamental for measure development. • HHS should measure its own progress in reducing fragmentation experienced by front-line providers. • Target care coordination efforts based on individuals’ needs.

33. Additional Committee Recommendations, Continued • Accelerate the work of culture change to achieve person-centered, team-based care. • Continue standardization of data elements to support care planning and measurement. • Balance payment incentives carefully to fulfill all three aims of the NQS.

34. Comments and Questions

35. Next Steps • Homework Assignments: • Complete Pilot Survey • Sign up as an LCC Committed Member • Submit Pilot Documentation Proposals • Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG • Email to Lynette Elliott (Lynette.elliott@esacinc.com) • If you would like to learn more about participating in the eLTSS Initiative, please email Evelyn Gallego (evelyn.gallego@siframework.org)

36. LCC Initiative: Contact Information • LCC Leads • Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org) • Dr. Terry O’Malley (tomalley@partners.org) • Dr. Bill Russell (drbruss@gmail.com) • Sue Mitchell (suemitchell@hotmail.com) • LCC/HL7 Coordination Lead • Dr. Russ Leftwich (Russell.Leftwich@tn.gov) • Federal Partner Lead • Jennie Harvell (jennie.harvell@hhs.gov) • Initiative Coordinator • Evelyn Gallego (evelyn.gallego@siframework.org) • Project Management • Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com) • Use Case Lead: Becky Angeles (becky.angeles@esacinc.com) LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care

37. FACA Updates • As of 07/07/2014

38. FACA Updates: HITPC MU WG 06/20/14 HITPC MU WG will be presenting the suggestions from 4 (Provider, Hospital, ACO, Vendor) panels back to HITPC’s next meeting in July. • See following the slides for comments by each panel

39. FACA Updates: HITPC MU WG 06/20/14, cont’d… Panel 1 (Provider) Suggestions: • Shift ToC to MU 3 • 2-year cycle too fast • Require implementation (demonstrate use), but not specific percentage for everyone • Focus on outcomes-based measures • Focus on interoperability, but not % • Focus on reporting to registries and public health agencies

40. FACA Updates: HITPC MU WG 06/20/14, cont’d… Panel 2 (Eligible Hospitals) Suggestions: • Meaningful use is transformative and increases transparency, but standardization for exchange is needed • Standards needed to exchange information across state boundaries • Need more time to get ready for stage 3 • Vendors not ready • Need time for recipients to get ready for exchange • Need time to learn from stage 2 • Need alignment of CQMs

41. FACA Updates: HITPC MU WG 06/20/14, cont’d… Panel 3 (Advanced Models of Care) Suggestions: • Momentum needs to continue • Exchange in the local community is most important • Additional and more stable funding to support the public health informatics infrastructure will be critical to sustaining public health gains • Electronic lab reporting and syndromic surveillance will lead to greater capacities for early disease detection and more real-time population health assessments during public health emergencies • Build greater HIT capabilities for immunizations and reportable conditions • Patient portals must accommodate a wide range of literacy and should provide access in preferred language and interoperability with assistive devices

42. FACA Updates: HITPC MU WG 06/20/14, cont’d… Panel 4 (Vendor) Suggestions: • Need more time to develop, test, certify • 18 mo lead time after all regs, specifications, tools finalized • Focus on high priority areas where infrastructure is needed (interoperability for care coordination and CQMs) • Policies to facilitate interoperability needed: • State regs • Patient matching • Alignment of CQMs • Allow 90-day reporting period for each new stage

43. FACA Updates: HITPC MU WG 06/20/14, cont’d… Overall Suggestions: • Prioritize information exchange for care coordination and patient engagement • Proprietary business interests impede exchange • Policies for exchange across state boundaries and patient matching are needed • There has been too much focus on the letter rather than the spirit of meaningful use • Need to avoid being overly prescriptive • Quality measure alignment is needed Next Steps • • Present back to HIT Policy Committee on 7/8

44. FACA Updates: HITPC Cert/Adoption WG 06/26/14 The workgroup considered draft recommendations brought forward by a subgroup Recommendations to publicize the results of the ONC workforce development programs and studies to identify core competencies have been accomplished Information was presented on recommendations pertaining to program development to meet the emerging needs of the HIT workforce. However, no direct action by ONC was reported on these recommendations: • Recommend additional funding for new workforce programs that create a workforce development pipeline with a focus on inclusion of rural, underserved learners, veterans and middle school students • Recommend funding studies of the impact of HIT on the workforce

45. FACA Updates: HITPC Cert/Adoption WG 06/26/14, cont’d… Members decided to repeat the two above recommendations, urging ONC to take advantage of several existing opportunities. The subgroup carried out its recommendation that ONC host a SOC input process from the HIT community. The Department of Labor is currently soliciting comments due July 21, 2014. • The subgroup is compiling a report with the intent of adding a new code for health informatics under health care occupations. • Members agreed to ask the HITPC to support the new health informatics SOC.

46. FACA Updates: HITPC Cert/Adoption WG 06/26/14, cont’d… Two new recommendations were presented for the workgroup’s approval for submission to the HITPC: • Recommend that the focus on the health IT workforce is retained in the new HITPC workgroup structure as part of health IT implementation. • Recommend that the ONC continue to connect with other federal agencies and key stakeholders to further the workforce needs required to establish and sustain an effective and efficient interoperable health IT ecosystem. Members agreed on the two new recommendations without making comments. Next Steps: • Minor changes win the slides for the submission of the recommendations to the HITPC in July.