Meeting Name
Location:
Meeting Date and Time:
Next Meeting Scheduled:
LCC Pilots WG Meeting
Web / Conference Call
Monday, May 12, 2014 @ 11:00am ET
Monday, June 9, 2013 @ 11:00am ET
Agenda
 Welcome and Announcements
 Presentation: GSI Health LCC Direct Subscription Pilot Presentation (Vince Lewis, Mike Carbery and Sean

Kelly)
Next Steps
Attendance
Name/Affiliation
Abhishek Khowala
Alex Baker
Amy Koizim
Annalisa Wilde
Atia Amin
Barbara Gage
Becky Angeles
Becky McClaren
Benjamin Flessner
Beth Halley
Bonnie Kohr
Brett Marquard
Catherine Payne
Cathy Walsh
Cheryl Irmiter
Chris Clark
Christol Green
Cindy Levy
David Foster
David Nessim
David Tao
Dawn Foster
Deb Castellanos
Diane Evans
Donna Doneski
Elaine Ayers
Elizabeth Amato
Ernest Grove
Elizabeth Serraino
Enrique Meneses
Evelyn Gallego
Gayathri Jayawardena
Gordon Raup
Harrison Fox
Holly Miller
Holly Urban
Iona Thraen
Jack Kemery
Janel Welch
Page 1
Email
akhowala@nyehealth.org
alexander.baker@hhs.gov
amy.koizim@gsihealth.com
awilde@healthix.org
atia.amin@network-health.org
bgage@brookings.edu
rebecca.angeles@esacinc.com
bmcclaren@starmulticare.com
benjamin@epic.com
ehalley@mitre.org
bkohr@frrcpas.com
brett@riverrockassociates.com
catherine.payne@erlanger.org
cwalsh@starmulticare.com
cirmiter@easterseals.com
chris.r.clark@wv.gov
christol.green@anthem.com
clevy@shapehitech.com
dfoster@healthwise.org
david.nessim@mckesson.com
dtao12@gmail.com
dawn.foster@cerner.com
deb.castellanos@xerox.com
diane.evans@impact-advisors.com
donna@nasl.org
eayres@nih.gov
eamato@nyehealth.org
egrove@shapehitech.com
elizabeth.serraino@omnicare.com
enrique.meneses@careflow.com
evelyn.gallego@siframework.org
gayathri.jayawardena@esacinc.com
graup@datuit.com
hfox@ccitiny.org
hmiller@medallies.com
hurban@zynx.com
ithraen@utah.gov
jwelchrd@earthlink.net
Attended
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Name/Affiliation
Jeffrey Levy
Jennie Harvell
Jennifer VanWinkle
Jim Younkin
Joanne Lynn
Kari Ballou
Kate Wetherby
Kathleen McGrow
Kathy Applin
Kelly Cronin
Kelton Swartz
Kerrie Petrin
Kris Cyr
Kunal Agarwal
Larry Atkins
Larry Garber
Larry Seltzer
Laura Heerman Langford
Laurene Vamprine
Lee Jones
Lee Unangst
Leigh Sterling
Lenel James
Les Morgan
Lester Keepper
Liora Alschuler
Lisa Peters-Beumer
Lorie Smith
Lynette Elliott
Marie Chesley
Mark Pilley
Mark Roche
Matthew Arnheiter
Michael Carbery
Michael Lardieri
Mina Rasis
Nora Kershaw
Okaey Ukachukwu
Pam Russell
Parag More
Pat Rioux
Paul Burnstein
Paul Lomayesva
Renee Tolliver
Rich Brennan
Rita Torkzadeh
Robert Dieterle
Robert Drake
Robin Bronson
Rodolfo Alvarez del Castillo
Russ Leftwich
Sandra Raup
Page 2
Email
jeff@careathand.com
Jennie.Harvell@hhs.gov
jennifer.vanwinkle@mckesson.com
jryounkin@geisinger.edu
joanne.lynn@altarum.org
kballou@aorn.org
kathryn.wetherby@samhsa.hhs.gov
kmcgrow@umaryland.edu
kathy.applin@ahch.org
Kelly.cronin@hhs.gov
kelton.swartz@cerner.com
petrin_kerri@bah.com
kristopher.cyr@accenture.com
kagarwal@ccitiny.org
latkins@ltqa.org
Lawrence.Garber@reliantmedicalgroup.org
lseltzer@ntst.com
laura.heerman@imail.org
laurene.vamprine@erlanger.org
leroy.jones@gsihealth.com
unangstl@cc.nih.gov
lsterling@ethin.org
lenel.james@bcbsa.com
lesmorgan.gh@gmail.com
lkeepper@shapehitech.com
liora.alschuler@lantanagroup.com
lpeters@easterseals.com
lorie.smith@maine.gov
lynette.elliott@esacinc.com
marie.chesley@mckesson.com
m.pilley@strategichs.com
mrochemd@gmail.com
marnheiter@ntst.com
mcarbery@maimonidesmed.org
mikel@thenationalcouncil.org
mrasis@nyehealth.org
nkershaw@ccbq.org
okaey.ukachukwu@caradigm.com
prussell@corhio.org
parag.more@gsihealth.com
p.rioux@elsevier.com
paul.burnstein@mdiachieve.com
paul.lomayesva@intersystems.com
rtolliver@mchs.com
rdb@nahc.org
ritork3@gmail.com
rdieterle@enablecare.us
robert_drake@lcca.com
robin.bronson@allscripts.com
radcastillo@yeamanandassociates.com
russell@thecomio.com
sraup@datuit.com
Attended
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Name/Affiliation
Scott Zacks
Sean Kelly
Stacy Mandl
Steve Stasiak
Su-Hsiu Wu
Sue Mitchell
Susan Campbell
Susan McKeever
Sweta Ladwa
Tara McMullen
Terry O’Malley
Tom Moore
Vincent Lewis
Wan Li
Wen Dombrowski
Zabrina Gonzaga
Zachary May
Email
scott.zacks@gmail.com
sean.kelly@gsihealth.com
stella.mandl@cms.hhs.gov
sstasiak@chpnet.org
swu@ele.uri.edu
suemitchell@hotmail.com
Bostoncampbell@mindspring.com
smckeever@adsdatasystems.com
sweta.ladwa@esacinc.com
tara.mcmullen@cms.hhs.gov
tomalley@partners.org
tmoore@healthix.org
vincent.lewis@gsihealth.com
wli@ntst.com
wen@vnahg.org
zabrina.gonzaga@lantanagroup.com
zachary.may@esacinc.com
Attended
Yes
Yes
Yes
Yes
Yes
Discussion



The meeting was introduced with a reminder for participants to join the LCC Work Group via the “Join the
Initiative” tab in the wiki and to complete the Pilot Survey on the LCC Pilots WG wiki page.
Meeting reminders were presented and included LCC WG, relevant HL7 WG meetings and meeting dates
and times. Special dates/events include the following:
o AHIMA 2014 LTPAC Health IT Summit.
 WHAT: Provides thought-provoking, interactive sessions aimed at advancing HIT Priorities;
showcases implementation successes; and puts the spotlight on LTPAC technologies
 WHEN: June 22nd to June 24th, 2014
 WHERE: Hyatt Regency Baltimore on the Inner Harbor
 Register at: http://www.ahima.org/events/2014june-ltpac
 For further information, contact Exhibits Manager: sarah.lawler@ahima.org
o LTPAC/BH Listening Session (HealthIT.gov)
 The Certification and Adoption Workgroup of the Health Information Technology Policy
Committee has been exploring the health IT needs of LTPAC and BH settings and how
those needs could be supported through ONC Voluntary EHR Certification.
 The Workgroup has developed a proposed set of certification criteria focused on
interoperability, privacy and security, and modularity and is now seeking public comment in
two ways.
 Participate in a listening session on Thursday, May 22th. There is limited time for this
session, please register early.
 During the week of May 12th, the full list of the proposed recommendations and an
opportunity to provide written comments on those recommendations will be provided.
 Click here to sign up for May 22nd listening session
Timelines and milestones were presented and Pilot Work Group Purpose and Goals were restated.
Presentation: GSI Health LCC Direct Subscription Pilot Presentation (Vince Lewis, Mike Carbery and Sean
Kelly)
 Sean Kelly began the presentation with a review of the agenda:
o Program Overview
o Technology Overview
o Demonstration
Page 3



Page 4
o Pilot Architecture
o Questions and Answers
Mike Carbery provided the program overview. The company has been working about ten years to get
where it is today with providing longitudinal care coordination across the full spectrum for seriously
mentally ill individuals with multiple core morbidities in Brooklyn. Diversity, language barriers and socioeconomic resources have been challenges.
o A timeline was provided depicting the milestones from 2005 to today, where they plan to provide
services for one million Medicaid patients.
o
A list of partners was displayed and included Care Management Providers as well as Network Providers.
o Question posed: Are you currently working with the community based care transitions program
awardees in Brooklyn?
 Response: I think that will be defined in the next nine months or so. We’re trying to get all
those types of organizations involved in a coordinated and organized way.
A slide depicting Care Team Responsibilities was displayed and described as being the way to engage all
members of the Care Team.

Page 5
o
The Brooklyn Health Home Model was displayed and included the layers of individuals and providers
involved in the care process. All fifty provider organizations involved with GSI Health’s program are using
the Health Home Dashboard (GSI Health Home Coordinator).
o This platform is standalone, available as Software as a Service, and is interoperable with Healthix,
which is the RHIO for most of downstate NY.
o

Page 6

Question posed: Are the Care Navigators the key point person among the interdisciplinary
team members?
 Response: The Care Manager is. The Care Navigator is more application and
administrative support for the team.
 Question posed: Are the services the Care Managers provide paid for with a per member
per month payment?
 Response: The reimbursement we get is for Care Management services, yes.
Everything else is billed directly, either as fee for service or capitation basis.
 Question posed: Have you been able to exchange a Care Plan from the GSI Health
platform to the Healthix platform?
 Response: We have been in discussion with Healthix on how to extend our platform
through this pilot to folks who need it at any one point in time. We’re also looking to
team with some of the providers in our own network to integrate with their legacy
systems.
 Response: In terms of the standard HIE model, we are currently exchanging the
data with Healthix through CCD. We want to evolve this into the LCC CDA and
Care Plan CDA.
A GSI Health Company Overview was presented by Sean Kelly.
o Veteran health IT team, including policy leadership with Federal and State governmental
appointments
o Product solutions focused exclusively on care coordination and population health management
o
o
o
o



Page 7
Extensible cloud-based platform
Care coordination apps provide workflow functionality for virtual care teams
Embedded HIE and Direct Infrastructure to interoperate with existing 3rdparty systems
Embedded analytics and reporting solution utilizing 4 data types: Clinical (HIE, EHR), Claims
(public and private sources), Administrative and Care Coordination
o Deep domain experience in Care Coordination, Interoperability, Medicaid ACOs and Health
Homes, complex patient populations
The GSI Health Coordination Platform provides connectivity to clinical care delivery information systems
that are already in place and leverage that information through the HIE that feeds into a clinical data
repository in a common information model.
o When information comes in, it can populate multiple applications and they can call upon the data as
they see fit.
o Alongside are Claims Systems sources that are populated with the data from the CDR into our data
warehouse to allow for applications to call upon them, whether it be analytics and reporting from
the data warehouse or what we call Care Coordination Apps, which are designed for everything
from secure messaging to managing patient consent, building virtual patient care teams, viewing
and coordinating care plans, and accessing patient summaries.
A demonstration was provided showing how a change can be made to a patient’s care plan. In making
that change, it will be triggering the automatic subscription based Direct messaging of the care plan to a
user. Because it uses Direct it can go to any type of Direct compatible system.
o In this demo, it used a specific app called the Messages app.
o The demo interface represented the Health Home dashboard. This is the user interface for the
virtual care team users and service providers.
o The dashboard apps shown included the following:
 Enrollment
 Care Teams
 Reports
 Care Plan
 Patient Engagement
 Messages
 Alerts
 Population Manager
 UHC Enrollment Report
o The Care Plan application was launched. This is where users come in to create documentation
and assessments and to coordinate care plans.
 Three crisis issues had been added to this example care plan in the Profile section. They
are each mapped to health concerns in the C-CDA. Diagnoses and associated care steps
were also displayed as part of the example.
 A new crisis issue was added to the example care plan. Users affiliated with this patient
have the ability to subscribe for notifications. When a new issue is added it alerts the
appropriate users that an update has been made.
 Subscriptions to the care plan trigger the creation of the C-CDA version of the care
plan, which gets attached to a Direct message. It goes through a Direct HISP to the
end user at a Direct compatible end point. The user can then open and view the
updated document (for this demo it was the Messages app).
An architecture diagram was presented and the point was made that the messages get forwarded and the
data gets captured in the Subscription Manager, which sends out notifications each time it receives
updated data.
o
o
o
o
o
Page 8
Question posed: When you send a CDA document to that EHR, do they know why they’re
receiving that?
 Response: This is part of the XDR protocol—the “why” they’re receiving it is in the
metadata. It will include the patient, the reason for the exchange, the type of document
being exchanged and other machine parsable data. They’re not getting the raw CDA.
They’re getting metadata content, as well.
Question posed: Are there well defined triggers for the actual exchange or update to be sent?
There could be an oversharing of information.
 Response: It’s configurable by customer. We do everything we can to define the
triggerable parameter. Here we’ve defined specific parts of the care plan for sharing.
Question posed: Who determines rule based access?
 Response: In the classic sense of an HIE for consent is a huge part of the system, but it’s
not part of Direct. Direct does not require consent in New York for push data. Consent is
configurable in the system, but the push model allows for the provider to send to another
provider without consent in the receiving provider.
 Response: The virtual care teams are identified and persist within the platform, so care
team members always know who they’re collaborating with. The consent and exposure is
also included in the enrollment process so that the patient can choose who has access to
what information.
Question posed: On an earlier slide you talked about the ability to receive EHR data to support the
development of this care plan.
 Response: This diagram is a small subsection of the overall system. In the absence of
pervasive transparency and exchange of care plans in C-CDA format by other systems,
what we often get is information in the form of CCD that can feed into our platform that can

eventually evolve into issues in the care plan. What we’ve demonstrated here in moving the
care plan out is the first step in moving to being able to have XML formed care plan data
that can move from system to system.
o Question posed: This is an issue that’s come up with our FACAs about backward compatibility.
Are you saying that by sending it using XML you’ve been able to address that issue?
 Response: Broadly, being able to receive documents in XML format is still not dominantly
deployed in the market. We feel this is a component in the care plan process where
organizations are supplying clinical content but not care plans, which are still on the
evolutionary track. We convert between legacy type XML or exchange to the new stuff. We
help support adaptation of old protocols and changing them to the new.
 Response: We want to have as a goal to ultimately provide feedback based on the
paradigm of use. A nuance I wanted to point out is that this idea of exchanging care plan
and the CCD that’s traditionally being used are two different concepts. It’s not just a matter
of backward compatibility and establishing equity between those different formats. What we
demonstrated is not an electronic health record, per se, but a planning activity. The
paradigm for sharing, including triggers, is different than in a CCD case. We’re not
matching up all the XML schemas so they can all be supported.
o A sample message triggered by a subscription was displayed. An attachment to the message was
opened and contained a summary of content as XSL and XML. The content was broken out by
Health Concerns, Goals, Interventions, etc.
 NOTE: The content shown in this slide is available in the pdf provided by the GSI Health
team, which is posted on the LCC Pilots wiki:
http://wiki.siframework.org/file/view/GSI%20Health%20Supplemental%20Info.pdf/50831369
4/GSI%20Health%20Supplemental%20Info.pdf
A summary was provided to state that GSI Health is working to identify third party organizations that can
receive and digest CDA to promote and further understand not only the transference and equity of sharing
information in the C-CDA format, but also to understand operationally how it can best work.
o The team highlighted mapping care plan documents to various applications’ internal fields
proprietary to standard and leveraging them from a technical and clinical inside perspective.
o There are several high value use cases in New York where work is being done with virtual care
teams and complex care plans.
o Question posed: If you’re sharing outside of Brooklyn with an EPIC user does there need to be
additional work to take structured data within the template and make sure that it’s used?
 Response: We’re talking about internally the type of business process that doesn’t
necessarily map to a document. Once it goes outside our door, the standard should be
consumable and readable by anyone. We’d like to come back to this group about where we
have differences in our business processes and what’s in the current document. We want
to make sure our notion of a care plan for coordinated care among disparate providers
maps appropriately to the standard.
Proposed Next Steps
 Homework Assignments:
o Complete Pilot Survey
o Sign up as and LCC Committed Member
o Submit Pilot Documentation Proposals
 Available on the LCC Pilot WG wiki: http://wiki.siframework.org/LCC+Pilots+WG
 Email to Lynette Elliott (lynette.elliott@esacinc.com)
 The next meeting will be held Monday, June 9th at 11am ET.
Action Items
Page 9
Name
Page 10
Task
Due Date