1. Longitudinal Coordination of Care (LCC) Workgroup (WG) Review of HITPC MU Stage 3 Request For Comments (RFC) January 09, 2013 1

2. Overview S&I Longitudinal Coordination of Care (LCC) Overview Key Accomplishments of the LCC WG Care Plan & Meaningful Use Health IT Policy Committee (HITPC) MU3 Request for Comment (RFC) –RFC Care Plan Questions –S&I LCC WG Care Plan Considerations Summary & Discussion Next Steps: –Expanded collaboration and participation 2

3. S&I Longitudinal Coordination of Care (LCC) Workgroup Initiated in October 2011 as a community-led initiative with multiple public and private sector partners, each committed to overcoming interoperability challenges in long-term, post-acute care (LTPAC) transitions Supports and advances interoperable health information exchange (HIE) on behalf of LTPAC stakeholders and promotes LCC on behalf of medically-complex and/or functionally impaired persons Goal is to identify standards that support LCC of medically-complex and/or functionally impaired persons that are aligned with and could be included in the EHR Meaningful Use Programs Seeks to influence Meaningful Use Stage 3 Consists of three sub-workgroups (SWGs): –Longitudinal Care Plan (LCP) –LTPAC Care Transition –Patient Assessment Summary (PAS) 3

4. Longitudinal Coordination of Care Workgroup Patient Assessment Summary (PAS SWG LTPAC Care Transition SWG Longitudinal Care Plan SWG Providing subject matter expertise and coordination of SWGs Developing systems view to identify interoperability gaps and prioritize activities, and align identified standards with the EHR MU Program Engage directly with HL7 to establish the standards for the exchange of patient assessment summary documents Inform the development of the Keystone Beacon PAS Document Exchange Identify the key business and technical challenges that inhibit LTC data exchanges Define data elements for long-term and post-acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries Identify standards for an interoperable, longitudinal care plan which aligns, supports and informs person-centric care delivery regardless of setting or service provider 4 LCC Sub Workgroups (SWG) *Care Plan will enable providers to create, transmit and incorporate goals, objectives, and outcomes for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers. GOALSGOALS COMMUNITY-LED INITIATIVE

5. Key Accomplishments 1.LCC Use Case. Outlines three scenarios for health information exchanges between LTPAC and acute care settingsLCC Use Case 2.LCC Whitepaper. Meaningful Use Requirements For: Transitions of Care & Care Plans For Medically Complex and/or functionally Impaired Persons.LCC Whitepaper. 3.Transitions of Care Data Set. Developed 480+ data elements needed by receiving clinicians to safely and appropriately care for patients at times of transitions of Care.Transitions of Care Data Set 4.Stage 2 MU C-CDA Refinements. Supported and advanced, with HL7, refinements to C-CDA for interoperable exchange of Functional Status, Cognitive Status, & Pressure UlcerStage 2 MU C-CDA Refinements 5.HL7 Balloted Patient Assessment IGs (avail. DEC2012)HL7 Balloted Patient Assessment IGs (avail. DEC2012) –CDA R2 Questionnaire Assessment –Consolidated CDA LTPAC Summary (formerly Patient Assessment Summary) 5

6. 6 CARE PLANS & MU Jennie Harvell, ASPE Jennie.harvell@hhs.gov

7. Why Exchange of a Care Plan is Important The S&I LCC WG believes that: –The exchange of a care plan is needed to support coordination and continuity of care, particularly on behalf of medically complex/functionally impaired persons; and –The concept of Care Plan and its component parts needs to be unambiguously defined for interoperable exchange. The LCC WG has been considering advancing to the HITPC recommendations that MU3 include requirements for the interoperable exchange of a care plan and component parts 7 We need your input on care plan components necessary to support Transitions of Care and Coordination of Care.

8. Information Exchange Needs to Support Transitions and Coordination of Care HIE at times of transition in care (ToC) and referrals in care is critically important to support care coordination, particularly on behalf of medically complex/functionally impaired persons MU2 requirements identify some required data elements that should be included in Summary Care Records at times of ToC and referrals in care 8

9. MU2 Requirements and Exchange of Care Plan Content MU2 includes requirements related to the exchange of care plans: Care plan content, if known, is required in the Summary Care Record for each transition of care or referral Care plan content required in the Summary Care Record includes: –Care plan field, including goals and instructions. –Care team including the primary care provider of record and any additional know care team members beyond the referring or transitioning provider and the receiving provider. 9

10. MU2 Requirements and Exchange of Care Plan Content cont. The MU Stage 2 Final Rule also provides the following definition of Care plan: For purposes of the clinical summary, we define a care plan as the structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome) (page 54001). 10

11. 11 Health IT Policy Committee MU3 Request for Comment Dr. Terry OMalley, Partners HealthCare tomalley@partners.org

12. HITPC MU 3 RFC – Care Plans In section SGRP 304, four questions are posed related to Care Plans: –How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers? –What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management? –How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. –What data strategy and terminology are required such that the data populated by venue specific EHRs can be exchanged? How might existing terminologies be reconciled? 12

13. LCC WG Care Plan Considerations To help frame responses to the RFC, the LCC WG has developed definitions for key terms, structure, and components of a care plan to support transitions in and coordination of care These terms/components apply to both the care plan andplan of care: –Health concern –Goals –Instructions –Interventions –Outcomes –Team member 13

14. 14 Term/Component:CARE PLAN MU2: Not defined HIT PC RFC: How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers? LCC Proposed Definition: The S&I LCC believes that the exchange of care plans is important to support collaboration across care settings and providers, and allows for and can encourage team based care. The S&I LCC believes that a care plan considers the whole person and focuses on a number of health concerns to achieve high level goals related to healthy living. In contrast, some clinicians use the concept of plan of care to focus on discrete problems, the specific interventions to address the problem, and achieve a certain goal related to the problem. The S&I LCC WG believes that both the Care Plan and Plan of Care share the components: health concern, goals, instructions, interventions, and team member

15. 15 Term/Component:HEALTH CONCERN MU2: Health concern is not defined. Problem is defined as The focus of the care plan HIT PC RFC: What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management? How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. LCC Proposed Definition: Health concerns reflect the issues, current status and 'likely course' identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member. Problems and diagnoses will capture medical/surgical diagnosis but are insufficient to capture the full array of issues that are important to individuals. Health concerns include: Medical/surgical diagnoses and severity Nursing/Allied Health/Behavioral Health issues Patient reported health concerns Behavioral/Cognition/Mood issues Functional status, including ADL issues Environmental factors (e.g. housing and transportation) Social factors including availability of support and relationships Financial issues (e.g. insurance, eligibility for disability)

16. 16 Term/Component:GOALS MU2: The target outcome; target or measure to be achieved in the process of patient care (an expected outcome). HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers? What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management? LCC Proposed Definition: A defined outcome or condition to be achieved in the process of patient care. Includes patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes.

17. 17 Term/Component:INSTRUCTIONS MU2: By clinical instructions we mean care instructions for the patient that are specific to the office visit. Although we recognize that these clinical instructions at times may be identical to the instructions included as part of the care plan, we also believe that care plans may include additional instructions that are meant to address long- term or chronic care issues, whereas clinical instructions specific to the office visit may be related to acute patient care issues. Therefore, we maintain these as separate items in the list of required elements later. HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. LCC Proposed Definition: Information or directions to the patient and other providers including how to care for the individuals condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice. Detailed list of actions required to achieve the patient's goals of care.

18. 18 Term/Component: INTERVENTIONS MU2: Not defined HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. LCC Proposed Definition: Actions taken to maximize the prospects of achieving the patient's or providers' goals of care, including the removal of barriers to success. Instructions are a subset of interventions.

19. 19 Term/Component: OUTCOMES MU2: Target outcome; target or measure to be achieved in the process of patient care (an expected outcome). HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members. LCC Proposed Definition: Status, at one or more points in time in the future, related to established care plan goals.

20. 20 Term/Component: TEAM MEMBER MU2: Care team includes the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider. HIT PC RFC: How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non- professional caregivers? LCC Proposed Definition: Parties who manage and/or provide care or service as specified and agreed to in the care plan, including: clinicians, other paid and informal caregivers, and the patient.

21. 21 Exchange Requirement Standards Implications MU2: Care plans are to be included if known in the summary care record. Summary care records are to be represented using the HL7 Consolidated-CDA. HIT PC RFC: What data strategy and terminology are required such that the data populated by venue specific EHRs can be exchanged. How might existing terminologies be reconciled? LCC Proposed Recommendation: The LCC WG believes the care plans and its component parts should be represented in the HL7 Consolidated-CDA (C-CDA). The LCC WG believes that available C-CDA templates should be reused to the extent possible. For example, templates (currently exist for functional status, cognitive status, diagnoses, etc. and should be reused to support the representation of needed care plan content. The LCC WG recognizes that work is needed to fully represent in the C-CDA the care plan and its component parts. Exchange of Care Plan & MU Standards

22. 22 Summary & Discussion Jennie Harvell, ASPE Jennie.harvell@hhs.gov

23. Summary & Discussion The S&I LCC WG anticipates advancing to the HITPC recommendations that MU Stage 3 include requirements for the interoperable exchange of care plans and component parts: –Health concerns –Goals –Instructions –Interventions –Outcomes –Team member 23 WE WANT TO HEAR FROM YOU! LETS DISCUSS…

24. 24 NEXT STEPS

25. We welcome your thoughts on the need for these care plan concepts and definitions as a way to respond to the HITPC RFC due January 14 2013 Please share with us! –Evelyn Gallego-Haag, S&I LCC Initiative Coordinator at evelyn.gallego@siframework.org evelyn.gallego@siframework.org –Becky Angeles, S&I LCC Support, rebecca.angeles@esacinc.com rebecca.angeles@esacinc.com 25 Participate & Collaborate! S&I Longitudinal Coordination of Care Workgroup http://wiki.siframework.org/Longitudinal+Coordination+of+Care

26. 26 Appendix: SUBMITTING RFC COMMENTS

27. Comments will only be accepted electronically Follow the Submit a comment instructions at http://www.regulations.gov http://www.regulations.gov Attachments should be in Microsoft Word or Excel, WordPerfect, or Adobe PDF HIT PC requests that duplicate comments not be submitted 27

28. 28 Search for "Office of the National Coordinator for Health Information Technology; Health Information Technology; HIT Policy Committee: Request for Comment"

29. 29 1.Enter identification information 2.Type comments 3.Upload files 4.Submit comments

30. 30 Appendix: HITPC RFC – CARE PLANS

31. 31 Improve Care Coordination ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments SGRP30 3 EP/EH CORE Objective: The EP/EH/CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides summary care record for each transition of care or referral. CORE Measure: 1.The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. 2.The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more EP/ EH / CAH Objective: EP/EH/CAH who transitions their patient to another setting of care or refers their patient to another provider of care. Provide a summary of care record for each site transition or referral when transition or referral occurs with available information Must include the following four for transitions of site of care, and the first for referrals (with the others as clinically relevant): 1.Concise narrative in support of care transitions (free text that captures current care synopsis and expectations for transitions and / or referral) 2.Setting-specific goals 3.Instructions for care during transition and for 48 hours afterwards 4.Care team members team members, including primary care provider and caregiver name, *What would be an appropriate increase in the electronic threshold based upon evidence and experience?

32. 32 Improve Care Coordination ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments SGRP30 3 cont. 2.than 10% of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network. 3.An EP, eligible hospital or CAH must satisfy one of the two following criteria: A.(A) conducts one or more successful electronic exchanges of a summary of care document, as part of which is counted in measure 2 (for EPs the measure at 495.6(j)(14)(ii)); 4.role and contact info (using DECAF (Direct care provision, Emotional support, Care coordination, Advocacy, and Financial)) Measure: The EP, eligible hospital, or CAH that site transitions or refers their patient to another setting of care (including home) or provider of care provides a summary of care record for 65% of transitions of care and referrals (and at least 30%* electronically). Certification Criteria: EHR is able to set aside a concise narrative section in the summary of care document that allows the provider to prioritize clinically relevant information such as reason for transition and/or referral. Certification Criteria: Ability to automatically populate a referral form for specific purposes, including a referral to a smoking quit line.

33. 33 Improve Care Coordination ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments SGRP30 3 cont. A.(B) and for eligible hospitals and CAHs the measure at 495.6(l)(11(ii)(B)) with a recipient who has EHR technology that was developed by a different EHR technology developer than the senders EHR technology certified to 45 CFR 170.314(b)(2); or B.(C) conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period. Certification Criteria: Inclusion of data sets being defined by S&I Longitudinal Coordination of Care WG, which and are expected to complete HL7 balloting for inclusion in the C- CDA by Summer 2013: 1)Consultation Request (Referral to a consultant or the ED) 2)Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency) SGRP30 4 NEW EP/ EH / CAH Objective : EP/ EH/ CAH who transitions their patient to another site of care or refers their patient to another provider of care For each transition of site of care, provide the care plan information, including the following elements as applicable: Medical diagnoses and stages How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers? Interested in experience to date and the lessons learned. Think through these priority use cases:

34. 34 Improve Care Coordination ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments SGRP30 4 cont. Functional status, including ADLs Relevant social an d financial information (free text) Relevant environmental factors impacting patients health (free text) Most likely course of illness or condition, in broad terms (free text) Cross-setting care team member list, including the primary contact from each active provider setting, including primary care, relevant specialists, and care giver The patients long-term goal(s) for care, including time frame (not specific to setting) and initial steps toward meeting these goals Specific advance care plan (Physician Orders for Life- Sustaining Treatment (POLST)) and the care setting in which it was executed 1.Patient going home from an acute care hospital admission 2.Patient in nursing home going to ED for emergency assessment and returning to nursing home 3.Patient seeing multiple ambulatory specialists needing care coordination with primary care 4.Patient going home from either hospital and/or nursing home and receiving home health services What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management? How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including

35. 35 Improve Care Coordination ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments SGRP30 4 cont. For each referral, provide a care plan if one exists. Measure: The EP, eligible hospital, or CAH that transitions or refers their patient to another site of care or provider of care provides the electronic care plan information for 10% of transitions of car to receiving provider and patient/ caregiver. Certification Criteria: Develop standards for a shared care plan, as being defined by S&I Longitudinal Coordination of Care WG. Some of the data elements in the shared care plan overlap content represented in the CDA. Adopt standards for the structured recording of other data elements, such as patient goals and related interventions. Advance orders, and care team members. What data strategy and terminology are required such that the data populated by venue specific EHRs can be exchanged. How might existing terminologies be reconciled? What are the requirements (legal, workflow, other considerations) for patients and their identified team to participate in a shared care plan? Is it useful to consider role-based access as a technical method of implementing who will have access to and be able to contribute to the care plan? How will such access be managed?