1. electronic Long-Term Services & Supports (eLTSS) Initiative All-Hands Workgroup Meeting September 10, 2015 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 Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). o Please DO NOT use the Q&A—only the presenter sees Q&A, not necessarily the person facilitating the discussion From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute All Panelists 2

3. 3 Agenda TopicPresenterTimeframe Welcome Announcements eLTSS Roadmap Lynette Elliott10 mins Presentation: Leveraging Standards and Technologies Andrey Ostrovsky, Care At Hand Eric Frey, Peer Place Dane Meuler, Inofile/KNO2 Dr. Susan Abend, Right Care Now 50 mins

4. Announcements Accessibility & Usability in Health Information Technology (HIT): User-Driven Research and Actionable Strategies Responsive to People with Disabilities, Older Adults, and Caregivers – What: This two-day event will explore the advancement of the accessible HIT agenda from a compliance-focused paradigm toward one that is user-driven and responsive to human- centered experiences and contributes to improved health and wellness for individual disabilities, older adults, and caregivers. – When: Thursday and Friday, September 17 - 18, 2015 – Where: U.S. Department of Education, Potomac Center Plaza, 10th Floor Auditorium, 550 12th Street SW Washington, D.C. – To register: http://icdr.acl.gov/AHIT/index.htmlhttp://icdr.acl.gov/AHIT/index.html NOTE: Space is limited. Please register right away. 4

5. Announcements, cont’d... Health Information Exchange Annual Conference, sponsored by National Association for Trusted Exchange (NATE), Strategic Health Information Exchange Collaborative (SHIEC), and HIE Users Group (HUG) – What: Agenda includes pre-conference Data Provenance mini- summit, listening session with Steve Posnack (ONC), HIE Innovations Roundtable featuring leading HIEs from across the nation, patient engagement and care coordination sessions, etc. – When: September 27-30, 2015 – Where: Silver Baron Lodge ~ Park City, Utah – To register: http://events.r20.constantcontact.com/register/event?oeidk=a0 7eaz4e3j2253d5d13&llr=kvyj8qeab http://events.r20.constantcontact.com/register/event?oeidk=a0 7eaz4e3j2253d5d13&llr=kvyj8qeab 5

6. Announcements, cont’d… ONC 2015 Health IT Summit – What: The 2015 Consumer Health IT Summit will bring together federal and private sector leaders who are working to enable consumers to become involved partners in their health via health IT. The 2015 Consumer Health IT Summit will bring together federal and private sector leaders who are working to enable consumers to become involved partners in their health via health IT. – When: October 1, 2015 – Where: Washington Hilton ~ Washington, D.C. – To register: http://event.capconcorp.com/wp/e- health/registration/http://event.capconcorp.com/wp/e- health/registration/ – More info: http://event.capconcorp.com/wp/e-health/http://event.capconcorp.com/wp/e-health/ 6

7. Announcements, cont’d… mHealth Summit – What: The 2015 mHealth Summit explores what is new in mobile, telehealth and connected health—from the impact on healthcare delivery, clinical care and patient/consumer engagement to new technologies, research, investment activities, policy and shifts in the business environment. – When: December 8 – December 11, 2015 – Where: Gaylord National Resort and Convention Center ~ Washington, D.C. – To register: http://www.mhealthsummit.org/registrationhttp://www.mhealthsummit.org/registration 7

8. eLTSS Initiative Timeline 8 Phase 1 Pilots & Testing … Pilot Guide Development Use Case & Functional Requirements Pre-Discovery DEC 14JUNJAN FEBMAYJULAUGSEPOCTNOV Kick Off 11/06/14 Evaluation... Content Work Stream Content Work Stream eLTSS All-Hands Work Group Use Case 1. eLTSS Use Case eLTSS Plan Content SWG 1.eLTSS Plan Domains & Data Elements Pilot Guide Development 1.Candidate Standards & Technologies 2.Three-tiered implementation Approach 3.Functional Requirements Matrix MARAPRDEC 15JAN 16 Pilot Execution

9. Goals for the eLTSS Initiative Identify key assessment domains and associated data elements to include in an electronic Long-term Services & Supports (eLTSS) plan Create a structured, longitudinal, person-centered eLTSS plan that can be exchanged electronically across and between community-based information systems, clinical care systems and personal health record systems. 9

10. eLTSS Artifacts Final published Project Charter is located here: http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Charter http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Charter eLTSS Glossary posted here: http://wiki.siframework.org/eLTSS+Glossaryhttp://wiki.siframework.org/eLTSS+Glossary – The eLTSS Glossary is a working document containing eLTSS-relevant terms, abbreviations and definitions as defined by stakeholders – We are looking for your feedback and comments Discussion Thread available Submit any change requests via the Change Request Form located on the wiki Final published Use Case document is located here: – http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Use+Case http://wiki.siframework.org/electronic+Long- Term+Services+and+Supports+%28eLTSS%29+Use+Case 10

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12. Presenters Dr. Andrey Ostrovsky ~ Care At Hand ~ Andrey@careathand.comAndrey@careathand.com Eric Frey ~ Peer Place ~ efrey@peerplace.comefrey@peerplace.com Dane Meuler ~ Inofile/KNO2 ~ dmeuler@inofile.comdmeuler@inofile.com Dr. Susan Abend ~ Right Care Now ~ sabend@rightcarenowproject.org sabend@rightcarenowproject.org NOTE: Additional informational slides are included at the end of this presentation in the Background Materials section 12

13. Clinical Document Exchange September, 2015

14. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange MU2 EMR send CCD to MU2 EMR receive CCD Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CCD

15. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange MU2 EMR send CCD to Kno2 user receiving CCD or convert to PDF Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CCD

16. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange Kno2 user sends PDF (Kno2 converts to CDA ) to MU2 EMR receives CDA Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CDA

17. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange Case managers can receive all documents from all technologies and care settings Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CDA CCD HL7

18. Susan L Abend, MD, FACP

19. Purpose  Develop methods to improve the health and well being of individuals with D/ID  Improve care coordination  Remove barriers to integrating care  Improve accountability for optimal care

20. For Individuals with Developmental/Intellectual Disabilities Our Electronic Monitoring System:  Improves the quality and outcome of care plans  Creates “smart” Personal Health Records  Monitors implementation for accountability

21. Use Case Activities  Send and Receive Plan  Access, View, Review Plan  Update Plan

22. eClinicalWorks TM Platform The core product is built on these underlying components:  MSSQL database to hold all the metadata content  Tomcat - the application layer which is where our code operates from and interacts with the database  FTP server to host documents stored in the system with references to it

23. Interoperability  Interoperability achieved many different ways:  HL7 based interfaces  CCD exchange based interfaces  REST based services  DIRECT protocols etc  Not always straightforward  to pick a method and determine scope and costs we proceed to a requirements-gathering phase

24. Contact Susan L Abend, MD, FACP Chief Executive Officer The Right Care Now Project, Inc. 1900 West Park Drive, Suite 280 Westborough, MA 01581 (508)983-1488 sabend@rightcarenowproject.org

25. Next Steps Over the next few weeks, the eLTSS Internal Team will introduce the Exemplar Technical Solutions/Frameworks and associated Exemplar Standards These presentations will help to assist in the “matchmaking process” between committed vendors and TEFT states in preparation for the Pilots Phase If you are interested in piloting, please express your interest using the Pilot Interest Survey form: – http://wiki.siframework.org/electronic+Long+Term +Services+and+Supports+Pilot+Interest+Survey http://wiki.siframework.org/electronic+Long+Term +Services+and+Supports+Pilot+Interest+Survey 25

26. Comments/Discussion 26

27. eLTSS Initiative: Project Team Leads ONC Leadership – Mera Choi (mera.choi@hhs.gov)mera.choi@hhs.gov – Elizabeth Palena-Hall (elizabeth.palenahall@hhs.gov)elizabeth.palenahall@hhs.gov – Patricia Greim (Patricia.Greim@hhs.gov)Patricia.Greim@hhs.gov CMS Leadership – Kerry Lida (Kerry.Lida@cms.hhs.gov)Kerry.Lida@cms.hhs.gov Community Leadership – Andrey Ostrovsky (andrey@careathand.com)andrey@careathand.com – Mary Sowers (msowers@nasddds.org)msowers@nasddds.org – Terry O’Malley (tomalley@mgh.harvard.edu)tomalley@mgh.harvard.edu Initiative Coordinator – Evelyn Gallego-Haag (evelyn.gallego@siframework.org)evelyn.gallego@siframework.org Project Management – Lynette Elliott (lynette.elliott@esacinc.com)lynette.elliott@esacinc.com Use Case & Functional Requirements Development – Becky Angeles (becky.angeles@esacinc.com)becky.angeles@esacinc.com Pilot Guide Development – Grant Kovich (grant.kovich@accenture.com)grant.kovich@accenture.com – Atanu Sen (atanu.sen@accenture.com)atanu.sen@accenture.com Pilots Management – Jamie Parker (jamie.parker@esacinc.com)jamie.parker@esacinc.com Standards and Technologies Identification – Angelique Cortez (angelique.j.cortez@accenture.com)angelique.j.cortez@accenture.com 27

28. Comments/Discussion 28

29. Susan L Abend, MD, FACP

30. Purpose  Develop methods to improve the health and well being of individuals with D/ID  Improve care coordination  Remove barriers to integrating care  Improve accountability for optimal care

31. Who We Are  An interdisciplinary team of providers who care for individuals with D/ID  Recognize specific, complex health needs of the D/ID community  Frequently observe unmet needs and inadequate care  501 c(3) nonprofit organization

32. Disparities Increased Mortality: Lower life expectancy Increased Morbidity: Epilepsy, sensory impairment, GI disorders, fractures Increase in negative Obesity & underweight, low determinants of employment, fewer social health: connections & meaningful relationships Access to services: Low rates of uptake of health promotion Quality of services High rates of prescribed antipsychotics High rates of unrecognized disease -Krahn, 2006; Linehan 2005

33. Morbidity and Mortality  Adults with D/ID have ~2X prevalence of unmet medical needs  40% have unmet dental needs  Low rates of sensory assessments  >33% have obesity  up to 50% have low bone density  2-18X death rate for common causes Anderson, 2003; Special Olympics 2005; Tyrer, 2009; Nehring 2005; McCarthy 2011

34. Barriers to Care Integration Primary Care Behavioral Health Neurology Care

35. Failure Chain Weak information sources Weak knowledge of best practices Lack of expert careINEFFECTIVE CARE PLANS

36. A Solution: The RCNP Monitoring System  Acquires relevant information from each patient  Medical, behavioral, function, QOL  Collects data at regular intervals  Detects changes that indicate health risk  Changes in health/function/QOL  Missing preventative services

37. The RCNP Monitoring System  Made possible by generous donation from eClinical Works, Inc.  Foundation is eClinical Works ambulatory systems technology  ONC-HIT certified  Fully capable HIE

38. Implementation  Notify individuals and all stakeholders of detected health risks/issues  Extend expert assistance  Recommendations for evaluation and management  Best practices, consensus guidelines  Create accountability  Revisit to assess interventions/improvement

41. PHR 2.0- The Health Passport  Up-to-date, need-to-know information  Provides framework and context for all caregivers to identify issues  Empowers the individual to communicate  Important concerns that the caregiver needs to address  Issues that impact quality of life  Extends caregiver expertise

44. Consultative Support  National network of specialists with experience and skill in caring for individuals with D/ID  Interdisciplinary assessments available  In-person or video conferencing  Education and training for all stakeholders

45. Research and Education  Review data for trends  Collaboration with Human Services Research Institute  Evaluate best practices  Publish observations  Train residence and healthcare providers to identify and manage health issues and risks

46. Goal Improve care and decrease suffering by:  Monitoring for health risks  Coordinating caregivers to integrate care  Creating accountability through monitoring and notification  Learning and then teaching best practices of care

47. Vision We envision a future in which no adult living with intellectual disability suffers needlessly because of inadequate or inexpert care.

48. Contact Susan L Abend, MD, FACP Chief Executive Officer The Right Care Now Project, Inc. 1900 West Park Drive, Suite 280 Westborough, MA 01581 (508)983-1488 sabend@rightcarenowproject.org

49. Clinical Document Exchange September, 2015

50. Estella, age 65, is a widower and lives in her government assisted apartment. Her primary care giver is her 45 year old daughter, Rebecca and Estella also has non-medical home care for cleaning personal care, including bathing. Estella is being treated for renal failure and is also suffering from diabetes, related neuropathy and obesity. Estella is restricted to a wheel chair and just recently she was diagnosed with peripheral arterial disease (PAD). Rebecca recently had to take a second job and has not had time to visit Estella regularly and on a recent visit discovered that Estella’s right leg is discolored and cold. Estella is admitted to the hospital and gangrene is diagnosed and her right leg is amputated below the knee. After 2 days in the hospital Estella begins Physical therapy and 5 days after the surgery she is transitioned to a Rehab facility and 21 days later she is transitioned to the Skilled Nursing Facility because the wounds are not healing quickly enough to allow her to return to her apartment. She continues her dialysis treatment and is has regular visits to her various providers, which has recently be expanded to a mental health counselor due to depression from the loss of her lower right leg. The Care Plan outlines Estella’s goal to return to home and her cats. Estella’s 40 year old son, Mike, lives 200 miles away and now wants to be more involved with his mother’s healthcare and to have access to all of the information, so he set up a personal health record (PHR) in Microsoft Healthvault. Mike contacts Estella’s providers and requests the progress notes and other documents be sent to Estella’s PHR after each provider visit, using her Direct address.

51. Estella’s care team now includes: Jennifer her Case Manager Rebecca her daughter Mike her son Dr. Smith her Nephrologist, EMR, connected to HIE Dr. Jones her Internist, diabetes, EMR and paper Dr. Wilson her Cardiologist, EMR, connected to HIE Sara her Physical Therapist, paper Dr. Simon, Behavioral health counselor, EMR and paper The nurses at the Skilled Nursing Facility, EMR and paper Documents that need to be available Advance Directive Power of Attorney Transitions of care CCD (C-CDA) Therapy notes Medication lists and reconciliation Lab results ADT messages from the hospital Progress notes from each provider Each provider wants their own complete record for Estella and currently they fax documents back and forth to each other, as needed prior to and after each office visit. Problem The context for Estella’s office visits and her providers is manual and needs to be automated and available to all providers of her care. Not all of the providers are using EMR’s or technology equally. Only some are connected to an HIE if present and not all of the needed information is available in an HIE. Solution Direct messaging that works for everyone and everything. Each provider wants their own complete record for Estella and currently they fax documents back and forth to each other, as needed prior to and after each office visit. Problem The context for Estella’s office visits and her providers is manual and needs to be automated and available to all providers of her care. Not all of the providers are using EMR’s or technology equally. Only some are connected to an HIE if present and not all of the needed information is available in an HIE. Solution Direct messaging that works for everyone and everything.

52. eLTSS Plan Physical Therapist PAPER Connecting the Community through Clinical Document Exchange Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER PHR eLTSS Record HIE Beneficiary - Estella Family POA EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS

53. Content and Structure Transport and SecurityCross Category SDO’s / Vendors C-CDA; HL7v2.0 Direct; Equifax Level 3 Assurance; Two-Factor Authentication; SSL; Hybrid AES/RSA, encryption for data at rest Microsoft Azure; HTML5; CSS3; Rest HL7; IETF; W3; Microsoft; NIST; Surescripts Tiers 1, 2 and 3

54. Direct; Direct message. Message only or with payload/attachment, structured or unstructured CCD, CCDA, HL7, PDF, Care Plan (Draft, Approved, Authorized, Modified) Surescripts HISP and HISP to HISP exchange DirecTrust accredited Activation Team and services Education Webinars about interoperability Transport

55. Online Registration process (10 minutes) Two-Factor Authentication Equifax Level 3 Assurance Reports for partner orgs for community connections SSL (encryption in transit) Hybrid AES/RSA (encryption for data at rest) Security

56. Microsoft Azure (http://azure.microsoft.com/en-us/support/trust- center/compliance/) – Trust Center and compliance categories including HIPAA.http://azure.microsoft.com/en-us/support/trust- center/compliance/ HTML5 for browser compatibility CSS3 for display of structured data Cross Category

57. HL7 (http://www.hl7.org/)http://www.hl7.org/ CDA release 2 HL7 2.x Patient Care Report release 1 - NEMSIS IETF (www.ietf.org) – Internet Engineering Task Forcewww.ietf.org W3 (http://www.w3.org/) – Web Standardshttp://www.w3.org/ Microsoft - Hosting environment NIST (http://www.nist.gov/) – Security, ID Proofinghttp://www.nist.gov/ SDO / Vendors

58.  All tiers are supported. Only need an internet connection and current browser, no need for a fax machine, fax service or fax server and receive only is $ 0. www.kno2.comwww.kno2.com o Tier I: Basic, Non-Electronic Information Exchange  “lightweight approach focused on establishing an information infrastructure that will support Tiers II and III. This Tier will target change management, workflow redesign and testing to facilitate future electronic information sharing” o Tier II: Secure, Electronic Data Exchange o Tier III: Complete eLTSS Data Model and Exchange  Sender of Direct messages dictates the original format and Kno2 recipient can adjust the format of the content for their environment  API’s are available for integration into any platform for sending and receiving Summary based upon Three Tiered Pilot approach

59. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange MU2 EMR send CCD to MU2 EMR receive CCD Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CCD

60. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange MU2 EMR send CCD to Kno2 user receiving CCD or convert to PDF Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CCD

61. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange Kno2 user sends PDF (Kno2 converts to CDA ) to MU2 EMR receives CDA Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CDA

62. Physical Therapist PAPER Connecting the Community through Clinical Document Exchange Case managers can receive all documents from all technologies and care settings Internist EMR/PAPER Hospital EMR Skilled Nursing-Rehab PORTAL Cardiologist EMR Nephrologist EMR Behavioral Health EMR/PAPER EMR Direct Messaging MU2 Home Health/Care PAPER CHARTS Payers/CMS Case Manager EMR Beneficiary Estella PHR EMR CDA CCD HL7