Longitudinal Coordination of Care Pilots WG Monday, November 11, 2013

TopicPresenter Welcome & OverviewEvelyn Cognitive Status & Mental Status DiscussionCommunity Next StepsEvelyn Agenda 2

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 Wednesdays from 10:00 – 11:00am Eastern WebEx: Dial In: ; Access Code: Focus on ballot reconciliation of HL7 C-CDA Ballot comments Thursdays from 10:00 – 12:00pm Eastern –WebEx: –Dial In: ; Access Code: –Focus on block voting of HL7 C-CDA Ballot comments

Meeting Reminders HL7 Patient Care WG Meetings Care Plan every 2 nd Wednesday from 4:00 – 5:30pm ET –Focus on Care Plan DAM Ballot Reconciliation –Next meeting scheduled for Nov. 13th –Phone: , Participant Code: NEW* Patient Care Health Concern Topic Meetings every 2 nd Thursday from 4:00 – 5:00pm Eastern Next meeting scheduled for Nov. 21st 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

CommentsComment #CommenterThoughts so far Please consider splitting into multiple sentences and add more detail on what is recommended for this section. This description is vague and overlaps with the Cognitive Status Observation and Mental Status Observation descriptions. All 3 sections refer to "mood". It is unclear which section to use regarding mood. If the line is not clear, people will put data wherever they wish. 897 (451, 674)Jennie HarvellI would think that mood should be in Mental rather than Cognitive Status Behavior should be included in Mental Status. It was referred to in the old Functional Status Observation, but has been stricken in this release. Where does the notion of "behavior" live in this release? 606Jennie HarvellThere is a small reference to "behavior in Cognitive Status Observation - but only "aggressive behavior" Why is Caregiver Characteristics included here? Is this just a reference to the caregiver that is in the header to provide more information on the caregiver? Is this the person doing the mental status observation? 877Jennie HarvellNeed to add something in description for the rationale behind including Caregiver Characteristics. Please consider adding examples on the Cognitive Status Observation vs Mental Status Observation at this level to help guide the reader. 884Brett Marquard Mental Status Section (NEW) 5 Description: The Mental Status Section contains observation and evaluations related to patient's psychological and mental competency and deficits including cognitive functioning (e.g., mood, anxiety, perceptual disturbances) and cognitive ability (e.g., concentration, intellect, visual-spatial perception).

Cognitive Abilities Observation (NEW) 6 CommentsComment #CommenterThoughts so far Cognitive Abilities and Cognitive Status are not clearly enough differentiated. Why are "ability to plan, logical sequencing ability, ability to think abstractly" in Cognitive Abilities, whereas "ability to make decisions" and memory (=ability to remember) are in Cognitive Status? I suggest combining them both into one template. They have similar data elements, and the additional elements in Cognitive Status could make sense for Cognitive Abilities anyway. If not combined, then clarify the text to make clear distinctions, and avoid overlapping examples. 888David TaoHmmm… Maybe not a good idea to use the word "ability" in the status observation. Here's my proposal re Cognitive Status Observation vs Cognitive Ability Observation. It elaborates upon my ballot comment, and also takes Jennie Harvell's comments into consideration. COMBINING the two entries is my main suggestion. I prefer the phrase "Cognitive Abilities" but could live with "Cognitive Status" too. The combined entry would use the attributes of Cognitive Status Observation (which more attributes than Cognitive Abilities). The value sets from Cognitive Abilities would also have to be brought into the combined template. Caveat: I am not a Behavioral Health SME! I make these observations from the point of view of an observer who notices the lack of clarity in the current descriptions. But the standard should be written realizing that implementers and even end users of CCDA documents are generally not going to be BH specialists either, so they need something unambiguous to implement consistently. If the two Cognitive ____ entries are not combined, then I would remove any discussion of "ability" from the "Cognitive Status Observation." As suggested by Jennie, myself, and others, remove "mood" from both of these, and leave it in the "Mental Status Observation" (which I suggested renaming to Psychological Status Observation). But if we remove mood, ability to make decisions, ability to remember (incl. amnesia) from Cognitive Status Observation, what would be left? Aggressive behavior, dementia? But dementia is also about "abilities." The Alzlheimer's Association definition of dementia: "Dementia is not a specific disease. It's an overall term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities." Wikipedia definition of dementia: "Dementia is a serious loss of global cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body." Description: The Cognitive Abilities Observation represents a patient’s ability to perform specific cognitive tasks (e.g., ability to plan, logical sequencing ability, ability to think abstractly).

Mental Status Observation (NEW) 7 CommentsComment #CommenterThoughts so far This description is vague and overlaps with the Cognitive Status Observation and Mental Status Section descriptions. All 3 sections refer to "mood". It is unclear which section to use regarding mood. If the line is not clear, people will put data wherever they wish. 674Jennie HarvellI would think that mood should be in Mental rather than Cognitive Status I don't think a subtype should have the same name as the section that contains other subtypes, thus my suggestion of "Psychological" instead of "Mental." But more significantly, it's not clear how to differentiate Mental Status Observation from "cognitive status observation." "Mood" is also mentioned under Cognitive Status Observation. "Intellectual and mental powers" overlaps w. Cognitive Status Observation as well (which lists "memory, ability to make decisions, and problems that limit cognition, e.g., amnesia, dementia, aggressive behavior"). I question whether the distinction between "mental status" and "cognitive status" and "cognitive abilities" is necessary or helpful, or whether they could all be consolidated. If not, the descriptions need to be cleaned up to minimize overlaps, or ambiguity in narrative such as "mood" and "abilities" and "intellectual and mental powers" 925David TaoThis is a good point - I agree - it seems odd to have a Mental Status Section that contains both Cognitive AND Mental Status. Wondering if there is a reason we called it "Mental" rather that "Psychological"? (Or maybe we shoudl rename the section to be "Psychological Status Section"). Though - why are we calling it "Status Section when we are making a distinction between "Status" and "Abilities" in the contained templates. Def agree we need to clean up descriptions. Seems like "mental powers" is more about cognition? Description: This template represents observations relating intellectual and mental powers and state of mind. Mental status observations in a clinical note often have a psychological focus (e.g., level of consciousness, mood, anxiety level, reasoning ability).

Cognitive Status Observation (V2) 8 CommentsComment #CommenterThoughts so far This description is vague and overlaps with the Mental Status Observation and Mental Status Section descriptions. All 3 sections refer to "mood". It is unclear which section to use regarding mood. If the line is not clear, people will put data wherever they wish. Why is Non-Medicinal Supply Activity included? 451Jennie HarvellI would think that mood should be in Mental rather than Cognitive Status Description: This template represents a patient’s cognitive status (e.g., mood, memory, ability to make decisions) and problems that limit cognition (e.g., amnesia, dementia, aggressive behavior). The template may include assessment scale observations, identify supporting caregivers, and provide information about non-medicinal supplies.

Mental Status a. Level of Consciousness b. Appearance c. Behavior / Psychomotor d. Mood and affect e. Speech / Language f. Cognition (Include evaluation type: Orientation, memory (registration, recent, remote), literacy, calculations, visuospatial processing, attention and concentration, general knowledge, language, abstraction) g. Thoughts (Include evaluation type: Content, Process) h. Perception (Include evaluation type: Dissociative symptoms, Illusions, Hallucinations) i. Insight & Judgment (Include evaluation type: Insight, Judgment) Mental Status Hierarchy 9

Problem Concern Act – groups multiple Problem Observations (No Change) Mental Status Observation – includes objective and measured data Action Item: Community to propose updated description Mental Status Organizer (proposed NEW) – allows to group Mental Status Observation and any associated Assessment Scale Observations Action Item: Community to propose updated description REMOVE Cognitive Status templates (Cognitive Abilities Observation, Cognitive Status Observation, Cognitive Status Organizer) REMOVE Non-medicinal Supply Activity from Mental Status Section REMOVE Caregiver Characteristics from Mental Status Section Table 294 – Problem Type: REPLACE Cognitive Status Finding code WITH Mental state, behavior and/or psychosocial function finding REMOVE Assessment Scale Observation from Mental Status Observation and Cognitive Status Observation Table 359 – Mental Status Observation Type – enlarge table to include values from Cognitive and everything from Larry’s (Bill’s) Mental Status bulleted list. Also need to align with Care tool needs. TO DO: clarification on descriptions of templates. – Community to send proposals on template revisions (by Wednesday COB) Use part of the Thursday 5pm call to review updated descriptions Proposals 10

LCC Community to provide descriptions for the following C-CDA templates: Mental Status Observation includes objective and measured data Current Description: This template represents observations relating intellectual and mental powers and state of mind. Mental status observations in a clinical note often have a psychological focus (e.g., level of consciousness, mood, anxiety level, reasoning ability). Mental Status Organizer (proposed NEW) Allows grouping of Mental Status sections Next Steps 11

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 12 LCC Wiki Site: