1. Longitudinal Coordination of Care Pilots WG Monday, September 30, 2013

2. 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

3. TopicPresenter Introductions and PurposeLynette Overview of CORHIOPam Overview of Pilot wiki and toolsLynette Agenda 3

4. Purpose –Provide tools and guidance for managing and evaluating LCC pilot Projects –Create a forum to share lessons learned and best practices –Provide subject matter expertise –Leverage existing and new partnerships Goals –Bring awareness on available national standards for HIE and care coordination –Real world evaluation of parts of most recent HL7 C-CDA Revisions Implementation Guide (IG) –Validation of ToC and Care Plan/HHPoC datasets Pilot Work Group Purpose and Goals 4

5. 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

6. LCC Pilot WG Tasks 6 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

7. Longitudinal Coordination of Care Pilots WG CORHIO-LTPAC Transitions Program September 30, 2013 Pamela Russell, LTPAC Program

8. Agenda About CORHIO Initial Outreach through surveys and letters Participating LTPAC Providers Milestones and Measures Statistics on Usage and Queries Lessons Learned Q&A

9. About CORHIO Who We Are Colorado Regional Health Information OrganizationColorado Regional Health Information Organization A nonprofit, public-private partnershipA nonprofit, public-private partnership The state-designated entity for health information exchange (HIE) in ColoradoThe state-designated entity for health information exchange (HIE) in Colorado Vision Shared health information for all individuals in every Colorado community promoting the right care, at the right time and the right place.Shared health information for all individuals in every Colorado community promoting the right care, at the right time and the right place. Goals for 2015 Health information exchange deployed in every community 85% of providers are meaningful users of electronic health records (EHRs)

10. Health Information Organization Care Transitions: Long-Term & Post- Acute Care Medicaid EHR Incentive Program Outreach Behavioral Health Integration Regional Extension Center Assist providers with EHRs & Meaningful Use CORHIO Health Information Exchange (HIE)

11. CORHIO By the Numbers Office-Based Physicians/Providers Connected or in Implementation Hospitals Connected or in Implementation (30 are already connected to the HIE) Unique Patients With Clinical Data in the HIE Data current as of Aug 20, 2013 Long-Term, Post-Acute Care, Home Health Facilities Connected or in Implementation 45 119 1,800+ 2,582,675

12. Labs Participating in HIE Cedar Diagnostics Colorado Lab Services LabCorp Quest Diagnostics Schryver Medical Bold = Connected to HIE (Live) Non-bold = Under agreement, in implementation

13. LTPAC Program –The Beginning Whats HIE? Initial Outreach – Survey letters to LTPAC Providers Community Meetings in targeted communities – Area Agency on Aging – CFMC – state QIO – CHA – Colorado Hospital Association – CHCA – Colorado Healthcare Association Collaborations with hospitals, physician practices, care coordinators and care transition community groups Participant Agreement Milestones and Measures

14. What is HIE in Colorado? The ability to electronically exchange patient health information including: Lab/pathology results Imaging/radiology reports Scheduled Orders ADTs, H & Ps Discharge Summaries Transcribed notes Continuity of Care Documents (CCDs) …when its needed for patient care.

15. CORHIO HIE CORHIO, as SDE, manages the State Medicaid Health IT Plan and has a strategic roadmap for statewide HIE projects CORHIO currently supports HL7 2.5.1 transaction level information, Human readable CCDs in PDF directly from HIE. CORHIO is actively working on extracting structured CCDAs from CEHRT and publishing CCDAs into the HIE by Spring 2014. CORHIO will align with Colorado OIT recommendations supporting commercial technical solutions utilizing industry standards including Direct, Blue Button, HL7, etc. These developments will support PHR implementations throughout Colorado

16. It Takes a Community… CORHIO Helps All Providers in the Community Share Info & Coordinate Care

17. LTPAC Program Outreach Survey letters sent to 350 long-term and post-acute care providers Gathered information on IT readiness, internal resources and interest Participant Agreements completed and sent Business Associate Agreements completed and sent – Revised Sept. 13 – Policies and Procedures - HIPAA – Opt Out language – User Request Forms with user name and password – Auditing Reports Workflow Process both internal and external assessed

18. Internal LTPAC Resources Internal CORHIO staff – LTPAC Program Manager – Finance/Contract Manager PAs BAAs Milestones and payments AARA Report – Surveys – all three – MarCom – video, collaterals – Ops – Implementation and Training including Policy and Procedures Opt Out language User Request Forms

19. External LTPAC Resources Core Users tied to milestones – Admission Coordinators – Health Information Managers/Medical Records/IT – Nursing Staff – especially night and week-end – Clinical Liaisons – Medical Directors Users – Therapists – Nurse Practitioner/Physician Assistants – Charge Nurses

20. LTPAC Milestones Milestones included: – Implementation and Training 30-45 days to train LTPAC Users One hour training can be one on one or group setting Implementation refresher webinar training accessed through CORHIOs 24/7 Help Desk – Core Usage and Monthly Utilization Reports Manual Process with goal to be automated – Surveys Pre-Work Flow/Baseline Satisfaction Surveys Qualitative Survey

21. Participating LTPAC Providers Skilled Nursing Assisted Living Home Health Hospice and Palliative Care Labs

22. LTPAC Participants And Many More! Long-Term, Post-Acute & Home Health Care

23. LTPAC Users - Quick Stats © 2013 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary - Not For Redistribution 23

24. Patient Care 360 ® LTPAC Customer Satisfaction Survey Results Has PatientCare 360 ® improved your patient care transitions? 100% of participants polled answered YES. We are able to obtain more current information and to obtain additionally requested information more quickly. Has PatientCare 360 ® made your job easier? 100% of participants polled answered YES. I get access to info more promptly than before. Do you believe that PatientCare 360 ® helps you provide better care to your patients? 100% of participants polled answered YES. Information needed is often readily available improving response time to physician inquiries. 2/11/2014 24 © 2010 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary - Not For Redistribution

25. LTPAC Challenge Grant Measures 80% of transitions to and from targeted LTPAC providers include electronic exchange of standard health information – Pre-Work Flow Surveys documented 0% to 10% – Post GO LIVE survey documented 100% 70% of transitions to and from targeted LTPAC providers include transmission of information within 2 hours of discharge – Pre-Work Flow Surveys averaged 32 hours (see slide) – Post GO LIVE Surveys shows 6 minutes

26. Workflow Improvement HIE saves LTPAC practices an average of 29 hours per admission

27. LTPAC Challenge Grant Measures, continued Providers in targeted communities respond to 100% of patient requests for copies of care summary information – All LTPAC providers have the ability to create and print CCDs for their patients/family members upon request – CCDs are documented on a monthly basis Manual process to show # created, viewed, printed and exported Need to further drill down for usage

28. Lessons Learned LTPAC Staff Resources – Turnover – Able to update resume with IT experience – Competing IT efforts Work Flow Process – Faxing for Data Senders (hospitals) - positive Hospital Discharge Flyers – Faxing for LTPAC Data Receivers - negative Impact on their ability to market to DC Planners EHR/HIE Integration – HL7 capability and ability to receive and send ADTs and CCDs

29. Standard HIE – PatientCare 360 Clinical Inbox Reports Tests CCD Exchange

30. How Query-Based HIE Works 30 © 2013 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary - Not For Redistribution Community Health Record Hospitals Public Health Departments Laboratories Radiology Centers Hospital ADT Info Lab Results Pathology Reports Radiology Reports Consult Reports Transcription Notes Public Health Alerts Immunizations Diagnostic-Quality Medical Images (with CTN) Medications lists Data Analytics Pharmacy Information CCD CCD Upload Orders Future CIIS Newborn Screening Results Reportable Conditions Immunizations Lab/Rad Immunizations

31. Break the Glass 2/11/2014 © 2011 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary – Not For Redistribution 31 Depending on your security settings, you may not be able to get into the patient chart without Breaking Glass, establish a relationship, to view a record Click on Break Glass Link…

32. Establishing a relationship… 2/11/2014 © 2011 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary – Not For Redistribution 32 If a user were going to break glass – they would be presented with this Confidentiality Alert. Staff must be associated with a provider in order for Long Term Access to function.

33. CCD CCDs allow you to compile historical summaries of the care that a patient has received through the community. 2/11/2014 33 Select in the upper right corner of any patient chart

34. Previewing CCD 2/11/2014 34 Click Save

35. LTPAC Initiatives Regional and statewide meetings to encourage HIE adoption for LTPACs Multi-state meetings to share LTPAC experience Collaborating with HCPF on the TEFT (Testing Experience and Functional Tools in Community-Based Long Term Services and Supports) – Demonstrate use of personal health record (PHR) systems with beneficiaries of CB-LTSS – Identify, evaluate and harmonize an electronic Long Term Services and Supports (e-LTSS) standard in conjunction with the Office of National Coordinators (ONC) Standard and Interoperability (S&I) Framework CORHIOs Consumer Engagement Strategy and PHR State Innovation Model (SIM) Grant CFMC/CORHIO Patient Transfer Form in Northern Colorado True North EMS and LTPAC Providers 2/11/2014 35 © 2010 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary - Not For Redistribution

36. CORHIO Making an Impact Click image to view video; Internet access required.

37. Other Participating Providers Visit www.corhio.org and select Participating Providers Interactive Map Full List of Providers Below

38. For More Information www.CORHIO.org Click on Long-Term Care Under For Providers LTPAC video

39. Pamela Russell Manager Business Development & Outreach Long Term Care prussell@corhio.org 720-285-3257 Contact Info at CORHIO

40. http://wiki.siframework.org/LCC+Pilots+WG How Can You Participate in the LCC Pilot SWG? 40

41. Summary of Documentation Templates & Reference Materials (Pilot Materials) 41 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.

42. Homework Assignment: –Complete Pilot Survey –Sign up as an LCC Committed Member –Submit Pilot Documentation Templates Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG http://wiki.siframework.org/LCC+Pilots+WG Email to Lynette Elliott (Lynette.elliott@esacinc.com)Lynette.elliott@esacinc.com NO Meeting next week due to HL7 WGM in Boston, MA Next Steps 42

43. LCC Leads –Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org) –Dr. Terry OMalley (tomalley@partners.org) –Dr. Bill Russell (drbruss@gmail.com) –Sue Mitchell (suemitchell@hotmail.com) LCC/HL7 Coordination Lead –Dr. Russ Leftwich (Russell.Leftwich@tn.gov) Federal Partner Lead –Jennie Harvell (jennie.harvell@hhs.gov) Initiative Coordinator –Evelyn Gallego (evelyn.gallego@siframework.org) Project Management –Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com) –Use Case Lead: Becky Angeles (becky.angeles@esacinc.com) LCC Initiative: Contact Information 43 LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Carehttp://wiki.siframework.org/Longitudinal+Coordination+of+Care