Longitudinal Coordination of Care LCP SWG Thursday, May 30, 2013

S&I Update Announcements and Reminders Use Case 2.0 –Schedule and Outline –12.0 Dataset Requirements –David Tao’s Comments on Base Flow, Alternate Flow, Assumption sections 2 Agenda

LCC WG participation in HITPC MU SWG #3 Care Coordination –Summary of May 24th meeting –Care Plan discussion scheduled for June 4 th, :30am – 1:30pm ET Participate online: Audio: https://altarum.adobeconnect.com/mu Reminder to register for 2013 LTPAC HIT Summit –Date: June 16-18, 2013 –Location: Baltimore, MD – 45cc c37baafhttp:// 45cc c37baaf Call for Pilot Participation! –If you or someone you know is interested in piloting Transitions of Care and/or Care Plan Exchange, please contact us at: 3 ONC S&I Update

Next week’s Thursday LCP call will be at 5:00-6:00pm ET Meeting Reminders (next week) –LTPAC SWG meeting – Monday at 11am ET –LCC HL7 Tiger Team SWG meeting – Wednesday at 11am ET –LCP SWG meeting – Thursday at 5pm ET Visit the LCC Use Case 2.0 Wiki Page for all current artifacts to review: ( –Use the comment form to provide feedback on UC sections ( 4 Announcements and Reminders

Work Group Schedules LCC WG SWG MeetingLCC LeadsDate/ TimeProjects LTPAC SWGLarry Garber Terry O'Malley Weekly Mondays, 11-12pm EST C-CDA: Transfer Summary, Consult Note, Referral Note LCC HL7 Tiger Team Russ LeftwichWeekly Wednesdays, pm EST LCC WG comments for HL7 Care Plan DAM LCP SWGBill Russell Sue Mitchell Jennie Harvell Weekly Thursdays 5 - 6pm EST (starting June 6) C-CDA: Care Plan, Home Health Plan of Care HL7 WG SWG MeetingHL7 LeadParticipating LCC Members Date/ TimeProjects HL7 Patient Care WGRuss Leftwich Elaine Ayers Stephen Chu Michael Tan Kevin Coonan Susan Campbell Laura H Langford Lindsey Hoggle Bi-weekly Weds, 5 - 6pm EST Care Plan DAM Care Coordination Services (CSS) HL7 Structured Documents WG Bob Dolin Brett Marquard Sue Mitchell Jennie Harvell Weekly Thursdays, 10-12pm EST CDA (various) HL7 SOA WG CCS ProjectJon Farmer Enrique Meneses (facilitators) Stephen Chu Susan CampbellWeekly Tuesdays 5 - 6pm EST Care Coordination Services (CSS) HL7 Patient Generated Document Leslie Kelly HallWeekly Fridays, 12- 1pm EST Patient-authored Clinical Documents

LCC Use Case 2 Development Schedule Items in italics will drawn directly from the LCC Project Charter or created offline directly from other sections and will be included in the end-to-end review DateItemHomework (Due Wednesday COB) 3/11 – 3/ Scenario (User Stories, Base/Alternate Flow, Functional Requirements) Review: User Stories 3/25 – 3/ Use Case Scope (Background, In / Out of Scope, Communities of Interest) Finalize: User Stories, Base Flows, In / Out of Scope Review: Communities of Interest, Assumption 4/1 – 4/2 3.4 Communities of InterestFinalize: Communities of Interest, Assumptions, Pre- Conditions, Post-Conditions Review: Actors and Roles 5.0 Use Case Assumptions 6.0, 7.0 Pre-Conditions, Post Conditions 4/8 - 4/11 Finalize: Assumptions, Pre-Conditions, Post- Conditions, Communities of Interest 8.0 Actors and Roles Finalize: Assumptions, Pre-Conditions, Post- Conditions, Actors and Roles 4/15 – 4/18 Finalize: Communities of Interest, Assumptions, Actors and Roles Review: Base/Alternate Flows, User Stories Activity Diagrams Review: Base Flows, Activity Diagrams Finalize: Base Flows, Activity Diagrams 4/22 – 4/ Risks, Issues, and ObstaclesFinalize: Risks, Issues and Obstacles Review: Sequence Diagrams 10.4 Sequence Diagram 5/2 – 5/ Functional RequirementsFinalize: Sequence Diagrams, Functional Requirements, Use Case Diagrams, Appendices Review: Community Feedback, Dataset Requirements 9.0 Use Case Diagrams Appendices 5/23Community Feedback 12.0 Dataset Requirements Review: Dataset Requirements 5/ Dataset RequirementsEnd-to-End Review (preliminary)

1.0 Preface and Introduction** 2.0 Initiative Overview –2.1 Initiative Challenge Statement** 3.0 Use Case Scope –3.1 Background** –3.2 In Scope –3.3 Out of Scope –3.4 Communities of Interest 4.0 Value Statement** 5.0 Use Case Assumptions 6.0 Pre-Conditions 7.0 Post Conditions 8.0 Actors and Roles 9.0 Use Case Diagram Use Case Outline 10.0 Scenario: Generic Provider Workflow –10.1 User Stories –10.2 Activity Diagram o Base Flow o Alternate Flow –10.3 Functional Requirements o Information Interchange Requirements o System Requirements –10.4 Sequence Diagram 11.0 Risks, Issues and Obstacles 12.0 Dataset Requirements Appendices –Related Use Cases –Previous Work Efforts –References –Glossary 7 ** Leverage content from Charter Draft sections complete Content available for review

Care Plan Document Descriptive Data Elements –Document Description –Document Change –Presentation –Question Context Privacy and Security Patient –Patient Data –Encounter Event – Keep? –Observation Event – Keep? 12.0 Dataset Requirements 8

Care Plan Data Elements –Health Concerns Active issues affecting health and well-being that require management Inactive issues that provide context to proposed interventions (example: hx +PPD and proposed steroid use) Type –Med/Surg Issues –Nursing diagnoses –Function –Behavioral: mood, cognition, DSM IV, V –Environmental (housing, community supports, employment, transportation, legal –Health maintenance, prevention –Risks –Barriers to intervention Descriptive Data –Current Management »Active »Inactive –Status »USE LIST OF CODES TO BE PROVIDED BY BILL –Impact on Health or Wellbeing »High »Medium »Low »Unknown –Severity (SOMEONE TO PROVIDE THE ICD10 structure for the dimensions of severity/progression/stability/etc) –Priority Type »Patient »Physician »Result –Priority Level »High »Medium »Low 12.0 Dataset Requirements 9

Care Plan Data Elements –Interventions Status Assessments –Goals or Desired Outcome of Interventions to address Health Concerns Status Timeline Milestones –Overall Goals for Care –Longitudinal Care Team Members (Patient, Principle Care Physician, Care Plan Manager, Principle Healthcare Provider, Principle Care Giver, Others (Relevant Specialists, Therapists, SW, etc) –Identification and Contact Information –Responsibility to Health Concern Set / Responsibility for Intervention (includes assessment) 12.0 Dataset Requirements 10

Care Plan Process Elements –Input data All potential Health Concerns –Problems –Risks –Barriers All potential Interventions All potential Goals –Prioritization Decision Making –Probabilities –Preferences –Overarching Goals –Potential Interventions 12.0 Dataset Requirements 11

12.5 Care Plan Data Elements, starting at line 73. "Current Active Problems" and "Problem List" are confusing/overlapping. EHRs already typically produce a Problem List (required for MU1 and MU2), of active problems. It may also contain resolved or inactive problems, marked with the appropriate status to distinguish them from active problems. So the CP should either just say "Problem List" with statuses indicated on each problem, or if there is one section that says "Current Active Problems" then the other section should be "Inactive Problems" or some such title. Also, the cardinality seems like apples and oranges. "Current active problems" has "multiple" cardinality. But "Problem List" is "Single" whereas a Problem List by definition can contain multiple problems. David Tao’s Comments from the Wiki 12

Health Concerns Standard Data Set for each health concern. Items G and H (Current Severity, Severity of worst...) don't seem to make sense for the "Past Surgical History" type of concern. Basically, the data set for "Problems" should be different from the data set for "Procedures." There may be a few common elements, but mostly they will be different (as evidenced by the many different C-CDA entries used for Problems vs Procedures). David Tao’s Comments from the Wiki 13

12.5 Care Plan Data Set -- Interventions. Some of the data elements do not seem properly categorized as "interventions." Is an assessment an intervention? I don't think so. Doesn't an assessment identify the patient's condition which then may LEAD to interventions? Also, how can Allergies and intolerances be interventions? And why isn't "Related interventions" under "interventions" rather than under "Goals?" David Tao’s Comments from the Wiki 14

Care Plan Data -- Longitudinal Care Team. It is not clear what is the difference between "Principal Care Physician" and "Principal Health Care Provider." Also, is the cardinality of "Single" for these members too restrictive? Couldn't there be multiple family members who take turns as caregivers, for example? Or multiple providers and physicians? Not every patient will be cared for by a fully coordinated team with a PCMH or even a PCP, yet there could still be benefit in a shared care plan. David Tao’s Comments from the Wiki 15

Care Plan Process Elements. "Problem List" and "Current Active Problems" are listed here, but also are listed in 12.5 Care Plan Data Elements. Why are they listed in both places, and what would be put in 12.5 vs. 12.6? Also, Figure 5 at the end of 12.6, "Cross Walk of Care Plan Components" is not understandable. What does an "X" in a cell mean? That is not explained. If it just means "the concept in the row is related to the concept in the column" it still doesn't seem to make sense, because shouldn't there be an X in the "Goals / Outcomes" cell, for example? Or between Team Members and Goals? David Tao’s Comments from the Wiki 16

Show Use Case 2.0 document – – Base Flow for Scenario 1 comments – – Alternate Flow Text comments –5.0 – Assumptions (already modified) David Tao’s Comments from the Wiki 17