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

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 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 Reminder Join the LCC WG & Complete Pilot Survey

TopicPresenter Welcome & AnnouncementsEvelyn Debrief on CORHIO Sept. 30 PresentationLynette Debrief on HL7 Plenary MeetingsLarry/Russ Update on C-CDA Ballot ReconciliationLarry Update on Patient Care WG MeetingsRuss Status of IMPACT Go-LiveLarry Overview of LCC Pilot Documentation TemplateEvelyn Presentation of IMPACT Pilot DocumentationLarry Next StepsEvelyn Agenda 4

Meeting Reminders S&I Framework Hosted Meetings: 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: –Dial In: ; Access Code: –Focus on ballot reconciliation of HL7 C-CDA Ballot

Meeting Reminders HL7 Patient Care WG Meetings Care Plan every 2 nd Wednesday from 5:00 – 6:30pm ET (4:00 in Nov) –Focus on Care Plan DAM Ballot Reconcilation –Next meeting scheduled for Oct. 30 th –Phone: , Participant Code: NEW* Patient Care Health Concern Topic Meetings every 2 nd Thursday from 4:00 – 5:00pm Eastern Next meeting scheduled for Oct 24th Phone: , Participant Code: 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

LCC Pilot WG Timeline: Aug 2013 – Sept 2014 Aug-Sept 13Oct- Nov 13Dec- Jan 14Feb- Mar 14Apr- May 14Jun- Jul 14Aug- Sep 14 Milestones Updated HL7 C- CDA IG Complete HL7 Fall Ballot Close LCC Pilot Monitoring & Evaluation LCC Pilot Proposal Review HL7 Ballot Publication LCC Pilots Close HL7 Ballot & Reconciliation LCC Pilot WG Launch IMPACT Go-Live NY Care Coordination Go-Live HL7 C-CDA IG Revisions LCC Pilot Wrap-Up LCC Pilot Test Spec. Complete HL7 Ballot LCC Pilot WG

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 Pilot Work Group Purpose and Goals 8

On Sept. 30 th, 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: +Meeting+Artifactshttp://wiki.siframework.org/LCC+- +Meeting+Artifacts RECAP: CORHIO Presentation 9

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 HL7 Plenary & Working Group Meeting Cambridge, MA Sept

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

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 HL7 Patient Care WG: Health Concern DAM 12

[Larry] Status of IMPACT Project 13

LCC Pilot Documentation Template 14

Summary of Documentation Templates & Reference Materials (Pilot Materials) 15 Document NameDescription Pilot Overview Document An overview of the LCC Pilots Workgroup including a Value Statement for Participating Entities, Benefits of Participation as an LCC Pilot Site and steps for How to Get Started. Work Group Planning Presentation A Reference presentation for potential pilots that provides an overview of the Transition of Care and Longitudinal Coordination of Care Problems, the Role of Standards for Problem Resolution, and Overviews of the IMPACT and Downstate New York Care Coordination Projects. Pilot Documentation Template A PowerPoint template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot. Pilot Plan Template A word template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot. Templates available on LCC Pilot WG wiki page:

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

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 17 NameRole

Full Disclosure?

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. 19

Which of the 5 C-CDA Revisions are 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. 20 SDC Standard / GuidanceSpecifics to PilotNotes

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: Requirements Requirements Link to download Consensus Approved Use Case 2:

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

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)

Timeline What is your proposed timeline given we want to wrap-up Pilots by Q Guidance: ~6 months minimum / ~1 year maximum Evaluation: 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 MilestoneTarget DateResponsible Party

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

Example: IMPACT Performance Metrics Target Outcom e Target ValueTarget PopulationData Source NumeratorDenominator Reduce hospital readmissi on rate 5% decrease in 30 day hospital readmission rates from baseline Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites Fallon Community Health Plan’s claims data via Reliant Medical Group Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period Reduce Hospital Admissio n Rate 5% decrease in Hospital Admission Rate from baseline Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER Fallon Community Health Plan’s claims data via Reliant Medical Group Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER Increase overall complete ness of data included in transition process 70% of patients transferred with complete set of required data elements included in electronic Universal Transfer Form (UTF) Unique patient transfers between IMPACT pilot sites LAND and SEE data Number of unique patient transfers between IMPACT Pilot Sites during measurement period with complete set of required data elements in electronic UTF Number of unique patient transfers between IMPACT Pilot Sites during measurement period

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:

Risks & Challenges Identify any risks or challenges

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).

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

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

Pilot Team 32 NameRole Larry Garber, MD Principal Investigator in charge of technology and collaboration algroup.org Terry O’Malley, MD Co-investigator in charge of data standards

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

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 34

Which of the 5 C-CDA Revisions is being Piloted 35 SDC Standard / GuidanceSpecifics to PilotNotes Transfer Summary 10 “SEE” sites will test sending the Transfer Summary (while 6 “LAND” sites will send CCDs). All 16 sites will receive either of these document types The 10 “SEE” sites will test incorporating and reusing the data elements, while the 6 “LAND” sites will simply receive them transformed into a text document

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

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)

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

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

Converter Inbound Configurations

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

Timeline MilestoneTarget DateResponsible Party LAND & SEE Go-lives October 2013Larry Garber, MD Pilot evaluationMay 2014Larry Garber, MD

IMPACT Success Criteria Target Outcome Target ValueTarget PopulationData SourceNumeratorDenominator Reduce hospital readmission rate 5% decrease in 30 day hospital readmission rates from baseline Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites Fallon Community Health Plan’s claims data via Reliant Medical Group Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period Reduce Hospital Admission Rate 5% decrease in Hospital Admission Rate from baseline Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER Fallon Community Health Plan’s claims data via Reliant Medical Group Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER Reduce ER visit rate 5% decrease in ER visit rate from baseline Unique FCHP members in an IMPACT Pilot site’s care during measurement period that are transferred to any hospital ER Fallon Community Health Plan’s claims data via Reliant Medical Group Number of transfers of FCHP members in an IMPACT Pilot Site’s care during measurement period to any hospital ER Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period Reduce Total Resource Utilization 5% decrease in Total Resource Utilization from baseline Unique FCHP members in an IMPACT Pilot site’s care during measurement period Fallon Community Health Plan’s claims data via Reliant Medical Group Total Resource Utilization for FCHP members in an IMPACT Pilot Site’s care during measurement period N/A

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

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

Questions / Needs None

Homework Assignments: –Complete Pilot Survey –Sign up as an LCC Committed Member –Submit Pilot Documentation Proposals Available on the LCC Pilot SWG Wiki: to Lynette Elliott Next Steps 47

LCC Leads –Dr. Larry Garber –Dr. Terry O’Malley –Dr. Bill Russell –Sue Mitchell LCC/HL7 Coordination Lead –Dr. Russ Leftwich Federal Partner Lead –Jennie Harvell Initiative Coordinator –Evelyn Gallego Project Management –Pilots Lead: Lynette Elliott –Use Case Lead: Becky Angeles LCC Initiative: Contact Information 48 LCC Wiki Site: