1. Longitudinal Coordination of Care Pilots WG Monday, September 30, 2013

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. TopicPresenter Introductions and PurposeLynette Overview of CORHIOPam Overview of Pilot wiki and toolsLynette Agenda 3

4. Purpose –Provide tools and guidance for managing and evaluating LCC pilot Projects –Create a forum to share lessons learned and best practices –Provide subject matter expertise –Leverage existing and new partnerships Goals –Bring awareness on available national standards for HIE and care coordination –Real world evaluation of parts of most recent HL7 C-CDA Revisions Implementation Guide (IG) –Validation of ToC and Care Plan/HHPoC datasets Pilot Work Group Purpose and Goals 4

5. LCC Pilot WG Timeline: Aug 2013 – Sept 2014 Aug-Sept 13Oct- Nov 13Dec- Jan 14Feb- Mar 14Apr- May 14Jun- Jul 14Aug- Sep 14 Milestones Updated HL7 C- CDA IG Complete HL7 Fall Ballot Close LCC Pilot Monitoring & Evaluation LCC Pilot Proposal Review HL7 Ballot Publication LCC Pilots Close HL7 Ballot & Reconciliation LCC Pilot WG Launch IMPACT Go-Live NY Care Coordination Go-Live HL7 C-CDA IG Revisions LCC Pilot Wrap-Up LCC Pilot Test Spec. Complete HL7 Ballot LCC Pilot WG

6. LCC Pilot WG Tasks 6 Target MMPilot WG Tasks (Agenda)WG Homework Sept 13 Launch LCC Pilot WG Review Pilot Planning Tools Review and submit LCC Pilot Documentation Templates Oct 13 Present MA IMPACT Go-Live Plan Review Pilot Requirements Traceability Matrix (RTM) Review Pilot Proposal Criteria Matrix Present Pilot Proposals Review: LCC Pilot RTM Submit LCC Pilot Proposals Evaluate Pilot Proposals Nov-Dec 13 Present NY Downstate Go-Live Plan Present and evaluate Pilot Proposals Present IMPACT Pilot Status Present NY DD Pilot Status Review: Pilot Evaluation Template Jan-Feb 14 Present LCC Pilots Status Review Phase 1 Performance Metrics for IMPACT & NY DD Pilots Gather Pilot Performance Data Mar-Apr 14 Present LCC Pilots Status Review Phase 1 Performance Metrics for NEW* Pilot Sites Gather Pilot Performance Data May-Jun 14 Present LCC Pilots Status Review Phase 1 Performance Metrics for NEW* Pilot Sites Review Phase 2 Performance Metrics for IMPACT & NY DD Pilots Review recommended revisions to C-CDA IG Gather Pilot Performance Data Submit recommended C-CDA revisions July-Sept 14 Review Phase 2 Performance Metrics for NEW* Pilots Review and consolidate recommended revisions to C-CDA IG Close out Pilots LCC Pilots Open House Gather Pilot Performance Data Review recommended C-CDA revisions

7. Longitudinal Coordination of Care Pilots WG CORHIO-LTPAC Transitions Program September 30, 2013 Pamela Russell, LTPAC Program

8. Agenda About CORHIO Initial Outreach through surveys and letters Participating LTPAC Providers Milestones and Measures Statistics on Usage and Queries Lessons Learned Q&A

9. About CORHIO Who We Are Colorado Regional Health Information OrganizationColorado Regional Health Information Organization A nonprofit, public-private partnershipA nonprofit, public-private partnership The state-designated entity for health information exchange (HIE) in ColoradoThe state-designated entity for health information exchange (HIE) in Colorado Vision Shared health information for all individuals in every Colorado community promoting the right care, at the right time and the right place.Shared health information for all individuals in every Colorado community promoting the right care, at the right time and the right place. Goals for 2015 Health information exchange deployed in every community 85% of providers are meaningful users of electronic health records (EHRs)

10. Health Information Organization Care Transitions: Long-Term & Post- Acute Care Medicaid EHR Incentive Program Outreach Behavioral Health Integration Regional Extension Center Assist providers with EHRs & Meaningful Use CORHIO Health Information Exchange (HIE)

11. CORHIO By the Numbers Office-Based Physicians/Providers Connected or in Implementation Hospitals Connected or in Implementation (30 are already connected to the HIE) Unique Patients With Clinical Data in the HIE Data current as of Aug 20, 2013 Long-Term, Post-Acute Care, Home Health Facilities Connected or in Implementation 45 119 1,800+ 2,582,675

12. Labs Participating in HIE Cedar Diagnostics Colorado Lab Services LabCorp Quest Diagnostics Schryver Medical Bold = Connected to HIE (Live) Non-bold = Under agreement, in implementation

13. LTPAC Program –The Beginning What’s HIE? Initial Outreach – Survey letters to LTPAC Providers Community Meetings in targeted communities – Area Agency on Aging – CFMC – state QIO – CHA – Colorado Hospital Association – CHCA – Colorado Healthcare Association Collaborations with hospitals, physician practices, care coordinators and care transition community groups Participant Agreement Milestones and Measures

14. What is HIE in Colorado? The ability to electronically exchange patient health information including: Lab/pathology results Imaging/radiology reports Scheduled Orders ADT’s, H & P’s Discharge Summaries Transcribed notes Continuity of Care Documents (CCDs) …when it’s needed for patient care.

15. CORHIO HIE CORHIO, as SDE, manages the State Medicaid Health IT Plan and has a strategic roadmap for statewide HIE projects CORHIO currently supports HL7 2.5.1 transaction level information, Human readable CCDs in PDF directly from HIE. CORHIO is actively working on extracting structured CCDAs from CEHRT and publishing CCDAs into the HIE by Spring 2014. CORHIO will align with Colorado OIT recommendations supporting commercial technical solutions utilizing industry standards including Direct, Blue Button, HL7, etc. These developments will support PHR implementations throughout Colorado

16. It Takes a Community… CORHIO Helps All Providers in the Community Share Info & Coordinate Care

17. LTPAC Program Outreach Survey letters sent to 350 long-term and post-acute care providers Gathered information on IT readiness, internal resources and interest Participant Agreements completed and sent Business Associate Agreements completed and sent – Revised Sept. ‘13 – Policies and Procedures - HIPAA – Opt Out language – User Request Forms with user name and password – Auditing Reports Workflow Process both internal and external assessed

18. Internal LTPAC Resources Internal CORHIO staff – LTPAC Program Manager – Finance/Contract Manager PA’s BAA’s Milestones and payments AARA Report – Surveys – all three – MarCom – video, collaterals – Ops – Implementation and Training including Policy and Procedures Opt Out language User Request Forms

19. http://wiki.siframework.org/LCC+Pilots+WG How Can You Participate in the LCC Pilot SWG? 19

20. Summary of Documentation Templates & Reference Materials (Pilot Materials) 20 Document NameDescription Pilot Overview Document An overview of the LCC Pilots Workgroup including a Value Statement for Participating Entities, Benefits of Participation as an LCC Pilot Site and steps for How to Get Started. Work Group Planning Presentation A Reference presentation for potential pilots that provides an overview of the Transition of Care and Longitudinal Coordination of Care Problems, the Role of Standards for Problem Resolution, and Overviews of the IMPACT and Downstate New York Care Coordination Projects. Pilot Documentation Template A PowerPoint template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot. Pilot Plan Template A word template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot.

21. Homework Assignment: –Complete Pilot Survey –Sign up as an LCC Committed Member –Submit Pilot Documentation Templates Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG http://wiki.siframework.org/LCC+Pilots+WG Email to Lynette Elliott (Lynette.elliott@esacinc.com)Lynette.elliott@esacinc.com NO Meeting next week due to HL7 WGM in Boston, MA Next Steps 21

22. LCC Leads –Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org) –Dr. Terry O’Malley (tomalley@partners.org) –Dr. Bill Russell (drbruss@gmail.com) –Sue Mitchell (suemitchell@hotmail.com) LCC/HL7 Coordination Lead –Dr. Russ Leftwich (Russell.Leftwich@tn.gov) Federal Partner Lead –Jennie Harvell (jennie.harvell@hhs.gov) Initiative Coordinator –Evelyn Gallego (evelyn.gallego@siframework.org) Project Management –Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com) –Use Case Lead: Becky Angeles (becky.angeles@esacinc.com) LCC Initiative: Contact Information 22 LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Carehttp://wiki.siframework.org/Longitudinal+Coordination+of+Care