1. Longitudinal Coordination of Care (LCC) Pilots Template IMPACT 8/19/2013

2. Pilot Team 2 NameRoleEmail Larry Garber, MD Principal Investigator in charge of technology and collaboration Lawrence.Garber@reliantmedic algroup.org Terry OMalley, MD Co-investigator in charge of data standards tomalley@partners.org

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

4. 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 4

5. Which of the 5 C-CDA Revisions is being Piloted 5 SDC Standard / GuidanceSpecifics to PilotNotes Transfer Summary 10 SEE sites will test sending the Transfer Summary (while 6LAND 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 6LAND sites will simply receive them transformed into a text document

6. Relevant Scenario (from the Use Cases) supported by Pilot Exchange of Clinical Information from Provider to Provider

7. 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)

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

9. Outbound LAND Transformations 9 CCD Document XML Document LAND Converter Transfer of Care CDA Document HL7 v2.5.1 ORU MDS XML Document OASIS XML Document CCD Document

10. Converter Inbound Configurations

11. Inbound LAND Transformations 11 LAND Converter CDA Document Text Document HL7 v2.5.1 MDM CCD HL7 v2.5.1 ORU XML Non-CDA Document

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

13. 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 Plans 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 Plans claims data via Reliant Medical Group Number of unique FCHP members in an IMPACT Pilot Sites 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 Sites 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 sites care during measurement period that are transferred to any hospital ER Fallon Community Health Plans claims data via Reliant Medical Group Number of transfers of FCHP members in an IMPACT Pilot Sites care during measurement period to any hospital ER Number of unique FCHP members in an IMPACT Pilot Sites care during measurement period Reduce Total Resource Utilization 5% decrease in Total Resource Utilization from baseline Unique FCHP members in an IMPACT Pilot sites care during measurement period Fallon Community Health Plans claims data via Reliant Medical Group Total Resource Utilization for FCHP members in an IMPACT Pilot Sites care during measurement period N/A

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

15. 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

16. Questions / Needs None

17. Useful Links LCC Wiki Main Page: http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29 Use Case 1.0 Transfer of Care: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements Use Case 2.0 Care Plan Exchange: http://wiki.siframework.org/LCC+WG+Use+Case+2.0 http://wiki.siframework.org/LCC+WG+Use+Case+2.0 Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+Post- 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: http://wiki.siframework.org/LCC+Pilot+Planhttp://wiki.siframework.org/LCC+Pilot+Plan

18. 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 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 Appendix A: LCC Timeline