Longitudinal Coordination of Care
(LCC) Workgroup (WG)
Pilot Planning Presentation for ONC LTPAC CoP
July 17, 2013
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Overview
• Introduction: Longitudinal Coordination of Care (LCC)
Problem Overview
• Role of Standards for Problem Resolution
– ONC S&I & LCC WG Overview
– Intro to Piloting & Validation of Standards
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IMPACT Project
NY Project
Next Steps
Q&A
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Today
• We want you to become pilot sites
• We’ll tell you
– Why
– What needs piloting
– How to sign up
And the Problems are…
Transitions of Care
and
Longitudinal Coordination of
Care (LCC)
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Patients that Drive Trend
• Profile of the high cost patient
– Elderly
– Frail
– Multiple chronic conditions
– Functional impairments
– Behavioral/cognitive impairments
– Dual eligible
– With a new superimposed acute illness
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Number of Chronic Conditions/Pt
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Per Beneficiary Medicare Spending
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Proportion of Spending
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# of Emergency Department Visits/Pt
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Hospitalizations
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Readmissions by # of Chronic
Conditions
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Where do patients go after a
hospitalization?
Everywhere!
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Post-Acute Care Utilization
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Consider a Pilot If…
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HIE capability exists
High proportion of Medicare beneficiaries
High proportion of dual eligibles
Presence of ACOs and other at risk provider groups
High readmission rates
Issues with transitions of care
Inability to exchange a longitudinal care plan
Receiver Needs vs. Sending CCD
Data Elements for Longitudinal
Coordination of Care
IMPACT Data Elements
for basic Transition of
Care needs
CCD Data Elements
• Many “missing” data elements can
be mapped to CDA templates with
applied constraints
• 20% have no appropriate templates
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Piloting Opportunities
• New exchange standards for
– Home Health Plan of Care
– Permanent transfer of care (discharge)
– Consultation request and response (PAC to ED and
return)
– Test/Procedure request and post test response
• New software for HIE access
Role of Standards in
Addressing LCC Limitations
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What is the S&I Framework?
• The Standards and Interoperability (S&I)
Framework represents one investment and
approach adopted by the Office of Science &
Technology (OST) to fulfill its charge of
prescribing health IT standards and
specifications to support national health
outcomes and healthcare priorities
• The S&I Framework is an example of
“government as a platform”– enabled by
integrated functions, processes, and tools –
for the open community* of implementers and
experts to work together to standardize
* As of April 2013, 1100+ people had registered on the S&I
Framework wiki, and 450+ people representing 300+
organizations had committed to the S&I Framework
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ONC’s Interoperability Challenge
• Leverage government as a
platform for innovation to create
conditions of interoperability
• Health information exchange
is not one-size-fits-all; create a
portfolio of solutions that
support all uses and users
• Build in incremental steps –
“don’t let the perfect be the
enemy of the good”
S&I Longitudinal Coordination of Care
(LCC) Workgroup
• One of 11 active S&I Initiatives
• Initiated in October 2011 as a community-led initiative with multiple
public and private sector partners, each committed to overcoming
interoperability challenges in long-term, post-acute care (LTPAC)
transitions
• Goal is to identify standards that support LCC of medically-complex
and/or functionally impaired persons that are aligned with and could
be included in the EHR Meaningful Use Programs, specifically
Meaningful Use Stage 3
• Consists of four sub-workgroups (SWGs):
– Longitudinal Care Plan (LCP): focus on Care Plan exchange
– LTPAC Care Transition: focus on Transitions of Care
– HL7 Tiger Team: Alignment of LCC Care Plan standards with HL7 Care
Coordination Services (CSS) and Care Domain Analysis Model (DAM)
– Patient Assessment Summary (PAS)*: Balloted C-CDA refinements for
patient assessments
* The work of the PAS SWG completed in JAN13
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LCC WG Key Successes to meet MU3
needs
• Balloted 3 standards through HL7:
– C-CDA Refinements for interoperable exchange of Functional
Status, Cognitive Status, Pressure Ulcer & LTPAC Summary; MU2
incorporated requirements for functional and cognitive status
– Questionnaire Assessment
• Care Plan Glossary: Provides terms/components to
unambiguously define a Care Plan
– Presented to HITPC in response to MU3 RFC
• Two Consensus Voted Use Cases and one robust Dataset
(483+ data elements):
– Transitions of Care (driven by LTPAC SWG)
– Care Plan Exchange (driven by LCP SWG)
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Lantana C-CDA Revisions Project
• Lantana contracted to work with LCC WG to develop
Implementation Guidance (IG) based on functional requirements
identified in two LCC Use Cases & MA IMPACT Dataset
– Sponsored by MA IMPACT Project, NYeC, HealthIX, CCIt-NY, ASPE
• IG will be balloted as one Consolidated CDA Revisions Ballot
Package with HL7 in August 2013
• Ballot package will address 4 revisions to existing C-CDA (MU
Stage 2 standard for electronic transfer of Care Summary):
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Update to C-CDA Consult Note
Updated Consultation Request
Updated Transfer Summary
Updated Care Plan document type (will include HHPoC signature
requirements and will align with HL7 Patient Care WG's Care Plan
Domain Analysis Model- DAM)
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Next Phase: Piloting & Validation
• To ensure the C-CDA Revisions Implementation Guide is both
deployment-ready and implementer friendly prior to widespread
adoption (and inclusion in MU3 or ONC Certification Program),
we need organizations and entities to pilot and validate the IG
• LCC Pilot Participants realize several benefits including:
– Ability to leverage LCC Initiative Resources
– Demonstrate compliance and increase efficiency of development
and maintenance
– Contribute to the Community
– Be recognized as an early adopter
• Three organizations/projects committed to piloting LCC C-CDA
IG in 2013 are:
– MA IMPACT (August 2013)
– NY Downstate Care Coordination (Oct 2013)
– NYeC (Oct?)
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Developing Software
to Support
New CDA Document Types
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IMPACT Grant
February 2011 – HHS/ONC awarded $1.7M
HIE Challenge Grant to state of Massachusetts
(MTC/MeHI):
Improving Massachusetts
Post-Acute Care Transfers
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LAND & SEE
• Sites with EHR or electronic assessment tool
use these applications to enter data elements
– LAND (“Local” Adaptor for Network Distribution)
acts as a data courier to gather, transform, and
securely transfer data if no support for Direct
SMTP/SMIME or IHE XDR
• Non-EHR users complete all of the data fields
and routing using a web browser to access
SEE, their
“Surrogate EHR Environment”
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Sharing LAND & SEE
• LAND
– Orion Health’s Rhapsody Integration Engine
http://www.orionhealth.com/solutions/packages/rhapsody
– Currently Modular EHR certified for MU1. MU2
(2014) pending
• SEE
– Written in JAVA
– Baseline functionality software and source code that
can connect to Orion’s HISP mailbox via API
available for free starting ~October 2013 (Apache
Version 2.0 vs. MIT open source license)
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Piloting LAND & SEE
and the new
“Transfer of Care”
CDA Document
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Pilot Sites to Test the Datasets
• Selection Criteria:
– High volume of patient transfers with other pilot sites
– Experience with Transitions of Care tools/initiatives
• 16 Winning Pilot Sites:
– St Vincent Hospital and UMass Memorial Healthcare
– Reliant Medical Group (formerly known as Fallon
Clinic) and Family Health Center of Worcester (FQHC)
– 2 Home Health agencies (VNA Care Network &
Overlook VNA)
– 1 Long Term Acute Care Hospital (Kindred Parkview)
– 1 Inpatient Rehab Facility (Fairlawn)
– 8 Skilled Nursing and Extended Care Facilities
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HIE Guiding Principles
A successful HIE needs to:
• Provide value (Benefits > Cost)
• Fit into real-world workflows
• Earn the trust of the stakeholders
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HIE Guiding Principles
Value
Pilot Site Learning Collaborative
•Understand importance of care transitions
Trust
•Walk in each other’s shoes
–Sender needs to understand what data
are needed by receivers and why
–Receiver needs to appreciate the
difficulty or constraints in collecting data
Useable
•Satisfy data needs of receivers
•Ensure that data collection and transfer
leverages existing data and efficiently fits
into workflows
•Ensure software matches organization’s
level of technological progress
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Other Considerations
• Gap between what is currently collected and what is
needed
• How will you know when it’s ready to send and what the
recipient’s address is?
• How will copies be printed for patient and ambulance?
• Technology needed to make this work (e.g. LAND, SEE,
others…)?
• Vendor development to make this work?
• Do you still need to send CCDs to satisfy “Meaningful
Use”?
Other Considerations
• How will you know when new documents
arrive?
• Can any of the data elements be re-used?
• Additional computers, printers, or chairs
required? Are they in the right locations?
• Are the monitors big enough for aging eyes?
• Do you have the correct browser and version?
IMPACT Pilot Go-Live
• September 2013
• 10 SEE sites (full Transfer of Care
dataset)
• 6 LAND sites (initially send CCD but
receive any CDA document)
• 4/week starting with trading pairs (e.g.
Hospital  SNF)
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IMPACT Evaluation Metrics
• 30 day hospital readmission rates
• ER visit rate
• Hospital admission rate from ER
• Total Resource Utilization
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Downstate New York Care
Coordination Project
July 17, 2013
Overview
• Background and Purpose of Project
• Project Overview
• Budget, Funding
• Current Status
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Context
• NYS Medicaid Health Homes have implemented (or are
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implementing) care coordination solutions to meet their near term
requirements
Each Health Home currently uses a separate care management
system or EHR
In the Downstate NY region, there are many providers who are in
multiple Health Homes and multiple RHIOs and their patients will
cross borders
If various care management tools do not support interoperability,
providers may have to use 2 or 3 different systems and this is not
sustainable
Current state leaves untenable situation of no care plan
interoperability
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Goals and Objectives
• Develop consensus around functionality that would
enable enhanced care coordination, care plan
management and interoperability across Health Homes
and RHIOs through the SHIN-NY
• Align activity with developments at the national level
• Develop Requirements to support the interoperability
and joint management of Care Coordination Plans across
organizations
• Phase I implementation - Demonstrate the ability for two
sites with two different care management tools to
exchange Care Coordination Plans
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Short vs. Long Term
• To address time constraints of HEAL 17 funds offered by Healthix,
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deliverables must be achieved by October 15, 2013
Recognize that Phase I implementation will not meet the immediate
operational needs of all Health Homes
But believe this is an important activity that could frame state and
national interoperability efforts for care coordination
Going for long-term pay-off of reducing double data entry
Two major capabilities vendors would need to add to their care
management systems include:
• Capability to save care plans in a standard format and then send it
• Ability to consume an external care plan and support changes at the data
element level
• After this initial phase, we hope to add more vendors to
the implementation
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Collaboration
Since the first Downstate Care Coordination Workgroup session in
January
•Formed Tiger Team with 15-20 representatives from the following
stakeholders:
• RHIOs in the Greater NY area
• Phase 1 and 2 Health Homes in the Greater NY
• Health Home partners (e.g., acute care, behavioral health, community-based organizations,
home health, long-term care, managed care)
• New York eHealth Collaborative (NYeC)
• New York State Medicaid Health Home office and the NYC DOHMH
•Held five 1-hour weekly discussions with the Tiger Team to build consensus
around functionality, explore discussion points, and review updated drafts of the
Requirements document
•Held ad hoc discussions with subject matter experts to clarify important points
•Developed Functional Requirements v.1.0 for the Workgroup’s review
• In addition to Requirements, the document includes: Revision history, Use Case, Assumptions,
Founding Principles, Consent Considerations, Technical Considerations, Features for Future
Consideration
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Requirements
The DCC Workgroup agreed upon the following seven functions:
• Enrollment of Health Home patients
• Linking of patients and providers: care teams
• Exchange of interoperable care plans
• Clinical Event Notifications
• Secure Messaging
• Access to medical records for clinicians
• Access to care plans for non-clinicians
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Care Coordination Plan (CCP) Collaboration
What is a CCP?
• Care Coordination Plan (CCP) refers to a shared document that is used to
track problems, goals, interventions and outcomes related to both clinical and
social issues
• CCPs are a focus of collaboration for diverse care teams across
organizations
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Care Coordination Plan (CCP) Collaboration
Founding Principles
• Functionality must demonstrate the exchange of CCPs between at least two
different organizations using different tools
• Different care management systems must have the ability to interoperate,
specifically, to allow a CCP to:
1.
2.
3.
4.
Be authored in one tool;
Consumed by another tool;
Returned to the original system; and
Saved in the RHIO where it can be viewed by any authorized user.
• The RHIO will serve as a universal place where all qualified care team
members can view a current copy of the CCP
• Vendors will be expected to comply with standards for a CCP
•
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Standards are being developed by the Longitudinal Care Coordination workgroup
(http://wiki.siframework.org/Longitudinal+Coordination+of+Care) under the ONC’s
Standards & Interoperability Framework (available for vendors this spring 2013)
Care Coordination Plan (CCP) Collaboration
Use Case
1. Author will create
and edit the CCP in a
care management tool
that uses a national
agreed upon structure
for interoperable CCPs
v1
Author
Editor
v1 edits
v1
RHIO
Iterative process based
on interoperability
standards
v1
View only
3. Reader can view the
most recent CCP in the
RHIO, and provide
comments to the Author
through secure
messaging
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2. Editor will view the
CCP in their local care
management tool, and
suggest edits to the
Author for review and
approval. The Author
retains editorial control
of the CCP
Reader
Budget and Funding
• Healthix received funding from the NYS DOH Health Care
Efficiency and Affordability Law (HEAL) Program
• The aim of the grant is “Expanding Care Coordination
Through the Use of Interoperable Health Information
Technology”
• Healthix has allocated approximately one million dollars to
spearhead this initiative
• $760K reimbursed to the provider and their vendors
• $100K to cover Healthix technical development and project
management
• $100K to support standards effort
• Approximately $200K in-kind contributions by Continuum Health
Partners
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Healthix HEAL 17 – Project Highlights
• Identified two sites with two different vendors to participate in Phase 1
implementation, both part of Continuum Health Partners
• Addiction Institute of New York
• Methodone Treatment Program (Netsmart)
• Outpatient Treatment Program (Caradigm)
• Held kick off meeting with stakeholders in early June
• Agreed on Requirements and Phase 1/2 development
• June –Design phase in progress, will finalize Design document by
end of June
• July - August: Development, finalize draft data model for the standard
Care Coordination Plan with the LCC Standards Workgroup
• September: Testing, Acceptance
• October: Phase 1 Implementation, Evaluation
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Phase I Implementation - CCP Collaboration
Author
Editor
Netsmart
v1
Caradigm
AINY Methodone
Treatment Program
v1 edits
AINY Outpatient
Treatment Program
v1
v1
Addiction Institute of New York
(AINY) is a Division of the
Department of Psychiatry at St.
Luke’s-Roosevelt Hospital Center
and is affiliated with the Columbia
University College of Physicians and
Surgeons. Both sites participating in
the Phase 1 implementation (MTP
and OTP) are clinical treatment
programs of AINY.
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Iterative process based
on interoperability
standards
RHIO
View only
Reader
Healthix Clinical Viewer
Downstream Providers
THANK YOU
Tom Moore
Vice President, Innovation
tmoore@healthix.org
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NEXT STEPS
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Next Steps
 Participate in LCC Pilots Workgroup (WG)!
 LCC Initiative establishing the LCC Pilots Workgroup in August
 WG will serve to organize and guide deployment of Pilot
projects that will test the suitability of the LCC Consolidated
CDA IG in real-world settings
 WG will provide additional guidance on planning, executing
and monitoring of Pilot Projects
 LCC WG is inviting interested parties to complete the LCC
Pilot Interest Survey form:
http://wiki.siframework.org/LCC+Pilot+Interest+Survey
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LCC Initiative: Resources & Questions
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LCC Leads
– Dr. Larry Garber (Lawrence.Garber@reliantmedicalgroup.org)
– Dr. Terry O’Malley (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
– Becky Angeles (becky.angeles@esacinc.com)
– Lynette Elliott (lynette.elliott@esacinc.com)
LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care
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