1. Functional Requirements and Health IT Standards Considerations for STAGE 3 Meaningful Use for Long-Term and Post-Acute Care (LTPAC) Update to the HITPC MU WG – Subgroup #3: Standards & Interoperability: Longitudinal Coordination of Care (LCC) Workgroup (WG) and HL7 Activities

2. Content Overview: – Standards & Interoperability: Longitudinal Coordination of Care Workgroup (S&I LCC WG) and Sub-workgroup Activities – HL7 Activities – Piloting S&I LCC Next Steps Recommendations to the HITPC MU WG – Subgroup #3 (HITPC MU WG – SG #3)

3. The S&I LCC Initiative -- Overview The S&I LCC WG: – Collaborates with HL7 and provided input on refinements to Spring 2012 C-CDA ballot to include: functional status, cognitive status, and pressure ulcer content – Collaborates with Keystone Beacon Community and HL7 to identify content and standards needed for Patient Assessment Summary (PAS) Documents and support their on-going and future pilots. The S&I LCC WG achieved consensus (June 2012) on a foundational Use Case that leverages requirements in the Meaningful Use (MU) Program for eligible providers and hospitals to support four clinical document exchanges with LTPAC organizations: – Transfer from Acute Care Hospital to Home Health Care – Referral from Nursing Home to ED – Consult summary for shared care from ED to Nursing Home – Primary care physician and home health care sharing the Home Health Plan of Care (HH POC) The S&I LCC activities include: – Harmonizing existing standards, including content in the PAS document, and filling gaps, – Developing implementation guides and reference implementations, and – Enlisting pilots with a goal of providing tested IG(s) for the four transactions and documents for MU3 consideration mid 2013. The S&I LCC WG, in collaboration with HL7, has begun: – preliminary planning for a dynamic longitudinal care plan using the HH POC requirements as a foundation; and – an analysis of care plan requirements proposed for MU Stage 2.

4. S&I LCC Workgroup S&I LCC WG: – Includes 124 total and 63 committed members representing: LTPAC providers and vendors, physicians, nurses, AHIMA, ONC Challenge Grant and Beacon Community recipients, federal representatives (e.g., ASPE, CMS, ONC), and ONC contractor staff Three sub-work groups: – Patient Assessment Summary (PAS) – Transitions of Care (ToC) – Longitudinal Care Plan (LCP)

5. Patient Assessment Summary Sub- Workgroup Focus: Identify standards for interoperable exchange of patient assessment content and patient assessment summary documents to support the care of persons receiving LTPAC services. Background: – CMS requires that certain providers electronically transmit non-interoperable patient assessment instruments: Minimum Data Set 3.0 (MDS3.0) for nursing homes (NHs) Outcome and Assessment Information Set - C (OASIS-C) for home health agencies (HHAs) In-Patient Rehabilitation Facility- Patient Assessment Instrument (IRF-PAI ) for IRFs. – CMS piloted, in a payment demonstration, the CARE (Continuity Assessment Record & Evaluation) instrument at hospital discharge and at both admission and discharge from post-acute care (PAC)

6. Status: S&I PAS SWG, HL7 Activities, and Keystone PAS SWG and HL7 identified refinements to the Consolidate CDA (C-CDA) to represent and transmit: functional status, cognitive status, and pressure ulcers. – The HL7 May 2012 C-CDA ballot now includes templates for the representation and transmission of: functional status, cognitive status, and pressure ulcers. PAS SWG validated and refined clinically useful subsets of assessment content to support: Transition in Care, Shared Care, and Care Planning. PAS SWG, Keystone Beacon Community, and HL7 are collaborating to develop a document exchange standard for PAS document. – HL7 will ballot the standard in September 2012 ballot cycle. Pilot: The Keystone Beacon Community: – Is piloting the exchange of PAS documents using the CCD; and – Beginning in December 2012, will pilot the exchange of PAS documents using the HL7 standard balloted in June and September 2012.

7. S&I LTPAC Transitions of Care (ToC) Sub-Workgroup and ONC/ MA Challenge Grant Focus: identify standards needed for the exchange between Eligible Professionals/Eligible Hospitals, LTPAC providers and patients of an interoperable summary document to support transitions in care. Exchange recipient-defined clinical content for the following identified high- priority transitions: – Acute care hospital to home health – Nursing home to emergency room – Emergency room to nursing home Leverage and re-use selected data elements from PAS documents, leverage the C-CDA, identify available standards and gaps, and develop an implementation guide and other resources to support the interoperable exchange of an expanded recipient-defined clinical dataset across sites of care. Status: Work in progress. To be completed December 2012. Pilot: The ONC MA Challenge Gant (IMPACT): – Beginning in December 2012 will pilot the exchange of this expanded dataset based on the HL7 C-CDA as balloted in June and September 2012.

8. S&I Longitudinal Care Plan Sub-Workgroup Focus: Identify standards for the interoperable exchange of care plans focusing on: 1)Iterative exchange of the Home Health Plan of Care (HH POC) between home care providers and physicians. Background: The HH POC is nearly ubiquitous among HHAs as it is based on a former CMS POC requirement (i.e., the 485 form). S&I LCP SWG: Focus on HH POC: structured in collaboration with the Visiting Nurse Services of New York (VNSNY) to support the iterative exchange of the HH POC between: VNSNY, physician practice groups, and other stakeholders. S&I LCP will leverage the C-CDA, identify available standards and gaps, and develop an implementation guide to support the interoperable exchange of the HH POC between home care providers and physicians. 2)Identifying components of and standards for a longitudinal care plan and relationship of these components to the Meaningful Use EHR program requirements (see slide 10)

9. Status: S&I LCP SWG: HH POC and VNSNY Completed: Identified and refined data elements in HH POC. Activities underway/to be competed: – S&I Harmonization WG will: – Harmonize data elements across S&I ToC documents and PAS documents – Align and harmonize HH POC requirements with longitudinal care plan components (see slide 10). – Identify available standards and gaps in standards to support interoperable exchange of HH POC. – Work with HL7 to fill gaps in standards. – Enlist pilots and develop an implementation guide and schema leveraging work under way at the VNSNY to support the interoperable exchange of home care POC. Status: Work in progress. To be completed December 2012.

10. Preliminary S&I LCC Comments on Care Plans MU Stage 2 NPRM: Care Plan and Components Comments to ONCS&I MU Stage 3 Care Plan Components: Recommendations/Considerations Care Plan:1. Not adequately defined. 2. Described as part of a ToC Summary Care Record. 1.Care Plan Definition needed. 2.Care Plan should be separate/independent Summary Care Record. Problems1. Not defined. 2. CCDA focus is on medical problems 1. Definition needed. 2. Concept should support the broad array of health concerns present for medically complex/ functionally impaired persons. Instructions (that the provider has given to the patient) 1.Not defined. 2.Concept should be broader than patient instructions 1. Definition needed. 2. Concept should support the identification of interventions which includes patient instructions as a subset. Goals (the target outcome)Goals and outcomes are different. Separately define: goals and outcomes Goals need to support patient values/expectations/preferences. Team members (names and contact information of any additional known care team members beyond the referring or transitioning provider and the receiving provider) 1. Not sufficiently defined.1. The care plan should, at a minimum, identify all team members involved in the creation of the care plan, and roles of team members involved in the execution of the care plan. Care plan to be exchanged using the Summary Care Record/ C- CDA. 1. No Care Plan Document Type in C-CDA. 2. MU Stage 3 should support the: creation, transmission, and incorporation of a care plan across multiple settings and over time for care team members to deliver needed medical and other services to medically complex and functionally impaired individuals. S&I LCC WG will address the following questions: 1. Is a separate care plan document type needed in the C-CDA? 2. Can the summary of care record support the creation, transmission and incorporation of care plans? 3. Will the C-CDA permit linking a single Health Concern/Problem to multiple: Interventions/ Instructions, goals, and outcomes? 4. Will the C-CDA permit: linking outcomes back to various interventions/ instructions and health concerns/problems? Other needed care plan components Future Meaningful Use and Standards rules regarding care plans may need to include additional components (e.g. care plan decision modifiers, risk factors, advance directives, patient preferences)

11. S&I LCC WG Next Steps Recommend that S&I LCC: Continue its work (described below) to: – identify care plan functional and standards requirements for MU Stage 3; and – identify any gaps in ToC functional requirements and standards for MU Stage 3; and Provide updates to the HITPC and HITSC on (i) these activities, and (ii) inclusion in C-CDA of templates for: functional and cognitive status, and pressure ulcer, and opportunities to re-use this content/standards for various purposes in MU Stage 3. Longitudinal Care PlanTransitions in Care Identify needed longitudinal care plan components and identify and implement methods to obtain wide stakeholder input on: needed care plan components, inter-relationships, and standards. Review final MU Stage 2 functional requirements for the exchange of Care Plans to support transitions of care on behalf of functionally impaired/medically complex persons. Review final MU Stage 2 functional requirements for the exchange of Summary of Care Records to support transitions of care on behalf of functionally impaired/medically complex persons, and identify whether there are gaps in the ToC functional requirements that should be filled for MU Stage 3. Evaluate whether document exchange and vocabulary standards are available to support the creation, transmission and incorporation of longitudinal care plans for service delivery to medically complex and functionally impaired individuals. Leverage and extend standards harmonization activities from the Home Health Plan of Care Use Case. Collaborate with HL7 Structured Documents WG and HL7 Patient Care WG to evaluate the availability of, and gaps in, standards to support the creation, transmission and incorporation of a longitudinal care plan and its components. Evaluate the adequacy of MU Stage 2 document exchange and vocabulary standards to support transitions of care on behalf of functionally impaired/medically complex persons, and collaborate with HL7 to fill identified gaps.

12. Recommendations/Suggestions to the HITPC MU WG – Subgroup #3 The S&I LCC WG recommends that the HITPC MU WG – SG#3 recommend to the HITPC and HITSC that: 1.The HITPC and HITSC be updated on the inclusion in the HL7 C-CDA of clinical content to support the interoperable exchange of: functional status, cognitive status, and pressure ulcer content. The S&I LCC WG could provide an update on the C-CDA. 2.The HITPC and HITSC consider how MU Stage 3 requirements could/should leverage content and standards for: functional status, cognitive status, and pressure ulcers beyond their use in Care Plans and ToC. 3. The HITPC and HITSC recommend that MU Stage 3 requirements include functional requirements and standards needed on behalf of functionally impaired/ medically complex persons for: A.Care plans and needed components, including: defining care plan and identifying and defining needed components (e.g., health concerns, interventions, goals, outcomes, team members, patient preferences, other components); and B. Any needed updates to Summary of Care documents to support transitions of care for these individuals.