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

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

3. LCC WG participation in HITPC MU SWG #3 Care Coordination –Summary of May 24th meeting –Care Plan discussion scheduled for June 4 th, 2013 11:30am – 1:30pm ET Participate online: https://altarum.adobeconnect.com/mu; Audio: 1-877-705- 2976https://altarum.adobeconnect.com/mu1-877-705- 2976 Reminder to register for 2013 LTPAC HIT Summit –Date: June 16-18, 2013 –Location: Baltimore, MD –http://www.ahima.org/Events/EventCalendar/Event.aspx?Id=b88011a0-3d9f- 45cc-8454-60837c37baafhttp://www.ahima.org/Events/EventCalendar/Event.aspx?Id=b88011a0-3d9f- 45cc-8454-60837c37baaf 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: evelyn.gallego@siframework.org, lynette.elliott@esacinc.com, becky.angeles@esacinc.comevelyn.gallego@siframework.org lynette.elliott@esacinc.combecky.angeles@esacinc.com 3 ONC S&I Update

4. Next weeks 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: (http://wiki.siframework.org/LCC+WG+Use+Case+2.0)http://wiki.siframework.org/LCC+WG+Use+Case+2.0 –Use the comment form to provide feedback on UC sections (http://wiki.siframework.org/LCC+Use+Case+2.0+Comments)http://wiki.siframework.org/LCC+Use+Case+2.0+Comments 4 Announcements and Reminders

5. 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, 11 - 12pm 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

6. 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 – 3/18 10.0 Scenario (User Stories, Base/Alternate Flow, Functional Requirements) Review: User Stories 3/25 – 3/26 3.0 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 – 4/25 11.0 Risks, Issues, and ObstaclesFinalize: Risks, Issues and Obstacles Review: Sequence Diagrams 10.4 Sequence Diagram 5/2 – 5/16 10.3 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 5/3012.0 Dataset RequirementsEnd-to-End Review (preliminary)

7. 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 10.2.1 Base Flow o 10.2.2 Alternate Flow –10.3 Functional Requirements o 10.3.1 Information Interchange Requirements o 10.3.2 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

8. 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

9. 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

10. 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

11. 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. Show Use Case 2.0 document –10.2.1.1 – Base Flow for Scenario 1 comments –10.2.2 – Alternate Flow Text comments –5.0 – Assumptions (already modified) David Taos Comments from the Wiki 12