Longitudinal Coordination of Care

Pilots WGMonday, February 10, 2014

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 recordedo 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 Panelists 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 Panelists

• http://wiki.siframework.org/Longitudinal+CC+WG+Committed+Member+Guidance• http://wiki.siframework.org/LCC+Pilots+WG

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ReminderJoin the LCC WG & Complete Pilot Survey

** If your contact information has recently changed, please send your updated information to Becky Angeles at becky.angeles@esacinc.com

Topic Presenter

Welcome & Announcements Evelyn, Lynette

FACA Meeting Updates Evelyn

Update & Next Steps for Care Plan/Plan of Care Discussion Becky

Presentation: SEE Tool Demonstration for HIMSS Health Story Liora Alschuler

Next Steps Lynette

Agenda

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• 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

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Meeting RemindersS&I Framework Hosted Meetings: http://wiki.siframework.org/Longitudinal+Coordination+of+Care • LCC Pilot WG meetings are Mondays from 11:00– 12:00 pm Eastern

– Focus on validation and testing of LCC Standards for Transitions of Care & Care Plan exchange

• LCC All Hands WG meetings are Mondays & Thursdays from 5:00– 6:00 pm ET are on hold for now– These meetings are facilitated in partnership with Lantana and will focus on

discussion and review of HL7 C-CDA R2 Ballot Comments– 888 of 1013 ballot comments have been resolved

HL7 Structured Documents WG Meetings• Wednesdays from 10:00 – 11:00am Eastern

• WebEx: https://www3.gotomeeting.com/join/216542046• Dial In: +1 770-657-9270; Access Code: 310940• Focus on ballot reconciliation of HL7 C-CDA R2 Ballot comments

• Thursdays from 10:00 – 12:00pm Eastern– WebEx: https://iatric.webex.com/iatric/j.php?ED=211779172&UID=0&RT=MiMxMQ%3D%3D

– Dial In: 770-657-9270; Access Code: 310940– Focus on block voting of HL7 C-CDA R2 Ballot comments

HL7 Patient Care WG Meeting Reminders

• Care Plan Project– Developing user stories that define and differentiate Care Plan,

Plan of Care, Treatment Plan– Current working documents found here:

http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012

– Meetings every other Wednesday from 4:00 – 5:00pm ET • Next meeting scheduled for February 19th • Meeting Information:

– Web Meeting URL: nehta.rbweb.com.au

– Phone: 770-657-9270, Participant Code: 943377

HL7 Patient Care WG Meeting Reminders, cont’d...• Health Concern Topic

– Developing user stories highlighting the following: What is a Health Concern Observation; How Health Concern Tracker is Used; How Health Concern is different from Problem Concern

– Current working documents found here: http://wiki.hl7.org/index.php?title=Health_Concern

– Meetings every other Thursday from 4:00 – 5:00pm ET• Next meeting scheduled for February 27th • Meeting Information:

– Web URL: https://meetings.webex.com/collabs/#/meetings/joinbynumber

» Meeting Number: 239 498 434 – Phone: 770-657-9270, Participant Code: 943377

HL7 Patient Care WG Meeting Reminders, cont’d...• Coordination of Care Services Specification Project

– Provide SOA capabilities/models to support coordination of patient care across the continuum

– Current working documents found here: http://wiki.hl7.org/index.php?title=Coordination_of_Care_Services_Specification_Project

– Meetings every Tuesday 4:00 - 5:00 pm ET • Meeting Information:

– Web Meeting URL: https://meetings.webex.com/collabs/meetings/join?uuid=M55ZKYUA35CE2U3J4SV41XMZR3-3MNZ

» Meeting Number: 193 323 052

– Phone: 770-657-9270, Participant Code: 071582

FACA Meeting Updates

HITPC Certification and Adoption WG• Meeting held on Jan. 24th presented how the Five Factors Framework

relates to Behavioral Health• Factor 2 focuses on aligning with existing Federal/State programs

to standardize screening and assessment tools, use EHR transport standards for reporting, and quality measurement program standards

• It was pointed out that many of these issues also apply to LTPAC• Michael Alonso (Director of IT for Seneca Family Agencies in CA)

said, “We recommend that there be separate certification criteria sets for the BH and Long Term and Post-Acute Care (LTPAC) domains.”

• The WG will host a Virtual Hearing on Behavioral Health EHR Certification on January 28, 2014

FACA Meeting Updates

HITPC Meaningful Use WG• Meeting held on Jan. 28th reviewed care coordination &

population/public health priorities• MU WG presented recommendations to HITPC on Feb. 4th

• MU3 Listening session scheduled for March 3rd

Improving care coordination :Medication reconciliation

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Functionality Needed to Achieve Goals

• Core: Eligible Professionals, Hospitals, and CAHs who receive patients from another setting of care perform medication reconciliation.

• Threshold: No Change • FAQ: Reconciliation may also be performed for all

encounters

Stage 3 Functionality Goals

• Relevant patient information is shared among health care team and patient, especially during transitions (site or provider)

• Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination:Summary of care for transfers of care

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Functionality Needed to Achieve Goals

• Eligible Professionals/Eligible Hospitals/Critical Access Hospitals provide a summary of care* record during transfers of care from one site of care to another (e.g., Hospital to SNF, PCP, HHA, home, etc…; SNF, PCP, etc… to HHA; PCP to new PCP)

• Summary of care may (at the discretion of the provider organization) include:

– A narrative that includes a synopsis of current care and expectations for consult/transition

– Overarching patient goals and/or problem specific goals– Patient instructions, suggested interventions for care during

transition– Information about known care team members (including a

designated caregiver)• Threshold: No Change

Stage 3 Functionality Goals

• Relevant patient information is shared among health care team and patient, especially during transitions (site or provider)

• Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination: Summary of carefor consult requests and reports

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Functionality Needed to Achieve Goals

• *NEW* (Related to order tracking objective for tests, images, and consult requests (referrals))

• Menu: Eligible Professionals/Eligible Hospitals and CAH provide a summary of care* record that pertains to the type of care transition as indicted below:

• Types of transitions:– Consult (referral) request (e.g., PCP to Specialist; PCP, SNF, ED,

public health etc.)– Consult result note (e.g. ER note, consult note)

• Summary of care may (at the discretion of the provider organization) include:

– A narrative that includes a synopsis of current care and expectations for consult/transition

– Overarching patient goals and/or problem specific goals– Patient instructions, suggested interventions for care during

transition– Information about known care team members (including a

designated caregiver) • Threshold: Low *An electronic summary is preferred

Stage 3 Functionality Goals

• Relevant patient information is shared among health care team and patient, especially during transitions (site or provider)

• Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

Improving care coordination:Notifications

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Functionality Needed to Achieve Goals

• *NEW* Menu: Eligible Hospitals and CAHs send electronic notifications of significant healthcare events in a timely manner to key members of the patient’s care team (e.g., the primary care provider, referring provider, or care coordinator) with the patient’s consent if required

• Significant events include:– Arrival at an Emergency Department (ED)– Admission to a hospital– Discharge from an ED or hospital– Death

• Notifications should be automatically sent to the provider of record

• Low threshold • Modular certification is encouraged, this does not

need to be an EHR function

Stage 3 Functionality Goals

• Relevant patient information is shared among health care team and patient, especially during transitions (site or provider)

• Care plan components such as health concerns, goals, interventions and care team members are shared and tracked

FACA Meeting Reminders

HIT Policy Committee• Next meeting scheduled for March 11th from 9:30am – 3:00pm ET• http://www.healthit.gov/facas/calendar/2014/03/11/hit-policy-committee-virtual

HITPC Meaningful Use WG• Next meeting scheduled for Feb. 11th from 9:30am – 11:30am ET• http://www.healthit.gov/facas/calendar/2014/02/11/policy-meaningful-use-workgroup

HIT Standards Committee• Next meeting scheduled for Feb. 18th from 9:00am – 3:00pm ET• http://www.healthit.gov/facas/calendar/2014/02/18/hit-standards-committee

LCC Pilot WG Timeline: Aug 2013 – Sept 2014

Mile

ston

es

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

NY Care Coordination Go-Live

HL7 C-CDA IG Revisions

LCC Pilot Wrap-Up

LCC Pilot Test Spec. Complete

HL7

Bal

lot

LCC

Pilo

t WG

GSI Health Go-Live

IMPACT Go-Live

CCITI-NY Go-Live

• We have scheduled a joint LCC / PCWG meeting for Thursday, Feb 20th at 5pm ET.

• We will use the existing LCC All Hands meeting slot. • Becky Angeles is working with Laura Heerman Langford

to send out the invite to all interested parties. – Interested parties include: PCWG, SDWG, Payers,

LCC, etc.

Updates & Next Steps for Discussion on Definition of Episode for Care Plan/Plan of Care

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SEE Demo for HIMSS Health Story

Liora Alschulerliora.alschuler@lantanagroup.com

• Homework Assignments:– Participate in HITPC Public Meeting Feb.4th– Complete Pilot Survey– Sign up as an LCC Committed Member– Submit Pilot Documentation Proposals

• Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG

• Email to Lynette Elliott (Lynette.elliott@esacinc.com)

Next Steps

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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– Pilots Lead: Lynette Elliott (lynette.elliott@esacinc.com)– Use Case Lead: Becky Angeles (becky.angeles@esacinc.com)

LCC Initiative: Contact Information

21LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care