longitudinal coordination of care pilots wg monday, october 21, 2013
TRANSCRIPT
Longitudinal Coordination of Care
Pilots WGMonday, October 21, 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 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
Topic Presenter
Welcome & Announcements Evelyn
Debrief on CORHIO Sept. 30 Presentation Lynette
Debrief on HL7 Plenary Meetings Larry/Russ
Update on C-CDA Ballot Reconciliation Larry
Update on Patient Care WG Meetings Russ
Status of IMPACT Go-Live Larry
Overview of LCC Pilot Documentation Template Evelyn
Presentation of IMPACT Pilot Documentation Larry
Next Steps Evelyn
Agenda
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Meeting Reminders
S&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 Eastern – These meetings are facilitated in partnership with Lantana and will focus
on discussion and review of HL7 C-CDA Care Plan Ballot Comments
HL7 Structured Documents WG Meetings• Meetings are 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 ballot reconciliation of HL7 C-CDA Ballot
Meeting Reminders
HL7 Patient Care WG Meetings• Care Plan every 2nd Wednesday from 5:00 – 6:30pm ET (4:00 in Nov)
– Focus on Care Plan DAM Ballot Reconcilation
– Next meeting scheduled for Oct. 30th
– Phone: +1 770-657-9270, Participant Code: 943377
• NEW* Patient Care Health Concern Topic• Meetings every 2nd Thursday from 4:00 – 5:00pm Eastern
• Next meeting scheduled for Oct 24th
• Phone: +1 770-657-9270, Participant Code: 943377
• Care Coordination Service• Meetings every Tuesday 5:00- 6:30 pm ET (4:00 in Nov)• CCS ballot reconciliation, new CCS ballot for Jan 2014
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
IMPACT Go-Live
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
• 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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• On Sept. 30th, Pamela Russell provided overview of CORHIO-LTPAC Transitions Program
• Key Take-Aways:
– 119 of 350 LTPAC & Home Health Facilities connected to HIE; 1,577 total users
– HIE currently supports extract of CCDs in .pdf ; will extract structured C-CDAs and publish into HIE by 2014
– Value of Program outreach: survey letters and participant agreements
– Importance of work flow impact to senders & receivers
• CORHIO presentation and recorded webinar available on LCC Meeting Artifacts site: http://wiki.siframework.org/LCC+-+Meeting+Artifacts
RECAP: CORHIO Presentation
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• Plenary Theme: Care Coordination & HL7’s Role– Presentations from LCC Leads:
• Terry O’Malley: “Data Sets for Transitions & LCC”• Larry Garber: “Connecting Care Coordination Standards to the
Real World”• Call for LCC PILOT Participation (Thank you Larry!)
– CMS Presentation: “Post-Acute Care: Building Upon a Foundation and Current Strategy”
• Highlighted need to standardize assessment data needs across all PAC settings
• Critical to have uniform data elements and governance to support collection and dissemination
• Challenges: technical, policy & cultural– NPWF Presentation: “Consumer Priorities for Health & Care
Planning in an Electronic Environment”• Introduced next generation of care plans, Care Plans 2.0• Focus on dynamic, multi-dimensional, person-centered care
planning
HL7 Plenary & Working Group Meeting Cambridge, MA Sept. 22-27
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• Over 1,000 Ballot Comments received• 208 specific to Care Plan• Next block vote scheduled for Oct. 24th
– 127 Comments• Currently reviewing modeling of Health Concerns, Risks
and Problems– Seeking domain expert input and discussion
Status of C-CDA Update Ballot Reconciliation
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• Discussed and identified project during HL7 Meetings• 2009 Health Concern Ballot Package DSTU (expired)• Revisited following SDWG request to identify how Health
Concern was used in CDA• Expired DSTU needs to be updated to reflect new Care
Plan standards defined under:– HL7 Care Plan DAM– HL7 C-CDA Revisions
• Will harmonize with IHE and OpenEHR• NEW project scope statement developed to define
Health Concern concept• Propose to ballot in May 2014
HL7 Patient Care WG: Health Concern DAM
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• [Larry]
Status of IMPACT Project
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LCC Pilot Documentation Template
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Summary of Documentation Templates & Reference Materials (Pilot Materials)
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Document Name DescriptionPilot Overview Document
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.
Work Group Planning Presentation
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.
Pilot Documentation Template
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.
Pilot Plan TemplateA 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.
Templates available on LCC Pilot WG wiki page: http://wiki.siframework.org/LCC+Pilots+WG
Longitudinal Coordination of Care (LCC)
Pilots Template
Insert the Name of Your Pilot / Organization Here
MM/DD/YYYY
Pilot TeamIdentify the members of your organization who will be supporting this
pilot. If possible include the role he/she will play in the pilot and contact information
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Name Role Email
Full Disclosure?
Goal of the Pilot
Please include a write up or create a Visio diagram of what you intend to show/prove/support during the pilot process.
Make this an actionable statement with specifics.
Also include in this description what you hope to gain from this pilot.
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Which of the 5 C-CDA Revisionsare you Piloting?
Please use this section to document which of the 5 LCC Standards (Transfer Summary, Consultation Request, Consult Note, Care Plan, and/or Home Health Plan of Care ) you are intending to pilot. Please be as specific as possible.
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SDC Standard / Guidance Specifics to Pilot Notes
What Relevant Scenario (from the Use Cases) does your Pilot support?
Exchange of Clinical Information from Provider to Provider
Exchange of Clinical Information from Provider to Patient
Other: ____(Please specify)
Link to download Consensus Approved Use Case 1: http://wiki.siframework.org/LCC+WG+Use+Case+%26+Functional+Requirements
Link to download Consensus Approved Use Case 2: http://wiki.siframework.org/LCC+WG+Use+Case+2.0
Identify the Use Case Actors/Systems Involved:A pilot may involve the following participants from the longitudinal
coordination of care ecosystem:– Sending Entity Care Team– Receiving Entity Care Team– Sending Entity Information System (EHR)– Receiving Entity Information System (EHR)– Patient and/or Caregiver– Home Health Agency (HHA) Care Team– Home Health Agency (HHA) Information System (EHR)– PHR Application
Minimum Configuration
What is your current technical / infrastructure set up?
What systems / applications will you be using to conduct the pilot?
Examples:– Electronic Health Record (EHR) system– Health Information Exchange (HIE)– External database (which one/type)– Existing interfaces– New interfaces (to be developed as part of the pilot)
TimelineWhat is your proposed timeline given we want to wrap-up Pilots by Q4 2014Guidance: ~6 months minimum / ~1 year maximumEvaluation: starts @ 6-9 months / final evaluation when pilot is completeExample Timeline
– September – Kickoff and Logistics– October – Start Pilots– November – Continue with Pilots– March – Conclude Pilots
Milestone Target Date Responsible Party
Success Criteria
What will you/your organization use to determine the success of this pilot? This needs to be quantitative and not subjective in as much as possible.
Examples:– X% Reduction in readmission rate– X% Increase in number of unique patient transfers between sites
with complete set of Care Plan data elements
Example: IMPACT Performance MetricsTarget 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
Increase overall completeness of data included in transition process
70% of patients transferred with complete set of required data elements included in electronic Universal Transfer Form (UTF)
Unique patient transfers between IMPACT pilot sites
LAND and SEE data
Number of unique patient transfers between IMPACT Pilot Sites during measurement period with complete set of required data elements in electronic UTF
Number of unique patient transfers between IMPACT Pilot Sites during measurement period
In Scope / Out of Scope
If you already know what will be in and out of scope for your pilot (beyond the Implementation Guidance (IG) or the Use Case) please document it here.
Example:
Risks & Challenges
Identify any risks or challenges
Questions / Needs
Please include those items you wish to consider any questions you have or hope the pilot addresses.
Additionally, please include those items you need in order to succeed.
We will try to accommodate as many of these needs as possible within the scope of ONC, S&I and LCC (and resource availability).
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
Longitudinal Coordination of Care (LCC)
Pilots Proposal
IMPACT
8/19/2013
Pilot Team
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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
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Which of the 5 C-CDA Revisions isbeing Piloted
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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 (LCC Use Case 1.0)
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
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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
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LAND Converter
CDA Document
Text Document
HL7 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
• Homework Assignments:– 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 ([email protected])
Next Steps
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• LCC Leads– Dr. Larry Garber ([email protected])– Dr. Terry O’Malley ([email protected]) – Dr. Bill Russell ([email protected]) – Sue Mitchell ([email protected])
• LCC/HL7 Coordination Lead– Dr. Russ Leftwich ([email protected])
• Federal Partner Lead– Jennie Harvell ([email protected])
• Initiative Coordinator– Evelyn Gallego ([email protected])
• Project Management– Pilots Lead: Lynette Elliott ([email protected])– Use Case Lead: Becky Angeles ([email protected])
LCC Initiative: Contact Information
48LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care