Longitudinal Coordination of Care Pilots WG

1. Longitudinal Coordination of Care Pilots WG Monday, October 21, 2013

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

4. Agenda

5. Meeting Reminders S&I Framework Hosted Meetings: http://wiki.siframework.org/Longitudinal+Coordination+of+Care LCC Pilot WG meetings are Mondays from 11:00– 12:00 pm Eastern • Focus on validation and testing of LCC Standards for Transitions of Care & Care Plan exchange LCC All Hands WG meetings are Mondays & Thursdays from 5:00– 6:00 pm Eastern • These meetings are facilitated in partnership with Lantana and will focus on discussion and review of HL7 C-CDA Care Plan Ballot Comments HL7 Structured Documents WG Meetings Meetings are Thursdays from 10:00 – 12:00pm Eastern • WebEx: https://iatric.webex.com/iatric/j.php?ED=211779172&UID=0&RT=MiMxMQ%3D%3D • Dial In: 770-657-9270; Access Code: 310940 • Focus on ballot reconciliation of HL7 C-CDA Ballot

6. Meeting Reminders HL7 Patient Care WG Meetings Care Plan every 2nd Wednesday from 5:00 – 6:30pm ET (4:00 in Nov) • Focus on Care Plan DAM Ballot Reconcilation • Next meeting scheduled for Oct. 30th • Phone: +1 770-657-9270, Participant Code: 943377 NEW* Patient Care Health Concern Topic • Meetings every 2nd Thursday from 4:00 – 5:00pm Eastern • Next meeting scheduled for Oct 24th • Phone: +1 770-657-9270, Participant Code: 943377 Care Coordination Service • Meetings every Tuesday 5:00- 6:30 pm ET (4:00 in Nov) • CCS ballot reconciliation, new CCS ballot for Jan 2014

7. 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 Updated HL7 C-CDA IG Complete HL7 Ballot Publication HL7 Fall Ballot Close LCC Pilots Close LCC Pilot Test Spec. Complete Milestones IMPACT Go-Live NY Care Coordination Go-Live

8. 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

9. RECAP: CORHIO Presentation • On Sept. 30th, Pamela Russell provided overview of CORHIO-LTPAC Transitions Program • Key Take-Aways: • 119 of 350 LTPAC & Home Health Facilities connected to HIE; 1,577 total users • HIE currently supports extract of CCDs in .pdf ; will extract structured C-CDAs and publish into HIE by 2014 • Value of Program outreach: survey letters and participant agreements • Importance of work flow impact to senders & receivers • CORHIO presentation and recorded webinar available on LCC Meeting Artifacts site: http://wiki.siframework.org/LCC+-+Meeting+Artifacts

10. HL7 Plenary & Working Group Meeting Cambridge, MA Sept. 22-27 • Plenary Theme: Care Coordination & HL7’s Role • Presentations from LCC Leads: • Terry O’Malley: “Data Sets for Transitions & LCC” • Larry Garber: “Connecting Care Coordination Standards to the Real World” • Call for LCC PILOT Participation (Thank you Larry!) • CMS Presentation: “Post-Acute Care: Building Upon a Foundation and Current Strategy” • Highlighted need to standardize assessment data needs across all PAC settings • Critical to have uniform data elements and governance to support collection and dissemination • Challenges: technical, policy & cultural • NPWF Presentation: “Consumer Priorities for Health & Care Planning in an Electronic Environment” • Introduced next generation of care plans, Care Plans 2.0 • Focus on dynamic, multi-dimensional, person-centered care planning

11. Status of C-CDA Update Ballot Reconciliation • Over 1,000 Ballot Comments received • 208 specific to Care Plan • Next block vote scheduled for Oct. 24th • 127 Comments • Currently reviewing modeling of Health Concerns, Risks and Problems • Seeking domain expert input and discussion

12. HL7 Patient Care WG: Health Concern DAM • Discussed and identified project during HL7 Meetings • 2009 Health Concern Ballot Package DSTU (expired) • Revisited following SDWG request to identify how Health Concern was used in CDA • Expired DSTU needs to be updated to reflect new Care Plan standards defined under: • HL7 Care Plan DAM • HL7 C-CDA Revisions • Will harmonize with IHE and OpenEHR • NEW project scope statement developed to define Health Concern concept • Propose to ballot in May 2014

13. Status of IMPACT Project • [Larry]

14. LCC Pilot Documentation Template 14

15. Summary of Documentation Templates & Reference Materials (Pilot Materials) Templates available on LCC Pilot WG wiki page: http://wiki.siframework.org/LCC+Pilots+WG

16. Longitudinal Coordination of Care (LCC)Pilots Template Insert the Name of Your Pilot / Organization Here MM/DD/YYYY

17. Pilot Team Identify the members of your organization who will be supporting this pilot. If possible include the role he/she will play in the pilot and contact information

18. Full Disclosure?

19. Goal of the Pilot Please include a write up or create a Visio diagram of what you intend to show/prove/support during the pilot process. Make this an actionable statement with specifics. Also include in this description what you hope to gain from this pilot.

20. Which of the 5 C-CDA Revisionsare you Piloting? Please use this section to document which of the 5 LCC Standards (Transfer Summary, Consultation Request, Consult Note, Care Plan, and/or Home Health Plan of Care ) you are intending to pilot. Please be as specific as possible.

21. What Relevant Scenario (from the Use Cases) does your Pilot support? Exchange of Clinical Information from Provider to Provider Exchange of Clinical Information from Provider to Patient Other: ____(Please specify) Link to download Consensus Approved Use Case 1: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements Link to download Consensus Approved Use Case 2: http://wiki.siframework.org/LCC+WG+Use+Case+2.0

22. Identify the Use Case Actors/Systems Involved: A pilot may involve the following participants from the longitudinal coordination of care ecosystem: • Sending Entity Care Team • Receiving Entity Care Team • Sending Entity Information System (EHR) • Receiving Entity Information System (EHR) • Patient and/or Caregiver • Home Health Agency (HHA) Care Team • Home Health Agency (HHA) Information System (EHR) • PHR Application

23. Minimum Configuration What is your current technical / infrastructure set up? What systems / applications will you be using to conduct the pilot? Examples: • Electronic Health Record (EHR) system • Health Information Exchange (HIE) • External database (which one/type) • Existing interfaces • New interfaces (to be developed as part of the pilot)

24. Timeline What is your proposed timeline given we want to wrap-up Pilots by Q4 2014 Guidance: ~6 months minimum / ~1 year maximum Evaluation: starts @ 6-9 months / final evaluation when pilot is complete Example Timeline • September – Kickoff and Logistics • October – Start Pilots • November – Continue with Pilots • March – Conclude Pilots

25. Success Criteria What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible. Examples: • X% Reduction in readmission rate • X% Increase in number of unique patient transfers between sites with complete set of Care Plan data elements

26. Example: IMPACT Performance Metrics

27. In Scope / Out of Scope If you already know what will be in and out of scope for your pilot (beyond the Implementation Guidance (IG) or the Use Case) please document it here. Example:

28. Risks & Challenges Identify any risks or challenges

29. Questions / Needs Please include those items you wish to consider any questions you have or hope the pilot addresses. Additionally, please include those items you need in order to succeed. We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and LCC (and resource availability).

30. Useful Links LCC Wiki Main Page: http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 Use Case 1.0 ‘Transfer of Care’: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements Use Case 2.0 ‘Care Plan Exchange’: http://wiki.siframework.org/LCC+WG+Use+Case+2.0 Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+Post-Acute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documents Care Plan Exchange Harmonization: TBD Pilots Wiki Page: http://wiki.siframework.org/LCC+Pilot+Plan

31. Longitudinal Coordination of Care (LCC)Pilots Proposal IMPACT 8/19/2013

32. Pilot Team

33. Full Disclosure? We have no apparent or real conflicts of interest to disclose

34. Goals of the Pilot Determine if recipients of patients can receive the data that they need to care for their patients, and identify missing data elements Determine if senders of patient are able to reuse data when generating the Transfer of Care Summary Determine if senders of patient are able to find all of the data elements necessary to populate the Transfer of Care Summary Continue to care for patients without a decline in efficiency, quality, or safety Reduce the Emergency Room visit rate Reduce the admission rate from the Emergency Room Reduce the 30-day hospital readmission rate Reduce the total cost of healthcare

35. Which of the 5 C-CDA Revisions isbeing Piloted

36. Relevant Scenario (from the Use Cases) supported by Pilot Exchange of Clinical Information from Provider to Provider (LCC Use Case 1.0)

37. Use Case Actors/Systems Involved: Sending Entity Care Team Receiving Entity Care Team Sending Entity Information System (EHR) Receiving Entity Information System (EHR) Home Health Agency (HHA) Care Team Home Health Agency (HHA) Information System (EHR)

38. Configuration – SEE sites CCD+ = Transfer Summary PCP CCD+ CCD+ KeyHIE Transform SEE CCD+ MDS Hospital Billing Program MDS Nursing Facility

39. CCD Document “Transfer of Care”CDA Document XML Document Outbound LAND Transformations HL7 v2.5.1 ORU LAND Converter CCD Document MDS XML Document OASIS XML Document

40. Converter Inbound Configurations

41. Text Document HL7 v2.5.1 MDM  Inbound LAND Transformations CDA Document CCD   LAND Converter Non-CDA Document HL7 v2.5.1 ORU   XML  Non-CDA Document 

42. Timeline

43. IMPACT Success Criteria

44. Out of Scope Incorporating discrete data elements into EHR beyond those in the CCD

45. Risks & Challenges Delay in project deployment due to legal issues surrounding hosting of SEE software and state “accessibility” requirements. Challenging EHR workflows regarding patient matching and routing to correct provider Unclear how difficult it will be to know when the summary is ready to send. Unclear how difficult it will be to determine who to send the summary to Potential delays by EHR vendors configuring their interfaces Hospitals and physician practices needed to send CCDs to satisfy Meaningful Use regardless of what else they send (i.e. the Transfer Summary) Will the monitors be large enough for SEE users to be effective

46. Questions / Needs None

47. 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)

48. 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