Longitudinal Coordination of Care Pilots WG Monday, February 3, 2014

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 ** If your contact information has recently changed, please send your updated information to Becky Angeles at

TopicPresenter Welcome & AnnouncementsEvelyn, Becky Discussion: Definition of Episode for Care Plan and Plan of CareSusan Campbell Presentation: LTPAC Engagement ToolJennie Harvell Presentation: ED Alert Notification from ReliantTerry O’Malley Next StepsBecky Agenda 4

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 5

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 ET are on hold for now –These meetings are facilitated in partnership with Lantana and will focus on discussion and review of HL7 C-CDA R2 Ballot Comments –888 of 1013 ballot comments have been resolved HL7 Structured Documents WG Meetings Wednesdays from 10:00 – 11:00am Eastern WebEx: Dial In: ; Access Code: Focus on ballot reconciliation of HL7 C-CDA R2 Ballot comments Thursdays from 10:00 – 12:00pm Eastern –WebEx: –Dial In: ; Access Code: –Focus on block voting of HL7 C-CDA R2 Ballot comments

HL7 Patient Care WG Meeting Reminders Care Plan Project –Developing user stories that define and differentiate Care Plan, Plan of Care, Treatment Plan –Current working documents found here: –Meetings every 2 nd Wednesday from 4:00 – 5:00pm ET Next meeting scheduled for Feb. 5 th Meeting Information: –Web Meeting URL: nehta.rbweb.com.aunehta.rbweb.com.au –Phone: , Participant Code:

HL7 Patient Care WG Meeting Reminders, cont’d... Health Concern Topic –Developing user stories highlighting the following: What is a Health Concern Observation; How Health Concern Tracker is Used; How Health Concern is different from Problem Concern –Current working documents found here: –Meetings every 2nd Thursday from 4:00 – 5:00pm ET Next meeting scheduled for Feb. 6 th Meeting Information: –Web URL: ber ber »Meeting Number: –Phone: , Participant Code:

HL7 Patient Care WG Meeting Reminders, cont’d... Coordination of Care Services Specification Project –Provide SOA capabilities/models to support coordination of patient care across the continuum –Current working documents found here: –Meetings every Tuesday 4:00 - 5:00 pm ET Meeting Information : –Web Meeting URL: 41XMZR3-3MNZ 41XMZR3-3MNZ »Meeting Number: –Phone: , Participant Code:

LCC Community members Datuit and Lantana will be participating in the Health Story Care Plan Exchange demonstration at the HIMSS Annual Conference (Feb 23-27) The demonstration will include: LCC Standards for Care Plan and Consult Note exchange Exchange of patient data with a cancer registry based on MU2 requirement for states to collect data on cancer patients HIMSS Care Plan Exchange Demonstration 10

FACA Meeting Updates HITPC Meaningful Use WG Meeting held on Jan. 28 th reviewed care coordination & population/public health priorities MU WG to present recommendations to HITPC on Feb. 4 th MU3 Listening session scheduled for March 3 rd

Improving care coordination : Medication reconciliation 12 Functionality Needed to Achieve Goals Core: Eligible Professionals, Hospitals, and CAHs who receive patients from another setting of care perform medication reconciliation. Threshold: No Change FAQ: Reconciliation may also be performed for all encounters Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination: Summary of care for transfers of care 13 Functionality Needed to Achieve Goals Eligible Professionals/Eligible Hospitals/Critical Access Hospitals provide a summary of care* record during transfers of care from one site of care to another (e.g., Hospital to SNF, PCP, HHA, home, etc…; SNF, PCP, etc… to HHA; PCP to new PCP) Summary of care may (at the discretion of the provider organization) include: – A narrative that includes a synopsis of current care and expectations for consult/transition – Overarching patient goals and/or problem specific goals – Patient instructions, suggested interventions for care during transition – Information about known care team members (including a designated caregiver) Threshold: No Change Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination: Summary of care for consult requests and reports 14 Functionality Needed to Achieve Goals *NEW* (Related to order tracking objective for tests, images, and consult requests (referrals)) Menu: Eligible Professionals/Eligible Hospitals and CAH provide a summary of care* record that pertains to the type of care transition as indicted below: Types of transitions: – Consult (referral) request (e.g., PCP to Specialist; PCP, SNF, ED, public health etc.) – Consult result note (e.g. ER note, consult note) Summary of care may (at the discretion of the provider organization) include: – A narrative that includes a synopsis of current care and expectations for consult/transition – Overarching patient goals and/or problem specific goals – Patient instructions, suggested interventions for care during transition – Information about known care team members (including a designated caregiver) Threshold: Low *An electronic summary is preferred Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination: Notifications 15 Functionality Needed to Achieve Goals *NEW* Menu: Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to key members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required Significant events include: – Arrival at an Emergency Department (ED) – Admission to a hospital – Discharge from an ED or hospital – Death Notifications should be automatically sent to the provider of record Low threshold Modular certification is encouraged, this does not need to be an EHR function Stage 3 Functionality Goals Relevant patient information is shared among health care team and patient, especially during transitions (site or provider) Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

FACA Meeting Reminders HIT Policy Committee Next meeting scheduled for Feb. 4 th from 9:30am – 3:00pm ET HITPC Meaningful Use WG Next meeting scheduled for Feb. 11 th from 9:30am – 11:30am ET HIT Standards Committee Next meeting scheduled for Feb. 18 th from 9:00am – 3:00pm ET

LCC Pilot WG Timeline: Aug 2013 – Sept 2014 Aug-Sept 13Nov 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 NY Care Coordination Go-Live HL7 C-CDA IG Revisions LCC Pilot Wrap-Up LCC Pilot Test Spec. Complete HL7 Ballot LCC Pilot WG GSI Health Go-Live IMPACT Go-Live CCITI-NY Go-Live

18 Care Plan Discussion Susan Campbell

How/whether to define the beginning and end of a Plan of Care (PoC) How to define whether something is to be considered a Plan of Care (Level 2) vs Care Plan (Level 3). How, once incorporated into Care Plan, a PoC would down-regulate, terminate: –By patient decision –By provider assessment and decision (if it is a simple Care Plan, effectively equal to the Plan of Care and there are few to no other providers involved). –By direct consideration of the Care Team during a team meeting, to notice and verify that a POC is low priority or not necessary. –By bundled care payment mechanism. –By algorithm and time frame such that for (e.g.) a pneumonia, by the end of 30 days it is considered complete if there has been no new charge for antibiotics or lab culture. Whether to establish & maintain population-based statistical mean(s) and upper & lower control limits at the population level to ensure fairness & affordability and with respect to what type(s) of Plans of Care or Care Plan –Consider geographic norms or national norms & age and/or complexity adjustment Discussion: Definition of Episode for Care Plan/Plan of Care 19

20 LTPAC Engagement Tool Jennie Harvell Presentation was Deferred to later date

21 ED Alert Notification from Reliant Terry O’Malley Presentation was Deferred to later date

Homework Assignments: –Participate in HITPC Public Meeting Feb.4th –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 22

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 23 LCC Wiki Site: