Longitudinal Coordination of Care
Pilots WG
Monday, September 16, 2013
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
Agenda
Topic
Presenter
Introductions and Purpose
Evelyn
Aims of LCC Pilot WG
Evelyn
Overview of standards to Pilot
Terry
Timeline for Piloting
Evelyn
Overview of LCC Committed Pilots: IMPACT
Larry
Overview of LCC Committed Pilots: NY Downstate
Tom
3
Why are we here today?
• Let’s discuss…
– Why you should pilot LCC standards
– Who should consider being a pilot
– What standards you can pilot
– How we can help you pilot these standards
– How you can learn for those already committed to
piloting LCC standards
4
Background of LCC WG
• 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, postacute care (LTPAC) transitions
• Supports and advances interoperable health information
exchange (HIE) on behalf of LTPAC stakeholders and
promotes LCC on behalf of medically-complex and/or
functionally impaired persons
• Goal is to identify standards that support LCC of medicallycomplex and/or functionally impaired persons that are aligned
with and could be included in the EHR Meaningful Use
Programs (focus on MU3)
• Activities supported via 4 sub-workgroups (SWGs):
–
–
–
–
Longitudinal Care Plan (LCP) *
LTPAC Care Transition (LTPAC) *
HL7 Tiger Team*
Patient Assessment Summary (PAS)*
* The work of the LCP and LTPAC completed in SEP2013, HL7 Tiger Team completed in AUG13 and PAS SWG completed in JAN13
5
Additional Contributor Input
•
•
•
•
•
•
MA Universal Transfer Form workgroup
Boston’s Hebrew Senior Life eTransfer Form
IMPACT learning collaborative participants
MA Coalition for the Prevention of Medical Errors
MA Wound Care Committee
Home Care Alliance of MA (HCA)
• NY’s eMOLST
• Multi-State/Multi-Vendor EHR/HIE Interoperability
Workgroup
• Substance Abuse, Mental Health Services Agency
(SAMHSA)
• Administration for Community Living (ACL)
• Aging Disability Resource Centers (ADRC)
• National Council for Community Behavioral
Healthcare
• National Association for Homecare and Hospice
(NAHC)
• Transfer of Care & CCD/CDA Consolidation
Initiatives
(ONC’s S&I Framework)
6
• Longitudinal Coordination of Care Work Group
(ONC S&I Framework)
• ONC Beacon Communities and LTPAC
Workgroups
• Assistant Secretary for Planning and Evaluation
(ASPE): Standardizing MDS and OASIS
• ASPE/Geisinger/HL7 : LTPAC Summary
Documents (using MDS and OASIS)
• Centers for Medicare & Medicaid Services
(CMS)(MDS/OASIS/IRF-PAI/CARE)
• INTERACT (Interventions to Reduce Acute Care
Transfers)
• Transfer Forms from Ohio, Rhode Island, New
York, and New Jersey
S&I Framework:
The Value of Community Participation
ENABLING
FACAs
Community
S&I Framework
• HIT Standards Committee
• HIT Policy Committee
• Tiger Team
SDOs
(LCC WG)
• Technology Vendors
• System Integrators
• Government Agencies
• Industry Associations
• Other Experts
• HL7
• OASIS
• Other SDOs
ONC Programs &
Grantees
• State HIE Program & CoPs
• REC Program & CoPs
• Beacon Program
7
LCC WG Partnerships
• Strong collaboration and engagement with broad
stakeholder groups to address gaps in standards for ToC
and Care Plan exchange
–
–
–
–
–
Other ONC S&I Initiatives: Transitions of Care (ToC) and esMD
HL7 WGs: Structured Documents, Patient Care
IHE Patient Care Coordination Technical Committee
AHIMA LTPAC HIT Collaborative
FACAs: MU3 Recommendations
• Contracts with Lantana to make and ballot revisions to
C-CDA for HL7 August 2013 Ballot Cycle
– One ballot package to address C-CDA revisions based on
IMPACT dataset
8
S&I Framework Phases
Phase
Pre-Discovery
Planned Activities
 Development of Initiative Synopsis
 Development of Initiative Charter
 Definition of Goals & Initiative Outcomes
Discovery



Creation/Validation of Use Cases, User Stories & Functional Requirements
Identification of interoperability gaps, barriers, obstacles and costs
Review of Vocabulary
Implementation




Creation of aligned specification
Documentation of relevant specifications and reference implementations such as guides,
design documents, etc.
Validation of Vocabulary
Development of testing tools and reference implementation tools
Pilot


Validation of aligned specifications, testing tools, and reference implementation tools
Revision of documentation and tools
Evaluation



Measurement of initiative success against goals and outcomes
Identification of best practices and lessons learned from pilots for wider scale deployment
Identification of hard and soft policy tools that could be considered for wider scale
deployments
9
Aim for the LCC Pilot SWG
• Bring awareness on available national standards for HIE
and care coordination
• Provide tools and guidance for managing and evaluating
LCC Pilot Projects
• Create a forum to share lessons learned and best
practices
• Real world evaluation of parts of most recent HL7 CCDA Revisions Implementation Guide (IG)
– Is this implementable? Useable?
• Validation of ToC and Care Plan/HHPoC datasets
– Do these data elements address your organization’s
information needs for effective care coordination??
10
Why Pilot LCC Standards?
• Demonstrate compliance with MU2 requirements and proposed
standards for MU3
• Increase efficiency of development and maintenance of these
standards
– LCC C-CDA IG can inform changes to existing HIT systems and the
process by which ToC & Care Plan information is exchanged
– These specifications are being harmonized with a broad consortium of
Standards Development Organizations (SDOs) including HL7 and IHE
• Meet CMS Quality Reporting Requirements
– i.e. Reduce Readmission Rates
• Enable LTPAC (non-eligible) providers to participate in HIE
• Increase access to LTPAC data to support caregiving (including
access by other members of clinical care team)
• Contribute to the community
• Be recognized as an early HIE adopter
11
Who Should Pilot LCC Standards?
• HIE capability exists
• High proportion of dual eligibles
• Integrated Delivery Networks including Managed Care
Organizations (MCO), ACOs and other at-risk provider
groups
• Other organizations participating in various CMS/CMMI
Demonstrations
• Providers with high readmission rates
• Those interested in addressing transition of care issues
• Those interested in exchanging care plans
12
Transition Datasets
1 2
• Test/Procedure Report & Request
• i.e SNF to IRA
3 4
• Consultation Request &
Response
• i.e. SNF to ED
5 6
• Transfer Summary/ Care Plan/HHPoC
• i.e. Hospital to Home Health Agency;
HHA  PCP
13
13
What Standards Can You Pilot?
• New exchange standards for:
– MU2 Patient Care Summary and proposed MU3 updates for:
•
•
•
•
Care Plan
Home Health Plan of Care
Report from Outpatient testing, treatment, or procedure
Referral to Outpatient testing, treatment, or procedure (including for
transport)
• Shared Care Encounter Summary (Office Visit, Consultation
Summary, Return from the ED to the referring facility)
• Consultation Request Clinical Summary (Referral to a consultant or
the ED)
• Permanent or long-term Transfer of Care to a different facility or
care team or Home Health Agency
• Exchange standards that easily enable low cost interoperable HIE
by LTPAC providers
• New software for HIE access
14
Sample Pilot Options
User Scenario
S&I Use Case
User Scenario
S&I Use Case
1.
Exchange of CCD
ToC Use Case
8.
Exchange of Care Plan
LCC Use Case 2.0
2.
Exchange of Transfer
Summary
LCC Use Case 1.0
9.
Exchange of Patient Goals
LCC Use Case 2.0
3.
Exchange of
Consultation Request
LCC Use Case 1.0
10. Exchange of Advance
Directives
LCC Use Case 1.0
4.
Exchange of Consult
Note
LCC Use Case 1.0
11. Exchange of Pre-Test
Screening Process
LCC Use Case 1.0
5.
Exchange of
Test/Procedure
Report
LCC Use Case 1.0
12. Exchange of Care Plan
components for Patient
Centered Value Management
LCC Use Case 2.0
6.
Exchange of
Test/Procedure
Request
LCC Use Case 1.0
LCC Use Case 2.0
7.
Exchange of HHPoC
LCC Use Case 2.0
13. Concordance- the extent to
which the patient’s goals,
interventions, concerns,
outcomes match to the
provider’s prioritization
14. Exchange of Transfer of Care
(Discharge and ED Consult
request)
LCC Use Case 2.0
15
How Can You Participate in the LCC Pilot SWG?
•
http://wiki.siframework.org/LCC+Pilots+WG
16
Aug-Sept 13
Oct- Nov 13
Dec- Jan 14
Feb- Mar 14
Apr- May 14
Jun- Jul 14
Aug- Sep 14
HL7 Ballot
LCC Pilot WG
LCC Pilot WG Timeline: Aug 2013 – Sept 2014
LCC Pilot Proposal Review
LCC Pilot Monitoring & Evaluation
LCC Pilot Wrap-Up
HL7 Ballot & Reconciliation
HL7 C-CDA IG Revisions
LCC Pilot
WG Launch
HL7 Ballot
Publication
Updated HL7 CCDA IG
Complete
Milestones
HL7 Fall Ballot Close
LCC Pilot Test Spec.
Complete
IMPACT Go-Live
NY Care Coordination Go-Live
LCC Pilots Close
LCC Pilot WG Tasks
Target MM
Pilot 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
18
Summary of Documentation Templates &
Reference Materials (Pilot Materials)
Document Name
Pilot Overview
Document
Work Group Planning
Presentation
Pilot Documentation
Template
Pilot Plan Template
Description
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.
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.
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.
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.
19
Improving Massachusetts
Post-Acute Care Transfers
20
IMPACT Grant
• February 2011 – HHS/ONC awarded $1.7M HIE
Challenge Grant to state of Massachusetts (MTC/MeHI)
• 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”
21
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
– We’re trying to make some standard configurations
available
SEE
– Written in JAVA
– Baseline functionality software and source code that can
connect to Orion’s HISP mailbox via API available for
free starting ~December 2013 (Apache Version 2.0 vs.
MIT open source license)
– Innovators can develop and charge for enhancements,
for example:
• Integration with other vendors’ HISP mailboxes
• Automated CDA document reconciliation
Pilot Sites to Test the IMPACT Datasets
• Selection Criteria:
– High volume of patient transfers with other pilot sites
– Experience with Transitions of Care tools/initiatives
• 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
23
IMPACT Pilot Participants
Org. Name
Type
Vendor/ Solution
Type
LCC Standards to Implement
Reliant Medical Group
PCMH
Epic
EHR
CCD; Transfer of Care Summary
Family Health Center of Worchester
FQHC
NextGen
EHR
CCD; Transfer of Care Summary
Saint Vincent Hospital
ACH
Meditech
EHR
CCD; Transfer of Care Summary
UMass Memorial Healthcare
ACH
Siemens Soarian
EHR
CCD; Transfer of Care Summary
VNA Care Network
HHA
Delta Health
Technologies
EHR
CCD; Transfer of Care Summary
Overlook VNA
HHA
Homecare Homebase
EHR
CCD; Transfer of Care Summary
Kindred Parkview
LTACH
SEE
HIE
Transfer of Care Summary
Fairlawn Rehab
IRF
SEE
HIE
Transfer of Care Summary
Beaumont Rehabilitation of
Westborough
SNF
SEE
HIE
Transfer of Care Summary
Christopher House of Worcester
SNF
SEE
HIE
Transfer of Care Summary
Holy Trinity Nursing & Rehab
SNF
SEE
HIE
Transfer of Care Summary
Jewish Healthcare Center
SNF
SEE
HIE
Transfer of Care Summary
LifeCare Center of Auburn
SNF
SEE
HIE
Transfer of Care Summary
SNF
SEE
HIE
Transfer of Care Summary
Notre Dame LTC
SNF
SEE
HIE
Transfer of Care Summary
Worcester Rehabilitation & Health Care
Center
SNF
SEE
HIE
Transfer of Care Summary
Millbury Healthcare Center
24
IMPACT Pilot Go-Live
• November 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)
25
Downstate New York Care
Coordination Project
September 16, 2013
Context
• NYS Medicaid Health Homes have implemented (or are
•
•
•
•
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
27
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
28
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
29
NY Downstate Pilot Participants
30
Org. Name
Type
Vendor/
Type
LCC Standards
Addiction Institute of NY- Methodone Mgmt Program
Behavioral Health
Netsmart
Care Mgmt
Care Plan
Addiction Institute of NY- Outpatient Treatment Program
Behavioral Health
Netsmart
Care Mgmt
Care Plan
St. Luke’s Roosevelt Hospital
Acute Care
Caradigm
HIE/ Care Mgmt
Care Plan
Continuum Health Home Network (CHHN)
IDN
Caradigm
HIE/ Care Mgmt
Care Plan
CHHN AIDS Service Center
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Americare
Home Care
Caradigm/ HealthIX
HIE
Care Plan
CHHN Argus Community
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Association for Rehab CM & Housing
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Beth Israel Medical Center
Acute Care
Caradigm/ HealthIX
HIE
Care Plan
CHHN Callen Lorde Community Health Center
PCP
Caradigm/ HealthIX
HIE
Care Plan
CHHN Dennelisse
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN NADAP
CBO
Caradigm/ HealthIX
HIE
Care Plan
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Puerto Rican Family Institute
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Ryan Health Center
PCP
Caradigm/ HealthIX
HIE
Care Plan
CHHN Services for the Under Served
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Westside Federation for Senior & Supportive Housing
CBO
Caradigm/ HealthIX
HIE
Care Plan
CHHN Institute for Family Health
PCP
Caradigm/ HealthIX
HIE
Care Plan
CHHN Isabella Nursing Home
NH
Caradigm/ HealthIX
HIE
Care Plan
CHHN Project Renewal
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
31
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
v1
Iterative process based on
interoperability standards
View only
3. Reader can view the
most recent CCP in the
RHIO, and provide
comments to the Author
through secure messaging
32
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
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 – July: Design phase; engaged Lantana to align the data model
with proposed standard as closely as possible
• 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
33
Next Steps
• 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
• Email to Lynette Elliott
(Lynette.elliott@esacinc.com)
• NO Meeting next week due to HL7 WGM in Boston, MA
34
LCC Initiative: Contact Information
•
•
•
•
•
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
– Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com)
– Use Case Lead: Becky Angeles (becky.angeles@esacinc.com)
LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care
35