1. HEALTH HOMES NOVEL PROTOTYPE

2. HEALTH HOMES ARE COOL SOLUTIONS FOR PROBLEMS THAT EXIST TODAY Patients don’t go to the right doctor What if a care coordinator could guide a patient Care transitions fail 70% of the time when the patient is responsible What if the patient didn’t have to facilitate communication between providers On average it take 17 years for a best practice to become a common practice

3. TECHNOLOGY STANDARDS AND SYSTEMS ENABLE HEALTH HOMES Standards Exist Integration Effort We are going to show you one simple scenario of how existing systems and standards can be the infrastructure that enable your health home policies

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5. SYSTEM STACK – ELEMENT 1 (EHRS) BH Providers (WITS) Hospitals Long-Term Care/ HCBS FQHCs Developmental Disabilities Quality Measures Custom Queries Providers and EHRs

6. STANDARDS STACK – ELEMENT 1 (EHRS) The Continuity of Care Document (CCD) Standardizes Medical Records File Formats So that people have portable medical records CCD BH Providers (WITS) Hospitals Long-Term Care/ HCBS FQHCs Developmental Disabilities Providers and EHRs

7. SYSTEM STACK – ELEMENT 2 (HIE) Secure Record Sharing HIE A DIRECT HIE is: 1.A Directory of Participating Care Provider Addresses (ex doctor@direct.hie.com) 2.Compatible with EHRs, email, and PHRs

8. STANDARDS STACK – ELEMENT 2 (HIE) Secure Record Sharing HIE CCD DIRECT An HIE is: 1.A Directory of Participating Care Providers (Internet Address) 2.Secure Transmission of Interoperable Records (Encryption) 3.Assured Record Authenticity (Digital Signing)

9. SYSTEM STACK – ELEMENT 3 (C2S) Patient Sharing Preferences enforced at the HIE level so that Providers only share records when the patient allows is Secure Record Sharing HIE Consent2Share 42 CFR pt2

10. STANDARDS STACK – ELEMENT 3 (C2S) So that providers only share records when the patient allows: Consent2Share uses an eXtensible Access Control Markup Language (XACML) standard so that HIEs can determine if the patient has provided permission Consent2Share DIREC T CCD XACM L Secure Record Sharing HIE Consent2Share 42 CFR pt2

11. Transition: txt SYSTEM STACK – ELEMENT 4 (POP HEALTH)

12. Quality Reporting Document Architecture QRDA STANDARDS STACK – ELEMENT 4 (POP HEALTH)

13. Transition: txt SYSTEM STACK – ELEMENT 5 (QUERY HEALTH)

14. Quality Reporting Document Architecture QRDA STANDARDS STACK – ELEMENT 5 (QUERY HEALTH) Continuity of Care Document CCD Health Quality Measures Format HQMF

15. STANDARDS STACK – ELEMENT 6 (HEALTH HOME) Transition: txt

16. SO THAT CARE COORDINATORS CAN…. Transition: txt

17. NOW A NOVEL LOOK AT A HEALTH HOME PROTOTYPE DIRECT CCD XACML Quality Measures Statistics

18. Secure Record Sharing Home Health Functions ReferralsPlans of Care Billing BH Providers (WITS) Hospitals Long-Term Care/ HCBS FQHCs Developmental Disabilities HIE Consent2Share 42 CFR pt2 Query Health popHealth Quality Measures Custom Queries Providers and EHRs Care Coordination

19. Home Health Functionality ReferralsPlans of CareCare CoordinationBilling BH Providers (WITS) Hospitals Long-Term Care/ HCBS FQHCs Developmental Disabilities Providers and EHRs CCD HIE Consent2Share 42 CFR pt2 XACML Query HealthGold popHealth Quality MeasuresCustom Queries DIRECT Quality Measures Statistics

20. Providers and EHRs

22. Health Information Exchange

23. Consent 2 Share