longitudinal coordination of care (lcc) pilots template impact 8/19/2013
TRANSCRIPT
Longitudinal Coordination of Care (LCC)
Pilots Template
IMPACT
8/19/2013
Pilot Team
2
Name Role Email
Larry Garber, MDPrincipal Investigator in charge of technology and collaboration
Terry O’Malley, MDCo-investigator in charge of data standards
Full Disclosure?
• We have no apparent or real conflicts of interest to disclose
Goals of the Pilot
• Determine if recipients of patients can receive the data that they need to care for their patients, and identify missing data elements
• Determine if senders of patient are able to reuse data when generating the Transfer of Care Summary
• Determine if senders of patient are able to find all of the data elements necessary to populate the Transfer of Care Summary
• Continue to care for patients without a decline in efficiency, quality, or safety
• Reduce the Emergency Room visit rate• Reduce the admission rate from the Emergency Room• Reduce the 30-day hospital readmission rate• Reduce the total cost of healthcare
4
Which of the 5 C-CDA Revisions isbeing Piloted
5
SDC Standard / Guidance Specifics to Pilot Notes
Transfer Summary
10 “SEE” sites will test sending the Transfer Summary (while 6 “LAND” sites will send CCDs). All 16 sites will receive either of these document types
The 10 “SEE” sites will test incorporating and reusing the data elements, while the 6 “LAND” sites will simply receive them transformed into a text document
Relevant Scenario (from the Use Cases) supported by Pilot• Exchange of Clinical Information from Provider to Provider
Use Case Actors/Systems Involved:– Sending Entity Care Team– Receiving Entity Care Team– Sending Entity Information System (EHR)– Receiving Entity Information System (EHR)– Home Health Agency (HHA) Care Team– Home Health Agency (HHA) Information System (EHR)
Hospital
PCP
SEE CCD+
MDS
Billing Program MDS
KeyHIE TransformCCD+
CCD+CCD+ = Transfer Summary
Nursing Facility
Configuration – SEE sites
Outbound LAND Transformations
9
CCD Document
XML Document
LAND Converter
“Transfer of Care” CDA Document
HL7 v2.5.1 ORU
MDS XML Document
OASIS XML Document
CCD Document
Converter Inbound Configurations
Inbound LAND Transformations
11
LAND Converter
CDA Document
Text DocumentHL7 v2.5.1
MDM
CCD
HL7 v2.5.1 ORU
XML
Non-CDA Document
Non-CDA Document
Timeline
Milestone Target Date Responsible Party
LAND & SEE Go-lives October 2013 Larry Garber, MD
Pilot evaluation May 2014 Larry Garber, MD
IMPACT Success CriteriaTarget Outcome
Target Value Target Population Data Source Numerator Denominator
Reduce hospital readmission rate
5% decrease in 30 day hospital readmission rates from baseline
Unique FCHP patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites
Fallon Community Health Plan’s claims data via Reliant Medical Group
Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital that are readmitted to any hospital from IMPACT Pilot Sites within 30 days during measurement period
Number of unique patient discharges from St. Vincent Hospital and UMass Memorial Hospital during measurement period
Reduce Hospital Admission Rate
5% decrease in Hospital Admission Rate from baseline
Unique FCHP members seen in St. Vincent Hospital and UMass Memorial Hospital ER that had been under the care of an IMPACT Pilot Site during the measurement period, that are subsequently admitted to the hospital from the ER
Fallon Community Health Plan’s claims data via Reliant Medical Group
Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER that are subsequently admitted to the hospital
Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period that are transferred to the St. Vincent Hospital or UMass Memorial Hospital ER
Reduce ER visit rate
5% decrease in ER visit rate from baseline
Unique FCHP members in an IMPACT Pilot site’s care during measurement period that are transferred to any hospital ER
Fallon Community Health Plan’s claims data via Reliant Medical Group
Number of transfers of FCHP members in an IMPACT Pilot Site’s care during measurement period to any hospital ER
Number of unique FCHP members in an IMPACT Pilot Site’s care during measurement period
Reduce Total Resource Utilization
5% decrease in Total Resource Utilization from baseline
Unique FCHP members in an IMPACT Pilot site’s care during measurement period
Fallon Community Health Plan’s claims data via Reliant Medical Group
Total Resource Utilization for FCHP members in an IMPACT Pilot Site’s care during measurement period
N/A
Out of Scope
• Incorporating discrete data elements into EHR beyond those in the CCD
Risks & Challenges
• Delay in project deployment due to legal issues surrounding hosting of SEE software and state “accessibility” requirements.
• Challenging EHR workflows regarding patient matching and routing to correct provider
• Unclear how difficult it will be to know when the summary is ready to send.
• Unclear how difficult it will be to determine who to send the summary to
• Potential delays by EHR vendors configuring their interfaces• Hospitals and physician practices needed to send CCDs to satisfy
Meaningful Use regardless of what else they send (i.e. the Transfer Summary)
• Will the monitors be large enough for SEE users to be effective
Questions / Needs
• None
Useful Links
• LCC Wiki Main Page: http://wiki.siframework.org/Longitudinal+Coordination+of+Care+%28LCC%29
• Use Case 1.0 ‘Transfer of Care’: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements
• Use Case 2.0 ‘Care Plan Exchange’: http://wiki.siframework.org/LCC+WG+Use+Case+2.0
• Transfer of Care Harmonization: http://wiki.siframework.org/LCC+Long-Term+Post-Acute+Care+%28LTPAC%29+Transition+SWG#Lantana%20Working%20Documents
• Care Plan Exchange Harmonization: TBD• Pilots Wiki Page: http://wiki.siframework.org/LCC+Pilot+Plan
LCC WG Timeline: Mar 2013 – Dec 2013
Mile
ston
es
Pilot Site Identification & Engagement
Care Plan C-CDA Revisions Complete
HL7 Project Scope Statement Due HL7 Intent to Ballot Due
HL7 Fall Ballot Open
NY Pilots Monitoring
LCC Care Plan Use Case 2.0 Development & Consensus
IMPACT ToC Pilot Monitoring
HL7 Ballot Publication
ToC IGs Development (Transfer Summary, Referral Note, Consult Note)
ToC C-CDA Revisions Complete
HL7 Final Ballot Due
LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS
Care Plan/ Home Health Plan of Care IG Development
HL7 Ballot Package Development
HL7 Ballot & Reconciliation
FACA LCC WG Briefings
LCC & HL7 Care Plan Coordination
IMPACT Go-Live NY Care Coordination Go-Live
Appendix A: LCC Timeline