1. Consumer Workgroup Interoperability Roadmap Comments Workgroup Discussion March 24, 2015 Christine Bechtel, chair

2. AGENDA I. Call to Order/Roll Call Michelle Consolazio, Office of the National Coordinator Meeting Objective: Review Interoperability Roadmap II. Review of Agenda Christine Bechtel, Chair III. Review Comments on Interoperability Roadmap – Section D - Workgroup Discussion: Slide contents reflect individual comments, NOT the views of the workgroup at this time. IV. Next Steps – Next Meeting: Tuesday, March 30, 2015; 9:30 – 11:00 a.m. 2

3. HITPC – Interoperability Road Map Consumer Workgroup - Charge WorkgroupConsumer General Questions (as they apply to the assigned Roadmap sections) Are the actions proposed in the draft interoperability Roadmap the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Roadmap Sections C. Individuals are empowered to be active managers of their health D. Care providers partner with individuals to deliver high value care 3

4. Member Comments Section D Section D should be revised to better emphasize the clinical-patient partnership Sections C and D –should consider integrating them both – at the very least an explanation of the broad principles and goals that underlie the section Section D technologies are very limited & restricted to existing health IT – new technologies, data liquidity, processing power and bandwidth will increase Section D is potentially overwhelming. Overall suggest – Focus more on outcomes and less on process. 4

5. Member Comments Absence of input & output filters that allow for trusted and efficient use of technology; consumers set preferences, providers ability to filter data so it is usable and useful Prohibition on cost shifting with regard to mHealth/HIT – addressing disparities 5

6. Section D: Categories 6 Section D: Care Providers Partner with Individuals to Deliver High Value Care

7. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS D1. Organization/ Governance 1. Call to action: Providers should participate in governance of interoperability at all levels, from regional efforts to nationwide coordinated governance 2. Call to action: Providers should continue to provide input on the evolution of coordinated governance to support a learning health system. 3. Call to action: Providers should remain active in coordinated governance.

8. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 8 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Providers should participate in governance of interoperability at all levels, from regional efforts to nationwide coordinated governance Rephrase: Providers, consumers, and patients should participate in governance of interoperability at all levels, from regional efforts to nationwide coordinated governance Where governance is needed patients and providers should be included Are there mechanisms to facilitate this? Few differences between the three timelines 2018-2020 Expand interoperable health IT and users Comments 2. Call to action: Providers should continue to provide input on the evolution of coordinated governance to support a learning health system. Rephrase: Providers, consumers, and patients should continue to provide input on the evolution of coordinated governance to support a learning health system. 2021-2024 Achieve nationwide LHS Comments 3. Call to action: Providers should remain active in coordinated governance. Rephrase: Providers, consumers, and patients should remain active in coordinated governance.

9. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set D2. Providers embrace a Culture of Interoperability and work with vendors and other supporting entities to improve interoperability 1. Call to action: Providers should routinely expect electronic access to outside information in the provision of care and engage with other providers to send, receive, find and use health information for their patients. 2. Call to action: Providers should recognize that valuable clinical information about their patients may reside with patients or caregivers themselves and that they may need to incorporate that information into their decision making. 3. Call to action: Providers and their organizations should embrace the use of enabling technologies such as publish/subscribe and query-based exchange with single sign-on to minimize workflow barriers to interoperability. 4. Call to action: Providers and their organizations should ensure contracts and agreements that they sign and re-sign with technology developers include necessary requirements for interoperability, to ensure they can share and incorporate patient information.

10. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2018-2020 Expand interoperable health IT and users D2. Providers embrace a Culture of Interoperability and work with vendors and other supporting entities to improve interoperability 5. Call to action: Providers should routinely access and use health information from other sources, including individuals, when making clinical decisions 6. Call to action: Providers should routinely populate key data when E-prescribing in support of unambiguous prescription for verification, counseling, monitoring and activities of comprehensive medication management. 7. Call to action: Providers and their organizations should work with necessary parties to configure systems to alert providers to the presence of relevant information from other sources and make it conveniently available to the provider. 8. Call to action: Providers and their organizations should work with necessary parties to configure systems so that the presentation of information to providers is configurable based on use case, provider specialty and other characteristics, to facilitate usability and patient safety.

11. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2021-2024 Achieve nationwide LHS D2. Providers embrace a Culture of Interoperability and work with vendors and other supporting entities to improve interoperability 9. Call to action: Providers should practice in a new way, with a new culture of electronic health information sharing, access and use for both clinicians and institutions is firmly established. 10. Call to action: Providers should routinely use and have access to robust and clinically relevant decision support (e.g. for medication management). 11. Call to action: Providers should regularly use and have access to the most relevant, integrated information, appropriate notifications. 12. Call to action: Providers should receive and provide continuous feedback to support the improvement of decision-making, care processes and outcomes. 13. Call to action: Providers should use new evidence-based guidelines and tools for care that are disseminated rapidly to providers through decision support and other timely and context-sensitive pathways.

12. D2. Providers embrace a Culture of Interoperability and work with vendors and other supporting entities to improve interoperability REPHRASE: Providers embrace a Culture of Interoperability and work with consumers, patients, vendors and other supporting entities to improve interoperability 12 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Providers should routinely expect electronic access to outside information in the provision of care and engage with other providers to send, receive, find and use health information for their patients. “Provision of services and supports” rather than “care” “outside information” not the best phrase. Are we talking peer-review curated/non-curated? Liability issues need to be worked thru with stakeholders New call to action: Vendors should build tools and interfaces that make “outside information,” including information from patients, easy to digest and act upon for providers, so it becomes a seamless part of their workflow. 2. Call to action: Providers should recognize that valuable clinical information about their patients may reside with patients or caregivers themselves and that they may need to incorporate that information into their decision making. Strongly support – critical to realizing meaningful partnerships between health care providers and patients Suggestion: Providers should encourage their patients to use digital health technologies to manage their health or Providers should accept patient generated data as part of clinical decision making. Will require documentation in MU/Certification (??) 3. Call to action: Providers and their organizations should embrace the use of enabling technologies such as publish/subscribe and query-based exchange with single sign-on to minimize workflow barriers to interoperability. Strongly support.

13. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 13 2015-2017 Send, receive, find and use a common clinical data set Comments 4. Call to action: Providers and their organizations should ensure contracts and agreements that they sign and re- sign with technology developers include necessary requirements for interoperability, to ensure they can share and incorporate patient information. Could this be operationalized through certification – so developers cannot block Requirements should include: o Patients able to send and create information to be shared. o ”Set and Forget” patients register the destination app of their choice so that all changes occurring (TOC) automatically sent to the app of their choice (Bluebutton Plus) o Provenance o “tamper proof seal” o Equal level of assurance for all stakeholders to include transparent directories for public level secure email exchange 2018-2020 Expand interoperable health IT and users Comments 5. Call to action: Providers should routinely access and use health information from other sources, including individuals, when making clinical decisions Include: Provenance, “tamper proof seal” ; Levels of identity assurance Other sources should include social and community-based services and supports important to the individual 6. Call to action: Providers should routinely populate key data when E- prescribing in support of unambiguous prescription for verification, counseling, monitoring and activities of comprehensive medication management. Statement is ambiguous

14. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 14 2018-2020 Expand interoperable health IT and users Comments 7. Call to action: Providers and their organizations should work with necessary parties to configure systems to alert providers to the presence of relevant information from other sources and make it conveniently available to the provider. # 7 and #8 should be combined to provide more clarity to the statement Alerting ecosystem should include CIT (?) You can see the value of recall data, say based on UDI matching triggering a patient-specific EMR alert. On the other hand drug company recommendations appearing might be less valuable. So, this needs to be fleshed out 8. Call to action: Providers and their organizations should work with necessary parties to configure systems so that the presentation of information to providers is configurable based on use case, provider specialty and other characteristics, to facilitate usability and patient safety. Individually configured usable design

15. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 15 2021-2024 Achieve nationwide LHS Comments 9. Call to action: Providers should practice in a new way, with a new culture of electronic health information sharing, access and use for both clinicians and institutions is firmly established. Focus on simple exchange and query, making all interoperability easy. This should be #1 albeit that the Call for action is that stakeholders should cooperate to figure out how to make this happen 10. Call to action: Providers should routinely use and have access to robust and clinically relevant decision support (e.g. for medication management). This should be earlier in the timeline Decision support will increasingly include the patient’s values and preferences. Shared decision making with patients, assures that decisions include evidence and patient concerns, values and direction. Certified decision aids 11. Call to action: Providers should regularly use and have access to the most relevant, integrated information, appropriate notifications. Including community living and social supports Use the HL7 infobutton standard in URL or query based exchange

16. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 16 2021-2024 Achieve nationwide LHS Comments 12. Call to action: Providers should receive and provide continuous feedback to support the improvement of decision-making, care processes and outcomes. This should also include shared decision making with patients and families Should this also connect to the research enterprise? 13. Call to action: Providers should use new evidence-based guidelines and tools for care that are disseminated rapidly to providers through decision support and other timely and context-sensitive pathways. Strongly support this notion, and clarify a link to evolving quality measures. OVERALL D2 SEEMS TO HAVE TO MANY OVERLAPPING UNDIFFERENTIATED CALLS TO ACTION

17. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS D3. Accurate Measurement 1. Call to action: Providers should leverage data beyond their internal systems for population health analytics and quality measurement (eCQMs) including supporting value- based payment models. 2. Call to action: Providers and other stakeholders should use standard metrics of interoperability to monitor and track improvement. 3. Call to action: Providers and other stakeholders should use standard metrics for interoperability and health outcomes to improve clinical care and processes. 4. Call to action: Providers should be able to report on measures based on the most representative data available about each patient. 5. Call to action: Public and private stakeholders should objectively measure and value interoperability and information sharing as an indicator of care coordination, quality and efficiency. 6. Call to action: Providers should be able to report on measures based on more complete and consistent representative data about each patient.

18. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions?

19. 19 2018-2020 Expand interoperable health IT and users Comments 4. Call to action: Providers should be able to report on measures based on the most representative data available about each patient. Providers can report on measures today – the problem is that the eCQMs we have today are not very advanced, and often don’t reflect interoperability. Government should invest in more advanced eCQMs and begin to slim down the focus on older process measures. Consider patient-reported measures here as well. 2021-2024 Achieve nationwide LHS Comments 5. Call to action: Public and private stakeholders should objectively measure and value interoperability and information sharing as an indicator of care coordination, quality and efficiency. Payment for outcomes that require interoperability – like robust care coordination, eVisits, reductions in duplicative testing, etc. These things must be paid for and measured. The government must begin now to outline a strategy for development of eCQMs, revision of current measure sets, and new payment approaches to incentive performance. Somewhere we need to emphasize the important grounding, baseline, reference to the cooperatively developed person-centered integrated services and support plan 6. Call to action: Providers should be able to report on measures based on more complete and consistent representative data about each patient. Rather than repeat same comments – WG will summarize comments that apply to this entire section.

21. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 21 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Providers should routinely leverage standards-based health IT to support prioritized workflows including: o Closed loop transitions of care o Secure clinical communications o Prior authorizations, medication co-pays and imaging appropriateness o CPOE for services and diagnostic testing o e-prescribing of controlled substances with concurrent availability of PDMP data Overall discussion point: Should this section focus on managing workfows for providers, or will the last section that advances measurement and payment necessarily drive workflow? Q: Are there specific patient/family-caregiver facing workflows that are important to add here? Does secure clinical communications include secure email between patients and providers (or only provider to provider)? Call to action: Providers should engage with an expanded set of interoperable workflows, including: Plug-and-play clinical decision support services - Including shared decision making with patients. -Decision aid certification (?? Seems like a role for government) Electronic consultations: Including virtual visits and coaching and shared decision making Reporting to specialty society registries Reporting to value-based payment programs e-prescribing supported by complete medication fill history Discovery and incorporation of information from patient-owned devices with tools for reconciliation and validation Recommendation of patients to relevant studies and trials Exchange of information to support comprehensive medication management and MTM services Workflow design must also consider workflow of patients and families, particularly as they evolve to being significant contributors and users of data

22. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 22 2018-2020 Expand interoperable health IT and users Comments 2. Call to action: Providers should engage with an expanded set of interoperable workflows, including: o Plug-and-play clinical decision support services o Electronic consultations o Reporting to specialty society registries o Reporting to value-based payment programs o e-prescribing supported by complete medication fill history o Discovery and incorporation of information from patient-owned devices with tools for reconciliation and validation o Recommendation of patients to relevant studies and trials o Exchange of information to support comprehensive medication management and MTM services

23. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 23 2021-2024 Achieve nationwide LHS Comments 3. Call to action: Providers should leverage a robust library of interoperable workflows to support care processes across the continuum of care, including tools for integration, reconciliation and validation of external information.

24. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS D5. Training and maintenance of certification for providers 1. Call to action: Public and private stakeholders should incorporate interoperability into the training of new providers and continuing professional education. 2. Call to action: Professional specialty boards and other certifying bodies should agree on standards for interoperable registries and maintenance of certification. 3. Call to action: Public and private stakeholders should agree on a way in which to measure progress and competency of trainees is evaluated and scored using interoperable, standards based clinical information. 4. Call to action: Professional specialty boards and other certifying bodies should receive most of the information required from their diplomats through information exchanged in a standard format. 5. Call to action: Professional specialty boards should utilize standardized electronic data and formats to populate registries.

25. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 25 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Public and private stakeholders should incorporate interoperability into the training of new providers and continuing professional education. WG not commenting on this section. 2. Call to action: Professional specialty boards and other certifying bodies should agree on standards for interoperable registries and maintenance of certification.

26. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 26 2018-2020 Expand interoperable health IT and users Comments 3. Call to action: Public and private stakeholders should agree on a way in which to measure progress and competency of trainees is evaluated and scored using interoperable, standards based clinical information. 4. Call to action: Professional specialty boards and other certifying bodies should receive most of the information required from their diplomats through information exchanged in a standard format. 5. Call to action: Professional specialty boards should utilize standardized electronic data and formats to populate registries.

27. Questions for Workgroup Discussion Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS D6. Innovation and Generation of New Knowledge and Evidence 1. Call to action: Providers currently engaged in clinical research and quality improvement should work together with research institutions and other public and private stakeholders to establish a strategic plan for research and the generation of new knowledge. 2. Call to action: Providers should further engage with the research community and should routinely offer patients and families participation in research and quality improvement programs. 3. Call to action: Community or region-wide Institutional Review Boards should ensure that the appropriate patient protections are in place to conduct multi- sourced clinical research. 4. Call to action: Researchers, providers and other stakeholders should accelerate and measure the pace of innovation and research, as well as the dissemination of new knowledge to improve health and care. 5. Call to action: Technology developers should enable patient- centered and future clinical research methods for accelerated deployment of research findings into clinical care.

28. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 28 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Providers currently engaged in clinical research and quality improvement should work together with research institutions and other public and private stakeholders to establish a strategic plan for research and the generation of new knowledge. Include the patient and Patient Reported Outcome Measures Such clinical research and quality improvement activities should be consistent with the philosophy and approach of PCORI (Patient-Centered Outcomes Research Institute) New call to action: Providers, researchers, vendors, and developers should use participatory research methods and engage consumers and patients in the co-design of digital health tools.

29. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 29 2018-2020 Expand interoperable health IT and users Comments 2. Call to action: Providers should further engage with the research community and should routinely offer patients and families participation in research and quality improvement programs. Should this be providers or associations or ? 3. Call to action: Community or region-wide Institutional Review Boards should ensure that the appropriate patient protections are in place to conduct multi-sourced clinical research.

30. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 30 2021-2024 Achieve nationwide LHS Comments 4. Call to action: Researchers, providers and other stakeholders should accelerate and measure the pace of innovation and research, as well as the dissemination of new knowledge to improve health and care. 5. Call to action: Technology developers should enable patient-centered and future clinical research methods for accelerated deployment of research findings into clinical care.

31. D7. Transparency of Value and engagement of patients, families, and caregivers

32. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 32 2015-2017 Send, receive, find and use a common clinical data set Comments 1. Call to action: Providers should work together with purchasers of care to have access to patient out- of-pocket costs and those of payers and purchasers. Providers are engaged in regional efforts to measure quality and maximize value. Providers should make cost, quality and value information available to patients, families and caregivers. (?- is this a call to providers or a call to employers, government and purchasers?) Patients and their representatives should also be engaged in regional efforts to measure quality and maximize value 2. Call to action: Providers should offer and encourage access to medical records and secure communications with all patients and any family and caregivers who are authorized to engage in such communications. Insert “authorized” family member and caregiver 3. Call to action: Providers should support consumers in downloading or transmitting their health information to a destination of their choice. And counsel them on the inherent privacy and security risks

33. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 33 2018-2020 Expand interoperable health IT and users Comments 4. Call to action: Providers should routinely utilize cost and quality data to make shared diagnostic and treatment planning decisions. Real time cost data for patients and providers. We should be working to integrate this cost data into shared decision making activities, platforms, etc. Clarify shared decisions with patients and families. 5. Call to action: Providers should work together with purchasers of care to develop, test and implement appropriate and credible indicators of value. How this relates to eCQMs and could these 2 be harmonized?

34. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 34 2018-2020 Expand interoperable health IT and users Comments 6. Call to action: Providers should support consumer-facing services such as: o Online scheduling o Medication refill requests o Electronic/Telehealth Visits o Patient provided device data, screenings and assessments o Informed consent and education modules o Integration of patient- generated health data in the medical record o Patient-defined goals of care o Shared care planning Shared “integrated person centered planning of services and supports” in place of “care” planning --Will be in overarching comments in the draft letter Timeline should be moved up for most of these items.

35. 1.Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 35 2021-2024 Achieve nationwide LHS Comments 7. Call to action: Providers should demonstrate the value of their care to those who receive and pay for it using objective, trusted metrics. 8. Call to action: Providers and individuals should work together to substantially reduce the burden of care coordination through patient- centered tools and sharing and use of electronic health information. “Services and supports coordination” rather than “care” coordination The burden for who? And shouldn’t this be done earlier? How can we connect this to the earlier actions around interoperability? 9. Call to action: Individuals should interact easily and seamlessly with their care team as they transition into and out of the health care system, communicating remotely with their care team as needed over time, rather than only in face-to- face care situations. “Services and supports team” rather than “care” team This seems like an outcome of many collective actions rather than a call to action. Clarify not waiting until 2021 to communicate remotely…. Expand the care team roster to include: Virtual care, coaching and education

36. Next Steps Next Meeting: Monday, March 30, 2015; 9:30 – 11:00 a.m. 36