Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting August 6,

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 o Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded o 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. o Send comments to All Participants 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 Participants

Agenda Summary of LCC WG Accomplishments for June and July 2013 LCC WG Timeline LCC Use Case 2.0 HL7 Ballot Tiger Team eLCC – Transition of Care C-CDA Revisions Care Plan C-CDA Development Next Steps 3

Summary of LCC WG Accomplishments Achieved consensus voting on LCC Use Case 2.0: Care Plan Exchange LCC HL7 Tiger Team developed and submitted recommendations on Care Plan DAM to HL7 Patient Care WG HITPC MU3 SWG Meetings –MU3 recommendations for Care Summary reference IMPACT Transfer of Care dataset: consult note, transfer summary and consultation request –Recommendations to be presented to HITPC on August 7th Lantana C-CDA Revisions Project (Transitions of Care and Care Plan/ Home Health Plan of Care) –Developed draft Implementation Guide/ Ballot Package for Transfer of Care and Care Plan/HHPoC –Ballot Package to be submitted for HL7 Balloting on August 15th

Summary of LCC WG Accomplishments (contd) Continued LCC Stakeholder & Pilot Engagement Activities –Participated in LTPAC HIT Summit June 16 to 18 –Call for Pilot Participation! New wiki site and pilot planning documents posted at: –Conducted Pilot Overview Session for ONC State HIE LTPAC CoP (Community of Practice)

Longitudinal Coordination of Care Workgroup Patient Assessment Summary (PAS SWG LTPAC Care Transition SWG Longitudinal Care Plan SWG Engage directly with HL7 to establish the standards for the exchange of patient assessment summary documents Inform the development of the Keystone Beacon PAS Document Exchange Identify the key business and technical challenges that inhibit LTC data exchanges Define data elements for long-term and post- acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries Identify standards for an interoperable, longitudinal care plan* which aligns, supports and informs person- centric care delivery regardless of setting or service provider 6 LCC Sub Workgroups (SWG) *Care Plan standards will enable providers to create, transmit and incorporate care plans and needed content for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers. GOALSGOALS COMMUNITY-LED INITIATIVE HL7 Tiger Team SWG Educate the LCC Community on related HL7 processes, framework and evolving standards relevant to LCC Gather and generate comments for HL7 Care Plan related evolving standards (Care Coordination Services & Care Plan Domain Analysis Model (DAM))

Work Group Schedules LCC WG SWG MeetingLCC LeadsDate/ TimeProjects LTPAC SWGLarry Garber Terry O'Malley Weekly Mondays 11am - 12pm EST C-CDA: Transfer Summary, Consult Note, Referral Note LCC HL7 Tiger Team Russ LeftwichWeekly Wednesdays 11am - 12pm EST LCC WG comments for HL7 Care Plan DAM LCP SWGBill Russell Sue Mitchell Jennie Harvell Weekly Mondays AND Thursdays 5pm - 6pm EST C-CDA: Care Plan, Home Health Plan of Care HL7 WG SWG MeetingHL7 LeadParticipating LCC Members Date/ TimeProjects HL7 Patient Care WGRuss Leftwich Elaine Ayers Stephen Chu Michael Tan Kevin Coonan Susan Campbell Laura H Langford Lindsey Hoggle Bi-weekly Weds 5pm - 6pm EST Care Plan DAM Care Coordination Services (CSS) HL7 Structured Documents WG Bob Dolin Brett Marquard Sue Mitchell Jennie Harvell Weekly Thursdays 10am - 12pm EST CDA (various) HL7 SOA WG CCS ProjectJon Farmer Enrique Meneses (facilitators) Stephen Chu Susan CampbellWeekly Tuesdays 5pm - 6pm EST Care Coordination Services (CSS) HL7 Patient Generated Document Leslie Kelly HallWeekly Fridays 12pm - 1pm EST Patient-authored Clinical Documents

LCC WG Timeline: Mar 2013 – Dec 2013 Mar 13Apr 13May 13Jun 13Jul 13Aug 13Sep 13Oct 13Dec 13 Milestones Pilot Site Identification & Engagement Care Plan C-CDA Revisions Complete HL7 Project Scope Statement Due HL7 Intent to Ballot Due HL7 Fall Ballot Open NY Pilots Monitoring LCC Care Plan Use Case 2.0 Development & Consensus IMPACT ToC Pilot Monitoring IMPACT Care Plan Pilot Monitoring HL7 Ballot Publication ToC IGs Development (Transfer Summary, Referral Note, Consult Note) ToC C-CDA Revisions Complete HL7 Final Ballot Due LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS Care Plan/ Home Health Plan of Care IG Development HL7 Ballot Package Development HL7 Ballot & Reconciliation FACA LCC WG Briefings LCC & HL7 Care Plan Coordination IMPACT Go-Live NY Care Coordination Go-Live

LCP SWG LCC Use Case 2.0 – Interoperable Care Plan Exchange

Use Case 2.0 – Interoperable Care Plan Exchange Focus on the functional requirements for an Interoperable Care Plan exchange –Will feed into the Care Plan component of the work Lantana is doing for the Aug/Sept HL7 Ballot Achieved Consensus on July 24, 2013 –28 total votes (LCC has 111 Committed Organizations) 19 Yes 8 Yes with Comments 1 Objection with Comments LCC Use Case 2.0 Wiki Page: To view Consensus and Votes ( –Final Use Case Available herehere 10

LCC HL7 Tiger Team SWG Update Lead: Dr. Russ Leftwich

Overview Tiger Team Objectives Importance of LCC Engagement with HL7 Harmonize Care Plan DAM and provide comments Care Plan DAM has been submitted for ballot

Tiger Team Objectives Educate the LCC Community on the HL7 processes and framework Educate the LCC Community on the HL7 Ballots relevant to LCC Generate comments to the Care Plan Domain Analysis Model (DAM) for September 2013 ballot to align LCC Objectives with HL7 Work Products

Importance of LCC and HL7 Coordination Shared glossary of terms Alignment of the various care plan components between LCC and HL7 (Health Concerns, Goals, Interventions, Risks, Barriers, Associations, Priorities, etc.) Recommendations of data elements/components to be added to or updated within DAM in order to support care plan exchange across multiple disciplines

15 The Domain Analysis Model (DAM) was created by the HL7 Patient Care WG (PCWG) The goal of LCC was to review the DAM and provide input from a provider perspective and to harmonize elements that overlap with LCC efforts around care plan exchange and workflow LCC Tiger Team presented ongoing recommendations and comments during PCWG meetings prior to ballot submittal The majority of comments/recommendations presented by the LCC Tiger Team were implemented in the DAM by the PCWG Harmonize Care Plan DAM

16 Review of final balloted Domain Analysis Model: Wednesday, Aug. 14 at 11am ET (NOTE: This will be the final LCC Tiger Team meeting) Overview of final DAM recommendations made to PCWG available on LCC Tiger Team wiki: Past Meeting Artifacts available on the LCC Wiki: Balloted DAM Review

LTPAC SWG eLCC – Transitions of Care C-CDA Revisions Leads: Mike Tushan & Zabrina Gonzaga (Lantana)

18 Objective Develop national data standards for information exchange of a Longitudinal Coordination of Care Dataset. Expand on the document types and templates to include HL7 Implementation Guides (IGs) for new and enhanced document types: New: Transfer Summary New: Consultation Request Enhanced: Consult Note

19 Background Improving Massachusetts Post Acute Care Transfer (IMPACT) project Resulted in a Transfer of Care Dataset: 500 data elements that are necessary during a patient transfer of care Data set is organized into 5 groups: Transfer of Care Consultation Request Shared Care Encounter Summary Care Plan Home Health Plan of Care

20 Stakeholders and Participants NYeC: New York eHealth Collaborative CCITI NY: Continuum of Care Improvement Through Information New York Healthix, Inc ONC S&I Framework IMPACT Project team HL7 International Structured Documents Work Group/ Patient Care WG ASPE (Care Plan)

21 Deliverables Project Scope Statement (approved by Structured Docs WG) Functional Specification Templates: create up to 30 new CDA templates Sample Files: sample files to accompany each document type Schematron: validation rules HL7 CDA IG(s): final implementation guide(s) for DSTU* HL7 Ballot Package HL7 Ballot Reconciliation Published HL7 CDA IG *Draft Standard for Trial Use

22 Project Timeline Apr Task 1: Background Analysis S&I stakeholder meetings Identify relevant precedent Task 2: Functional Specifications/Setting Specific Rules S&I stakeholder meetings Develop mapping sheet Define setting specific rules MayJunJulAugOctNovDecSep Task 4: Templates Develop templates Meetings Deliverables LEGEND: Task 6: Ballot Material Produce schematron validation rules Develop IG Review IG with Tiger Team Deliver IG to S&I Update and submit IG and materials for ballot Task 7: Reconciliation/Publication Develop ballot comment tracking table Lead reconciliation meetings Publish IG HL7 Reconciliation meeting frequency and dates TBD Draft

© 2011 Lantana Consulting Group, 23 LCC LTPAC Meeting Timeline Jul 22: Nutrition & Plan of Care Artifacts Jul 29: Documents-Transfer, Consult, Referral Jul 29: C-CDA to Technical Writers (Lantana) Aug 5: Highlight Incorporated Feedback Aug 8: Post to C-CDA to HL7 List-Serv for review (HL7) Aug 12: Ballot How to Aug 15: Approval to go to ballot (HL7) Aug 16: Ballot cycle opens(HL7)

LCP SWG Care Plan C-CDA Development Leads: Sarah Gaunt & Gaye Dolin (Lantana)

Overview Care Plan Document Type (NEW) –Goals Section (NEW) –Health Concerns Section (NEW) –Health Status Evaluations/Outcomes Section (NEW) –Interventions Section (V2) Discussed the following NEW Entry-Level Templates: –Act Reference –Author Participant –Goal Observation Patient Priority Preference Provider Priority Preference –Health Concern Act –Intervention Act –Outcome Observation –Prognosis Observation –Progress Toward Goal Observation 25

© 2011 Lantana Consulting Group, 26 IS CAUSE OF HAS SUPPORT HAS REASON Relationships (Happy Path) Health Concern [mood EVN] Goal [mood GOL] Outcome Observation [mood EVN] Intervention [mood: INT/ RQO/ etc.] [mood: EVN] Observation [mood EVN] REFERS TO HAS COMPONENT EVALUATES Progress Toward Goal Observation[ mood EVN] SUPPORTS REFERS TO EVALUATIONS/OUTCOMES HAS COMPONENT

© 2011 Lantana Consulting Group, 27 The following slides give a high level overview of the Care Plan templates that have been developed For further details, please see the latest C-CDA IG Care Plan templates

© 2011 Lantana Consulting Group, 28 Care Plan Care Plan Document-Level Template

© 2011 Lantana Consulting Group, 29 Goals Section Health Concerns Section Health Status Evaluations/Outcomes Section Interventions Section Care Plan Section-Level Templates

© 2011 Lantana Consulting Group, 30 Goal Observation Care Plan Entry-Level Templates

© 2011 Lantana Consulting Group, 31 Health Concern Act (truncated – see C-CDA IG for full list of Contained templates) Care Plan Entry-Level Templates

© 2011 Lantana Consulting Group, 32 Outcome Observation Care Plan Entry-Level Templates

© 2011 Lantana Consulting Group, 33 Intervention Act (truncated – see C-CDA IG for full list of Contained templates) Care Plan Entry-Level Templates

© 2011 Lantana Consulting Group, 34 Blog post by Grahame Grieve Identifiers in CDA Documents Act Reference template Referencing Objects internally

LCC WG Next Steps Initiative Coordinator: Evelyn

Next Steps Lantana to publish Transitions of Care and Care Plan C-CDA Implementation Guide for HL7 Ballot Voting –Fall Ballot Opens August 16 th –Ballot Reconciliation starts end of September Launch LCC Pilot WG on Sept. 16 th –LCC Committed Pilots: MA and NY –Continue to conduct outreach to potential pilot sites: MD, CT, TN Monitor IMPACT Project Go-Live in September Monitor NY Downstate Care Coordination Project Go-Live in October Review final Patient Care WG Care Plan DAM and submit any necessary ballot comments 36