1. Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting May 7, 2013 1

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 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

3. Agenda Summary of LCC WG Accomplishments for April 2013 LCC WG Timeline LCC Use Case 2.0 HL7 Ballot Tiger Team eLCC – CDA IG Development Next Steps 3

4. Summary of LCC WG Accomplishments Continued development LCC Use Case 2.0 focused on Interoperable Care Plan Exchange Presented LCC WG update to HITPC (03APR13) Kicked off LCC HL7 Tiger Team –Developed and submitted comments for HL7 CSS Comment only Ballot Kicked off Lantana C-CDA Revisions Project (HL7 ToC Implementation Guidance development) Reorganized LCC WG Structure and Meetings Continued LCC Stakeholder & Pilot Engagement Activities –State HIE F2F Presentation –NY Department of Health Presentation –Outreach to Vendors (EHR, HIE, Care Coordination) –Outreach to LTPAC Organizations & Vendors (Life Centers of America) –Outreach to Provider Organizations (ANA)

5. 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 5 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))

6. LCC WG Timeline: Mar 2013 – Dec 2013 Mar 13Apr 13May 13Jun 13Jul 13Aug 13Sep 13Oct 13Dec 13 Milestones Pilot Site Identification & Engagement Care Plan IG Complete Lantana Contract Awarded for Development of ToC IG 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 IGs 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-LiveNY Care Coordination Go-Live Lantana Contract Awarded for Development of Care Plan IG

7. LCC Use Case 2.0 – Interoperable Care Plan Exchange

8. Use Case 2.0 – Interoperable Care Plan Exchange Focus on the functional requirements for an Interoperable Care Plan exchange LCC Use Case 2.0 Wiki Page (http://wiki.siframework.org/LCC+WG+Use+Case+2.0)http://wiki.siframework.org/LCC+WG+Use+Case+2.0 –We have a comment form to provide feedback on UC sections (http://wiki.siframework.org/LCC+Use+Case+2.0+Commen ts)http://wiki.siframework.org/LCC+Use+Case+2.0+Commen ts 8

9. LCC Use Case 2 Development Schedule Items in italics will drawn directly from the LCC Project Charter or created offline directly from other sections and will be included in the end-to-end review DateItemHomework (Due Friday COB) 3/11 – 3/18 10.0 Scenario (User Stories, Base/Alternate Flow, Functional Requirements) Review: User Stories 3/25 – 3/26 3.0 Use Case Scope (Background, In / Out of Scope, Communities of Interest) Finalize: User Stories, Base Flows, In / Out of Scope Review: Communities of Interest, Assumption 4/1 – 4/2 3.4 Communities of InterestFinalize: Communities of Interest, Assumptions, Pre- Conditions, Post-Conditions Review: Actors and Roles 5.0 Use Case Assumptions 6.0, 7.0 Pre-Conditions, Post Conditions 4/8 - 4/11 Finalize: Assumptions, Pre-Conditions, Post- Conditions, Communities of Interest 8.0 Actors and Roles Review: Actors and Roles Finalize: Assumptions, Pre-Conditions, Post- Conditions, Actors and Roles 4/15 – 4/18 Finalize: Communities of Interest, Assumptions, Actors and Roles Review: Base/Alternate Flows, User Stories Activity Diagrams Review: Base Flows, Activity Diagrams Finalize: Base Flows, Activity Diagrams, 4/22 – 4/25 11.0 Risks, Issues, and ObstaclesFinalize: Risks, Issues and Obstacles Review: Sequence Diagrams, Functional Requirements 10.3 Functional Requirements 10.4 Sequence Diagram 5/210.3 Functional RequirementsFinalize: Sequence Diagrams Review: Functional Requirements, Use Case Diagrams 5/99.0 Use Case Diagrams Appendices Finalize: Functional Requirements, Use Case Diagrams Review: Appendices 5/1612.0 Dataset RequirementsEnd-to-End Review (preliminary)

10. Use Case Outline 1.0 Preface and Introduction** 2.0 Initiative Overview –2.1 Initiative Challenge Statement** 3.0 Use Case Scope –3.1 Background** –3.2 In Scope –3.3 Out of Scope –3.4 Communities of Interest 4.0 Value Statement** 5.0 Use Case Assumptions 6.0 Pre-Conditions 7.0 Post Conditions 8.0 Actors and Roles 9.0 Use Case Diagram 10 10.0 Scenario: Generic Provider Workflow –10.1 User Stories –10.2 Activity Diagram o 10.2.1 Base Flow o 10.2.2 Alternate Flow –10.3 Functional Requirements o 10.3.1 Information Interchange Requirements o 10.3.2 System Requirements –10.4 Sequence Diagram 11.0 Dataset Requirements 12.0 Risks, Issues and Obstacles Appendices –Related Use Cases –Previous Work Efforts –References ** Leverage content from Charter Draft sections complete Content available for review

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

12. Overview HL7 Tiger Team Issues/Topics –Tiger Team Objectives –Importance of LCC Engagement with HL7 Care Coordination Service (CCS) May Ballot (sponsored by HL7 Patient Care WG, co-sponsors Clinical Decision Support WG, Service Oriented Architecture WG) Care Plan Domain Analysis Model (DAM) September Ballot (sponsored by HL7 Patient Care WG, co sponsored by Structured Documents WG) Structured Documents WG –Establish artifacts and ballot comments –Harmonize Care Plan DAM –Schedule

13. 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 Coordination Service and Care Plan Domain Analysis Model (DAM) Ballots for May and September 2013 to align LCC Objectives with HL7 Work Products

14. Importance of LCC and HL7 Coordination Care Coordination Service May Comment Ballot (HL7 Patient Care and Service Oriented Architecture WGs) –This is being balloted separately from the Care Plan DAM, so LCC comment is necessary to harmonize the two work products Care Plan Domain Analysis Model September Ballot (HL7 Patient Care WG) –Shared glossary of terms –Alignment of the various care plan components between LCC and HL7 (Risks, Barriers, Relationships, Prioritization, etc)

15. Establish Tiger Team Artifacts and Ballot Comments Comments in MS Excel Ballot Package Presentations for updates to HL7 Workgroups HL7 SOA CCS Ballot comments were submitted April 29 HL7 Care Plan Domain Analysis Model ballot artifacts are due for submission on August 4

16. 16 Care Coordination Service Comments ballot Comments aggregated from last 3 weeks TT calls Submitted to HL7 for ballot close April 29 Aggregated comments will be posted on wiki for review Comments to be reviewed by CCS in coming weeks HL7 CCS project has offered to review with LCC Target to have normative ballot for functional model Sept 2013 CCS will have dependency on Care Plan DAM CCS ballots functional model, not Care Coordination Service HL7 Ballot Comments Debrief

17. 17 The Domain Analysis Model (DAM) was created by the HL7 Patient Care WG (PCWG). The goal of LCC is 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. Ideally comments will be rolled into the DAM before it goes to ballot in September. Harmonize Care Plan DAM

18. 18 Define differences between Risks and Health Concerns, map out how to categorize them Define Barriers, map out how to categorize them Define Goals, Concerns and Interventions, map out how to designate prioritization of each Map out how to mitigate irrational choices (this could fall under Risk discussion, as well) Map out how to assign Care Team Members to prioritized Goals, Concerns and Interventions Patient priorities vs. Care Team Member priorities Align terminologies, definitions and Use Cases between PCWG and LCC Points for Discussion

19. Schedule – April 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 123456 78910111213 11 AM ET: HL7 Care Coordination Services Overview to LCC 14151617181920 11 AM ET: LCC Tiger Team Meeting for CCS Ballot Preliminary CCS Ballot Comments Due 21222324252627 11 AM ET: Final LCC CCS Ballot Review Meeting Final CCS Ballot Comments Due 282930 LCC CCS Ballot Comments Due to HL7

20. Schedule – May 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 1234 11 AM ET Overview of HL7 LCC Domain Analysis Model 567891011 11 AM ET HL7 LCC DAM: Risks, Health Concerns, Barriers, Preferences 12131415161718 11 AM ET HL7 LCC DAM: Risks, Health Concerns, Barriers, Preferences 5 PM ET Tentative Touch Point with PCWG 19202122232425 11 AM ET HL7 LCC DAM: How to designate and/or model Prioritizations 262728293031 11 AM ET: HL7 LCC DAM: Assignment of Care Team Members to Prioritizations

21. Participate in the Tiger Team If you are interested in joining the LCC HL7 Ballot Tiger Team, please: –Participate in the Wednesday, April 10 th meeting at 11:00am EST –Check out the wiki: http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG

22. eLCC CDA IG Development Leads: Mike Tushan & Zabrina Gonzaga (Lantana)

23. 23 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: Referral Note Enhanced: Consult Note

24. 24 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

25. 25 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)

26. 26 Deliverables 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

27. 27 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

28. Next Steps Lantana developing scope statement for eLCC CDA Implementation Guide development –Care Plan/HHPoC IG development scheduled to start in May Monitor IMPACT Project Go-Live in June Continue outreach to key LCC Stakeholder groups –Professional Associations, EHR vendors, CMS Care Planning Programs –Coordination with other Care Plan Initiatives: DoD/VA, HIMSS Develop/Execute on Pilot Engagement Plan (Call for Participation!) –MA and NY entities have committed to pilot pre-balloted LCC standards before end of year –Engage TN LTPAC Entities and Life Centers of America Develop and submit Tiger Team Recommendations to HL7 WGs Continue participation in HITPC SWG MU3 #3 Care Coordination Participate in LTPAC HIT Summit (June) 28