Longitudinal Coordination of Care Pilots WG Monday, September 16, 2013

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

TopicPresenter Introductions and PurposeEvelyn Aims of LCC Pilot WGEvelyn Overview of standards to PilotTerry Timeline for PilotingEvelyn Overview of LCC Committed Pilots: IMPACTLarry Overview of LCC Committed Pilots: NY DownstateTom Agenda 3

Let’s discuss… –Why you should pilot LCC standards –Who should consider being a pilot –What standards you can pilot –How we can help you pilot these standards –How you can learn for those already committed to piloting LCC standards Why are we here today? 4

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 (focus on MU3) Activities supported via 4 sub-workgroups (SWGs): –Longitudinal Care Plan (LCP) * –LTPAC Care Transition (LTPAC) * –HL7 Tiger Team* –Patient Assessment Summary (PAS)* Background of LCC WG 5 * The work of the LCP and LTPAC completed in SEP2013, HL7 Tiger Team completed in AUG13 and PAS SWG completed in JAN13

Additional Contributor Input MA Universal Transfer Form workgroup Boston’s Hebrew Senior Life eTransfer Form IMPACT learning collaborative participants MA Coalition for the Prevention of Medical Errors MA Wound Care Committee Home Care Alliance of MA (HCA) 6 NY’s eMOLST Multi-State/Multi-Vendor EHR/HIE Interoperability Workgroup Substance Abuse, Mental Health Services Agency (SAMHSA) Administration for Community Living (ACL) Aging Disability Resource Centers (ADRC) National Council for Community Behavioral Healthcare National Association for Homecare and Hospice (NAHC) Transfer of Care & CCD/CDA Consolidation Initiatives (ONC’s S&I Framework) Longitudinal Coordination of Care Work Group (ONC S&I Framework) ONC Beacon Communities and LTPAC Workgroups Assistant Secretary for Planning and Evaluation (ASPE): Standardizing MDS and OASIS ASPE/Geisinger/HL7 : LTPAC Summary Documents (using MDS and OASIS) Centers for Medicare & Medicaid Services (CMS)(MDS/OASIS/IRF-PAI/CARE) INTERACT (Interventions to Reduce Acute Care Transfers) Transfer Forms from Ohio, Rhode Island, New York, and New Jersey

7 ONC Programs & Grantees Community S&I Framework FACAs SDOs State HIE Program & CoPs REC Program & CoPs Beacon Program Technology Vendors System Integrators Government Agencies Industry Associations Other Experts HL7 OASIS Other SDOs HIT Standards Committee HIT Policy Committee Tiger Team ENABLING S&I Framework: The Value of Community Participation (LCC WG)

Strong collaboration and engagement with broad stakeholder groups to address gaps in standards for ToC and Care Plan exchange –Other ONC S&I Initiatives: Transitions of Care (ToC) and esMD –HL7 WGs: Structured Documents, Patient Care –IHE Patient Care Coordination Technical Committee –AHIMA LTPAC HIT Collaborative –FACAs: MU3 Recommendations Contracts with Lantana to make and ballot revisions to C-CDA for HL7 August 2013 Ballot Cycle –One ballot package to address C-CDA revisions based on IMPACT dataset LCC WG Partnerships 8

S&I Framework Phases 9 PhasePlanned Activities Pre-Discovery  Development of Initiative Synopsis  Development of Initiative Charter  Definition of Goals & Initiative Outcomes Discovery  Creation/Validation of Use Cases, User Stories & Functional Requirements  Identification of interoperability gaps, barriers, obstacles and costs  Review of Vocabulary Implementation  Creation of aligned specification  Documentation of relevant specifications and reference implementations such as guides, design documents, etc.  Validation of Vocabulary  Development of testing tools and reference implementation tools Pilot  Validation of aligned specifications, testing tools, and reference implementation tools  Revision of documentation and tools Evaluation  Measurement of initiative success against goals and outcomes  Identification of best practices and lessons learned from pilots for wider scale deployment  Identification of hard and soft policy tools that could be considered for wider scale deployments

Bring awareness on available national standards for HIE and care coordination Provide tools and guidance for managing and evaluating LCC Pilot Projects Create a forum to share lessons learned and best practices Real world evaluation of parts of most recent HL7 C- CDA Revisions Implementation Guide (IG) –Is this implementable? Useable? Validation of ToC and Care Plan/HHPoC datasets –Do these data elements address your organization’s information needs for effective care coordination?? Aim for the LCC Pilot SWG 10

Demonstrate compliance with MU2 requirements and proposed standards for MU3 Increase efficiency of development and maintenance of these standards –LCC C-CDA IG can inform changes to existing HIT systems and the process by which ToC & Care Plan information is exchanged –These specifications are being harmonized with a broad consortium of Standards Development Organizations (SDOs) including HL7 and IHE Meet CMS Quality Reporting Requirements –i.e. Reduce Readmission Rates Enable LTPAC (non-eligible) providers to participate in HIE Increase access to LTPAC data to support caregiving (including access by other members of clinical care team) Contribute to the community Be recognized as an early HIE adopter Why Pilot LCC Standards? 11

HIE capability exists High proportion of dual eligibles Integrated Delivery Networks including Managed Care Organizations (MCO), ACOs and other at-risk provider groups Other organizations participating in various CMS/CMMI Demonstrations Providers with high readmission rates Those interested in addressing transition of care issues Those interested in exchanging care plans Who Should Pilot LCC Standards? 12

Transition Datasets 13 Test/Procedure Report & Request i.e SNF to IRA Consultation Request & Response i.e. SNF to ED Transfer Summary/ Care Plan/HHPoC i.e. Hospital to Home Health Agency; HHA  PCP

New exchange standards for: –MU2 Patient Care Summary and proposed MU3 updates for: Care Plan Home Health Plan of Care Report from Outpatient testing, treatment, or procedure Referral to Outpatient testing, treatment, or procedure (including for transport) Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility) Consultation Request Clinical Summary (Referral to a consultant or the ED) Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency Exchange standards that easily enable low cost interoperable HIE by LTPAC providers New software for HIE access What Standards Can You Pilot? 14

Sample Pilot Options 15 User ScenarioS&I Use Case 1.Exchange of CCDToC Use Case 2.Exchange of Transfer Summary LCC Use Case Exchange of Consultation Request LCC Use Case Exchange of Consult Note LCC Use Case Exchange of Test/Procedure Report LCC Use Case Exchange of Test/Procedure Request LCC Use Case Exchange of HHPoCLCC Use Case 2.0 User ScenarioS&I Use Case 8.Exchange of Care PlanLCC Use Case Exchange of Patient GoalsLCC Use Case Exchange of Advance Directives LCC Use Case Exchange of Pre-Test Screening Process LCC Use Case Exchange of Care Plan components for Patient Centered Value Management LCC Use Case Concordance- the extent to which the patient’s goals, interventions, concerns, outcomes match to the provider’s prioritization LCC Use Case Exchange of Transfer of Care (Discharge and ED Consult request) LCC Use Case 2.0

How Can You Participate in the LCC Pilot SWG? 16

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

LCC Pilot WG Tasks 18 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

Summary of Documentation Templates & Reference Materials (Pilot Materials) 19 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.

20 I mproving M assachusetts P ost- A cute C are T ransfers

February 2011 – HHS/ONC awarded $1.7M HIE Challenge Grant to state of Massachusetts (MTC/MeHI) Sites with EHR or electronic assessment tool use these applications to enter data elements –LAND (“Local” Adaptor for Network Distribution) acts as a data courier to gather, transform, and securely transfer data if no support for Direct SMTP/SMIME or IHE XDR Non-EHR users complete all of the data fields and routing using a web browser to access SEE, their –“Surrogate EHR Environment” IMPACT Grant 21

LAND –Orion Health’s Rhapsody Integration Engine –Currently Modular EHR certified for MU1. MU2 (2014) pending –We’re trying to make some standard configurations available SEE –Written in JAVA –Baseline functionality software and source code that can connect to Orion’s HISP mailbox via API available for free starting ~December 2013 (Apache Version 2.0 vs. MIT open source license) –Innovators can develop and charge for enhancements, for example: Integration with other vendors’ HISP mailboxes Automated CDA document reconciliation Sharing LAND & SEE

Selection Criteria: –High volume of patient transfers with other pilot sites –Experience with Transitions of Care tools/initiatives Winning Pilot Sites: –St Vincent Hospital and UMass Memorial Healthcare –Reliant Medical Group (formerly known as Fallon Clinic) and Family Health Center of Worcester (FQHC) –2 Home Health agencies (VNA Care Network & Overlook VNA) –1 Long Term Acute Care Hospital (Kindred Parkview) –1 Inpatient Rehab Facility (Fairlawn) –8 Skilled Nursing and Extended Care Facilities Pilot Sites to Test the IMPACT Datasets 23

IMPACT Pilot Participants 24 Org. NameTypeVendor/ SolutionTypeLCC Standards to Implement Reliant Medical Group PCMHEpicEHRCCD; Transfer of Care Summary Family Health Center of Worchester FQHCNextGenEHRCCD; Transfer of Care Summary Saint Vincent Hospital ACHMeditechEHRCCD; Transfer of Care Summary UMass Memorial Healthcare ACHSiemens SoarianEHRCCD; Transfer of Care Summary VNA Care NetworkHHADelta Health Technologies EHR CCD; Transfer of Care Summary Overlook VNA HHAHomecare HomebaseEHRCCD; Transfer of Care Summary Kindred Parkview LTACHSEEHIETransfer of Care Summary Fairlawn Rehab IRFSEEHIETransfer of Care Summary Beaumont Rehabilitation of Westborough SNFSEEHIETransfer of Care Summary Christopher House of Worcester SNFSEEHIETransfer of Care Summary Holy Trinity Nursing & Rehab SNFSEEHIETransfer of Care Summary Jewish Healthcare Center SNFSEEHIETransfer of Care Summary LifeCare Center of Auburn SNFSEEHIETransfer of Care Summary Millbury Healthcare Center SNFSEEHIETransfer of Care Summary Notre Dame LTC SNFSEEHIETransfer of Care Summary Worcester Rehabilitation & Health Care Center SNFSEEHIETransfer of Care Summary

November SEE sites (full Transfer of Care dataset) 6 LAND sites (initially send CCD but receive any CDA document) 4/week starting with trading pairs (e.g. Hospital  SNF) IMPACT Pilot Go-Live 25

Downstate New York Care Coordination Project September 16, 2013

Context NYS Medicaid Health Homes have implemented (or are implementing) care coordination solutions to meet their near term requirements Each Health Home currently uses a separate care management system or EHR In the Downstate NY region, there are many providers who are in multiple Health Homes and multiple RHIOs and their patients will cross borders If various care management tools do not support interoperability, providers may have to use 2 or 3 different systems and this is not sustainable Current state leaves untenable situation of no care plan interoperability 27

Goals and Objectives Develop consensus around functionality that would enable enhanced care coordination, care plan management and interoperability across Health Homes and RHIOs through the SHIN-NY Align activity with developments at the national level Develop Requirements to support the interoperability and joint management of Care Coordination Plans across organizations Phase I implementation - Demonstrate the ability for two sites with two different care management tools to exchange Care Coordination Plans 28

Requirements Enrollment of Health Home patients Linking of patients and providers: care teams Exchange of interoperable care plans Clinical Event Notifications Secure Messaging Access to medical records for clinicians Access to care plans for non-clinicians 29 The DCC Workgroup agreed upon the following seven functions:

NY Downstate Pilot Participants 30 Org. NameTypeVendor/TypeLCC Standards Addiction Institute of NY- Methodone Mgmt Program Behavioral HealthNetsmartCare MgmtCare Plan Addiction Institute of NY- Outpatient Treatment Program Behavioral HealthNetsmartCare MgmtCare Plan St. Luke’s Roosevelt Hospital Acute CareCaradigmHIE/ Care MgmtCare Plan Continuum Health Home Network (CHHN) IDNCaradigmHIE/ Care MgmtCare Plan CHHN AIDS Service CenterCBOCaradigm/ HealthIXHIE Care Plan CHHN AmericareHome CareCaradigm/ HealthIXHIE Care Plan CHHN Argus CommunityCBOCaradigm/ HealthIXHIE Care Plan CHHN Association for Rehab CM & HousingCBOCaradigm/ HealthIXHIE Care Plan CHHN Beth Israel Medical CenterAcute CareCaradigm/ HealthIXHIE Care Plan CHHN Callen Lorde Community Health CenterPCPCaradigm/ HealthIXHIE Care Plan CHHN DennelisseCBOCaradigm/ HealthIXHIE Care Plan CHHN NADAPCBOCaradigm/ HealthIXHIE Care Plan CHHN Project RenewalCBOCaradigm/ HealthIXHIE Care Plan CHHN Puerto Rican Family InstituteCBOCaradigm/ HealthIXHIE Care Plan CHHN Ryan Health CenterPCPCaradigm/ HealthIXHIE Care Plan CHHN Services for the Under ServedCBOCaradigm/ HealthIXHIE Care Plan CHHN Westside Federation for Senior & Supportive HousingCBOCaradigm/ HealthIXHIE Care Plan CHHN Institute for Family HealthPCPCaradigm/ HealthIXHIE Care Plan CHHN Isabella Nursing HomeNHCaradigm/ HealthIXHIE Care Plan

Care Coordination Plan (CCP) refers to a shared document that is used to track problems, goals, interventions and outcomes related to both clinical and social issues CCPs are a focus of collaboration for diverse care teams across organizations 31 Care Coordination Plan (CCP) Collaboration What is a CCP?

32 Care Coordination Plan (CCP) Collaboration Use Case 1. Author will create and edit the CCP in a care management tool that uses a national agreed upon structure for interoperable CCPs 2. Editor will view the CCP in their local care management tool, and suggest edits to the Author for review and approval. The Author retains editorial control of the CCP 3. Reader can view the most recent CCP in the RHIO, and provide comments to the Author through secure messaging Iterative process based on interoperability standards

Healthix HEAL 17 – Project Highlights Identified two sites with two different vendors to participate in Phase 1 implementation, both part of Continuum Health Partners Addiction Institute of New York Methodone Treatment Program (Netsmart) Outpatient Treatment Program (Caradigm) Held kick off meeting with stakeholders in early June Agreed on Requirements and Phase 1/2 development June – July: Design phase; engaged Lantana to align the data model with proposed standard as closely as possible July - August: Development, finalize draft data model for the standard Care Coordination Plan with the LCC Standards Workgroup September: Testing, Acceptance October: Phase 1 Implementation, Evaluation 33

Homework Assignment: –Complete Pilot Survey –Sign up as an LCC Committed Member –Submit Pilot Documentation Templates Available on the LCC Pilot SWG Wiki: to Lynette Elliott NO Meeting next week due to HL7 WGM in Boston, MA Next Steps 34

LCC Leads –Dr. Larry Garber –Dr. Terry O’Malley –Dr. Bill Russell –Sue Mitchell LCC/HL7 Coordination Lead –Dr. Russ Leftwich Federal Partner Lead –Jennie Harvell Initiative Coordinator –Evelyn Gallego Project Management –Pilots Lead: Lynette Elliott –Use Case Lead: Becky Angeles LCC Initiative: Contact Information 35 LCC Wiki Site: