Coordination of Care Service (CCS) Initial Submission

Coordination of Care Service (CCS) Initial Submission

Submission Team Members Coordination of Care Scope Symbols Coordination Of Care Service – Platform Independent Model Care Team Membership Model Care Team Permissions Domain Model Care Team Note Security Model Care Team Communications Domain Model Care Plan Domain Model Care Plan Operations Care Plan Exchange Model Reconciliation Domain Model Reconciliation Operations Coordination Of Care Services Implementation Considerations Coordination Of Care Services – PSM For Web Services Coordination Of Care Services – PSM For CCDA Coordination Of Care Services – PSM For FHIR Coordination Of Care Services – PSM For Direct Contents

Anujgopal Sreekanth Curt Vanriper Douglas Golub Dev Nathan Kalyan Emma Jones Gunther Meyer Michael Nelson Tracey Coleman Laurie Wissell Submission Team

MediSked’s story in Care Coordination
THE BIGGER PICTURE MediSked’s story in Care Coordination

Our Story in Care Coordination
MediSked, LLC was founded in 2003 to help provider agencies support individuals to receive the best possible quality of care, choice, and do so in a cost effective way. The software and services provided by MediSked, LLC fill a previously unmet need for individuals receiving long term services and supports. The population focuses around people with intellectual and developmental disabilities, traumatic brain injury, aged and physically disabled, and children. Mission: We are dedicated experts, committed to the same goals as those we support. MediSked’s story in care coordination begins with a passion and understanding for supporting individuals’ health, safety, goals, and valued outcomes. Through implementation of systems and processes with a person-centered focus, MediSked, LLC became established as a leading EHR vendor for providers in the long term services and supports space with Connect – Agency Management Platform.

Our Story in Care Coordination
The advancement of EHR standards and data sharing across medical, specialists, therapists, and long term services and supports providers enabled MediSked, LLC to provide the first platform for data sharing and business intelligence in the long term services and supports space with Connect Exchange – Multi-Agency Business Intelligence Platform. The next frontier in Care Coordination involves systems for care management, centered around the person, with focus on care teams and payer entities. MediSked’s Coordinate – Care Management Platform provides full care coordination capabilities and portal functionality to those care teams and individuals receiving long term services and supports. Conventional standards that focus around problems and issues with the person require a different perspective and architecture in the long term services and supports space. People’s disabilities are life-long, ever changing, and part of a meaningful life – not a problem. MediSked’s position in Care Coordination fills an unmet need in this space and offers a unique perspective to best support this population of individuals.

Systems and Capabilities
Person-Centered, Provider and Circle of Supports Portals Care Coordination Platform MediSked Assess Assessment Tools Message Routing and Data Warehouse Provider Electronic Health Records Admin, Reporting & Business Intelligence User Interface Administrative and State Oversight HIEs & RHIOs DME Vendor(s) Pharmacy Benefits Manager (PBM)

OMG CCCS Submitter Standards
MediSked’s membership in OMG and submission and adherence to care coordination service standards stems from a commitment to long term services and supports. As this space suffers from a lack of standards, the transition to managed care and care coordination presents a strategically important opportunity for MediSked, LLC to be on the cutting edge of standards and software functionality readiness. It helps set the stage for standards in our segment of the industry. Care team membership Care team permissions Care team communications Care plan Reconciliation (goals, interventions, health concerns, outcomes, problems medications, medication allergies)

Meet Evan… Evan is an adult with an intellectual disability who would like to be more independent The Care Team’s Goal: Assist Evan in living more independently and help him find a job Pertinent Data in Portal: Assessments and plans detailing Evan’s job skills, independent living skills, communication skills, and travel skills – along with the forms and documents needed for a successful job search Outcomes Improved by Data: Evan’s job coach is able to help him identify and apply for employment opportunities tailored to his strengths, Evan sets and works on goals that will help him achieve more independence so that eventually he can move into his own apartment

Mary is an elderly individual who needs guardianship
Meet Mary… Mary is an elderly individual who needs guardianship The Care Team’s Goal: Support Mary with successful housing and health outcomes Pertinent Data in Portal: Mary’s heath history, circle of supports, and plans detailing Mary’s needs Outcomes Improved by Data: Finding housing options (assisted living) to meet Mary’s needs, ensuring visits to her primary care physician, and successfully supporting Mary in achieving her health goals

Allscripts CareInMotion
THE BIGGER PICTURE

CareInMotionPLATFORM
CARE COORDINATION ANALYTICS Manage cost Identifies and stratifies Clinical outcomes Financial results Managing utilization ACO success Preventative/ Chronic Care CareInMotionPLATFORM CONNECTIVITY & DATA AGGREGATION PATIENT ENGAGEMENT Engage patients Better outcomes Manage every patient continuously Accurate patient data Exchange Aggregate The CareInMotion Platform serves multiple aspects of Population Health Management - Care Director is primarily focused in the Care Coordination workflow space

Precision Medicine/ Consumer Solutions
Allscripts Strategy PHARMACY HOSPITAL & HEALTH SYSTEMS SPECIALIST POST ACUTE PHYSICIAN PRACTICE Community Aware EHR CARE COORDINATION CONNECTIVITY & DATA AGGREGATION PATIENT ENGAGEMENT ANALYTICS CareInMotion PLATFORM Population Health Management Precision Medicine / Consumer Solutions INTELLIGENT INTERVENTION MOBILITY AND WEARABLES CLINICAL OMICS RESEARCH Precision Medicine/ Consumer Solutions Allscripts Community Architecture • Allscripts community-aware EHRs capture clinical data from care settings across the health continuum. • Clinical Data is fed in through our community architecture, Information is normalized creates a true harmonized view of patient Clinicians then use this info to create care plans, engage patients, and begin collaborating to achieve true population health management

Collaborative Care delivers the right capabilities for tackling chronic/complex patients
See Plan Execute Deliver visibility into relevant clinical information Develop and manage go-forward plan and team for cohorts of patients Collaborate across the entire care team We visualize the Care Coordination workflow today as SEE, PLAN, EXECUTE See the clinical information brought into the system Plan for how to care for the patients needs Execute the plan across the Care Team

Care Coordination = Care Teaming
Care Coordination is inherently a teaming challenge; high value organizations enable care teams to flexibly and effectively collaborate on a common care path “High-value health care organizations deliberately design microsystems — including staff, information and clinical technology, physical space, business processes, and policies and procedures that support patient care — to match their defined subpopulations and pathways.” “The first principle in structuring any organization or business is to organize around the customer and the need. In health care, that requires a shift from today’s silo-ed organization by specialty department and discrete service to organizing around the patient’s medical condition.” Care Coordination is not just an individual Care Coordinators job It’s the job of a Team of Care providers

Addressing the core unmet need means delivering a network solution, not an EMR centric solution
Relationship multiplicity and integration requirements with EMR solution prohibit scalability in reaching care team Network solution reaches every possible care team member, monetizing richness of access It takes a village…to care for a patient

Execute across the healthcare continuum
Ambulatory Acute Post Acute Community Consumer Physician Practices Clinics … Hospitals Health Systems … Home Health Long-Term Care Hospice Private Duty … Pharmacies Labs Specialists In- and out-of-network physicians YMCA’s … Patient Engagement Technologies Portals Wearable Tech Personalized Medicine … Care Director is built on-top of another solution in our portfolio called Care Management Over 1K Acute Hospitals referring to Post-Acute Network of 80K post-acute providers (eg. Homecare, SNF, Long-Term Care, Rehab) 15 yrs of Acute to Post-Acute network establishment Combined with the Ambulatory ‘network’ across our Pro and TW customer base, not to mention other ambulatory solutions outside of Allscripts Begin to add in the onset of Community/Social providers into the network (eg. YMCA, Care Coordination Agencies, Non-profit Homeless Shelters, Food Pantries, etc) Now That’s a NETWORK

Community Portal Access
Beth, 71 years old T2DM Hip breaking down, needs replacement Care Team : 10+ Providers Collaborative Care Tomorrow Plan of Care Clinical Data Single Care Plan Community Health Providers Specialists & Hospital PCP + Care Navigator Patient Rehab Community Portal Access Access at the point of care (CC Agent) Patient Portal Access DME Dietician Home Health Endocrinologist Hip & Knee Surgery Wound Care Coordinating care around a common patient history AND a common understanding of roles and responsibilities Easy to create sub-care teams for specific care plan segments Easy to engage peripheral/community providers & the patient’s family

Coordination of Care Functions

Coordination of Care – Functional Capabilities

Coordination of Care

Scope Specifications for Web services based on:
Platform-Independent Model (PIM) And Platform-Specific Model (PSM) This defines the capabilities and interfaces for Coordination of Care Services. These models fulfill the requirements specified in the normative sections of the HL7 ‘Coordination of Care’ Service Function Model while improving the simplicity and functional completeness of the service interface. Responses: • Take risks to drive greater control over ecosystem and enable improved revenue in risk-based contracts • Clinical integration: create alignment and improve cost and quality • Pursue ACO products and value-based contracts to improve revenue

Symbols Symbol Description
HER Electronic Health Record PCP Primary Care provider Family Doctor UI User Interface GUI Graphical User Interface CDS Clinical Decision Support WSDL Web Service Definition Language TLS Transport Layer Security Successor to SSL or https CCDA Consolidated CDA (Clinical Document Architecture) A consolidation of various CDA templates and implementation guides that had been developed by various organizations HL7 Health Level-7 Standards body for Healthcare standards IHE Integrating the Healthcare Enterprise FHIR Fast Healthcare Interoperability Resources PIX Patient Identifier Cross-Referencing An IHE standard for matching patient identifiers XDS.b Cross-Enterprise Document Sharing An IHE standard for managing the sharing of documents HPD Healthcare Provider Directory An IHE standard for supporting the management of healthcare provider information, both individual and organizational, in a directory structure eMPI enterprise master patient index An enterprise wide system that links patient information from various systems together Diagrams are developed using the UML 2.0 standard, so please refer to UML documentation for details on the symbols used. Responses: • Take risks to drive greater control over ecosystem and enable improved revenue in risk-based contracts • Clinical integration: create alignment and improve cost and quality • Pursue ACO products and value-based contracts to improve revenue

Coordination of care service – Platform Independent Model
There are a number of services that enable the management of Care Team, Communication between participant and the exchange of Care Plans. There is also a fine grained Care Plan service through which any element of a Care plan can be updated. Support for this is optional for the EHRs. Finally, there is a reconciliation service that performs reconciliation. It is stateless and can be leveraged by an participating EHR.

Coordination of care service – Platform Independent Model
The following model provides an overview of the main objects of the domain models Relationships between the main models are described in this PIM Please note that this model is not complete. Once the Care Plan PIM is completed this diagram will be updated

Care Team Membership Model
The Care Team object represents the root of the Care Team. The Care Team contains all the Care Team Members that participate in the care of the Patient. A Care Team is always about a particular patient, so patient is a required attribute

Care Team Membership Operations
Care Team Invitation workflow Add Care Team Members

Care team permissions domain model
A Participant is assigned one and only one Role. While this may seem restrictive, keep in mind that a Care Team Member can participate in a Care Team as multiple participants. Each time they participate they are assigned a different Security Role.

Care Team communication security model
Each Care Team Note is associated with a Security Level. Examples of security levels could be General Note - Entire care team can access this note Professional Care Team Note - All care team members Care Team members with Professional roles can access this note but no others Each Security Level is associated with multiple roles. The logic is the following when determining access to a Note for a Participant. Lookup the roles of the Participant Lookup the roles required for the Security Level Perform an intersection If the intersection is not empty, then the participant has access to the Note.

Care Team Communications domain model

Care Plan Domain model

Care Plan Domain Model

Care Plan Review model

Care Plan Exchange Model

Reconciliation Domain Model
The following is an example of the structure of a reconciliation result Reconciliation-Result | |-- Source Unique (Type List<Medication> |-- External Unique (Type List<Medication> |-- Identical (Type List<Medication> |--Similar (Type List<SimilarObject> | … First SimilarObject | |--Source object (Type Object<Medication> | |--External object (Type Object<Medication> |-- Similar attributes (Type List<SimilarAttributes> | … First SimilarAttribute | |--LocalValueFormattedString (string) | |-- ExternalValueFormattedString (string) |--AttributeName (string)

Reconciliation Operations
The Reconciliation UI (Clinical Reconciliation) allows the user to make decisions as to what changes to apply back to the local system, e.g. Add, Modify, Delete. It is important to understand that these should be the final decisions and input from the user, and that another reconciliation should not happen in the local system.

Template & Tagging

Coordination Of Care Services - Implementation Considerations
Security Sharing of information Clinical Decision Support Identifiers Screen Sharing and Collaborative Review and Editing

Coordination Of Care Services. –
Coordination Of Care Services – Platform Specific Model For Web Services AcceptInvitation We see this being implemented typically as a URL, not a SOAP service endpoint. In other words the Prospective Participant can click on a link to signal their response RejectInvitation ForwardInvitation MatchPatient Not required if PIX is supported ShareCarePlan (Document) Not Required if XDS.b is supported A PSM model for Web Services will be supported for all services, with these exceptions above Conformance criteria – Security TLS WS-Security WS-Federation

Coordination Of Care Services – Platform Specific Model For CCDA
This section WILL describe how the Care Plan model described previously maps into a CCDA document. Client applications that use the AddCarePlanDocument operation need to make sure that this mapping is followed correctly. This mapping will be provided for a later submission once the PIM is stable. Changes to HL7 CCDA Care Plan may be suggested at the same time. Conformance criteria – Identifiers and Provenance Identifiers and provenance information for all data elements that are shared should be provided.

Coordination of Care Services -Platform Specific Model for FHIR
Will be provided for a later submission once the PIM is stable. The goal with this standard is definitely to support FHIR, since we feel that this is a standard that is gaining a lot of traction in the Healthcare industry. However, FHIR, and especially the Care Team and Care Plan FHIR resources are immature. We will track FHIR closely and make a decision whether we will support FHIR for the version 1.0 final submission later. Because we see that FHIR is a REST-full implementation, we are not, at this point, planning to provide a specific REST implementation as part of this standard. We might change our opinion later, if FHIR adaption lags or if FHIR fails to meet it’s promises. But at this time developing another RESTful PSM does not make sense to the authors.

Coordination of Care Services - Platform Specific Model for IHE
We are expecting the following IHE profiles to be used by this standard PIX XDS.b HPD

Coordination Of Care Services – Platform Specific Model For Direct
We are expecting the following Direct profiles to be used by this standard DirectMessaging DirectText

THANK YOU

Care Team Membership Operations

USE CASE Walkthrough

Introduction to the Model

Structure e.g. InviteCareTeamParticipant PIM Classes with Attributes
e.g. CareTeamParticipant Operations e.g. InviteCareTeamParticipant PSM SOA / Web Services Operations grouped into Services e.g. CareTeamMembershipService Classes are used as parameters PSM CCDA CarePlan and CareTeam classes map to CCDA PSM REST (FHIR) Classes become resources Operations and resource operations or extended operations PSM IHE Some operations will map to IHE e.g. XDS.b

Pre-requisites EHRs are registered with the Care Coordination Hub PIM
PSM SOA / Web Services Service identities setup Certificates exchanged PSM CCDA PSM REST (FHIR) EHRs and Applications have been registered with the Care Coordination Hub PSM IHE

Coordination of Care – Use Case
UC ID / Name UC3 – Multiple problems / Health concerns that require care coordination assistance Description A PCP identifies multiple problems that need management by multiple specialties- maybe within the organization but also outside of the organization. Some are medical related and some are not (i.e. financial, social, mental, etc.). Care coordination is needed to prevent falling through the cracks. Actor(s) Patient, PCP, specialty providers, nurse, social work, care coordinator Triggers Referral order(s) entered in the system Assumptions All involved parties have ability to register as a care team member for this patient Preconditions Post-conditions Care Team Members (i.e. Healthcare Providers as well as Non-Healthcare Providers) will be provided with a Care Plan Care Team Members (i.e. Healthcare Providers as well as Non-Healthcare Providers) will have access to a multi-disciplinary Care Plan Workflow Provider sees patient (for whatever reason at whatever facility type) Provider Determines patient needs to be admitted to acute care/ hospital Care Coordinator notified of patient admit to begin the Care Coordination process Discharge planning include multiple referrals – inpatient rehab, eventual home care Social worker speaks with the patient and learns of other health concerns Care Coordinator contacted to coordinate the referrals and address the patient’s health concerns (incl. non-medical related). Note: Adding a care team Scenario Miss Everyman had a surgical procedure done approximately two weeks ago. She is complaining of a fever, and has noticed the wound site is red and hot. Mrs. Everyman is seen by her PCP who determines she needs to be admitted to the hospital. The Care Coordinator is notified of Mrs. Everyman’s admittance and begins the care coordination process. The social worker conducts an interview with Miss Everyman. During the interview process, the social worker learns Miss Everyman was diagnosed with chronic depression prior to her surgical procedure, and the complications from surgery have made her less motivated to participate in her care. She is a single parent with no income, and transportation who is having difficulty managing the complications from surgery. When the patient is ready to be discharged, she receives a referral to an orthopaedic surgeon (specialist) for follow-up care, a referral to home health nursing (wound care), and physical therapy (PT). A Care Plan is initiated.

Use Case Assumptions The EHRs (Ambulatory, Acute and Post Acute) have all been registered The following are members of the Care Team already Surgeon PCP Hospital Care Coordinator The patient is an existing patient with the following

Step 1: Surgeon sees the patient
The following are Captured in the Surgeon's EHR Encounter Procedure Instruction Note The surgeon does not capture a care plan The base clinical items (e.g. CCDA items) are part of the PIM

Step 2: Surgeon exchanges information with Care Coordination Hub
This could happen when the encounter note is signed CCDA document is produced [PIM] Invoke MatchPatient operation on the Care Coordination Hub [PSM IHE] PIX/PDQ [PIM] Invoke ShareCarePlan operation on the Care Coordination Hub [PSM IHE] XDS.b

Step 3: The information is incorporated into the Care Coordination Hub
"Parsing" of the CCDA document Technical Reconciliation Clinical Reconciliation

Reconciliation Overview

Technical Reconciliation
Uses the Terminology Service to expand the input data E.g. For Medication, determine the brand and the ingredients Uses rules to determine how similar items are

Reconciliation Domain Model

Reconciliation User Interface

Reconciliation Result

Step 4: The new information is shared
Consolidate the Information Produce a new CCDA document (Consolidated Care Plan) Share Consolidated Care Plan with the Care Team Member's EHRs [PIM] ConsolidatedCarePlanChangeNotification [PIM] RetrieveConsolidatedCarePlan

Step 5: Patient sees the PCP
PCP can see the surgery information via the new Consolidated Care Plan that was Shared PCP Captures Problems Fever Wound condition Intervention Send patient to Hospital

Step 6: PCP Transitions the Patient to the Hospital
Please note, there are referral Use Cases here that we will not go into at this time PCP shares the Care Plan with the Care Coordination Hub [PIM] Invoke MatchPatient operation on the Care Coordination Hub [PSM SOA] Part of the CareplanExchangeService [PIM] Invoke ShareCarePlan operation on the Care Coordination Hub [PSM SOA] Part of the CareplanExchangeService

Step 7: Patient Is admitted to the Hospital
Same as before, the encounter is shared with the Care Coordination Hub We are not going to go into detail here, but we assume that the relevant clinical information is shared from the Acute or ED EHR as appropriate, using the [PIM] ShareCarePlan described previously

Step 8: Care Team Membership
The Care Coordinator adds a Social Worker to the Care Team The Social worker is not part of the Care Team

Care Team Membership

Step 8: Care Team Membership (Continued)
Determine that there is not social Worker on the Care Team [PIM] FindCareTeam PatientID is the parameter, returns CareTeam [PIM] GetCareTeam Identifier of the CareTeam Find the Social Worker Can be in Care Coordination Hub HPD Local EHR

[PIM] FindCareTeamMember Search criteria are pre-populated (CareTeamMember is not part of the CC Hub) [PIM] InviteCareTeamMember [PSM] will typically be via [PIM] AcceptMembershipInvitation (Social Worker) [PSM] will typically a URL indicating their acceptance CC Hub will ask the user to create credentials Single Signon can be used

Invite the Social Worker to the Care Team [PIM] InviteCareTeamParticipant [PSM] will typically be via [PIM] AcceptParticipantInvitation (Social Worker) [PSM] will typically a URL indicating their acceptance A CareTeamParticipant object will be created

Step 9: Care Coordinator uses Care Team Communication in the Care Coordination Hub to communicate with the social worker [PIM] AddCareTeamNote (Care Coordinator) [PIM] FindNote (Social Worker in their EHR) Note that this can be used for Notifications as well via poling OR [PIM] CareTeamNoteUpdateNotification [PIM] AddCareTeamNoteComment Note: At this point the Care Cordinator can also create an activity for the Social Worker to see the patient

Care Team Communication

Step 10: Social Worker meets with Patient
Social Worker meets with Patient and determines the following Health Concern: Clinical Depression Health Concern: Single parent, no income, no transportation Same as before, the encounter is shared with the Care Coordination Hub and all participant notified of the changes We are not going to go into detail here, but we assume that the relevant clinical information is shared from the Acute or ED EHR as appropriate, using the [PIM] ShareCarePlan described previously

Step 11: Care Coordinator gets the patient ready to be discharged
[PIM] CreateCarePlan Intervention: Follow up Care with Orthopedic Surgeon Intervention: Referral to Home Health Intervention: Physical Therapy Goal: Patient is Ambulatory Goal: Patient can take care of wound Goal: Wound is healed

Care Plan Domain Model

Health Concern Domain Model

Step 12: Review A week later, the Care Coordinator schedules a review. During the review it becomes apparent that the patient is not going to PT The review can take place in a “Virtual Huddle Room” No specific technologies are proposed. The submitters feel that existing conferencing and screen sharing technologies are sufficient for the first release Simultaneous editing by multiple participants will be taken up in a future release of the standard if there is demand for it. During the review, all goals, interventions and health concerns are evaluated, outcomes are noted New goals and interventions can be added The review is only complete if every item has been reviewed

Care Plan Review Domain Model

Coordination of Care Service (CCS) Initial Submission

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