longitudinal coordination of care pilots wg monday, september 22, 2014
TRANSCRIPT
Longitudinal Coordination of Care
Pilots WGMonday, September 22, 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
Topic Presenter
Welcome & Announcements Lynette
Presentation: GSI Pilots Lessons Learned Lee JonesVince LewisMike Carbery
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 Reminders
S&I Framework Hosted Meetings: http://wiki.siframework.org/Longitudinal+Coordination+of+Care • LCC Pilot WG meetings are every other Monday from 11:00– 12:00
pm Eastern – Focus on validation and testing of LCC Standards for Transitions
of Care & Care Plan exchange
HL7 Structured Documents WG Meetings• Thursdays from 10:00 – 12:00pm Eastern
– WebEx: https://global.gotowebinar.com/register/144336339
– Dial In: 770-657-9270; Access Code: 310940•A pre-publication draft of CCDA R2.0 specification was distributed to the SDWG list serv on July 3rd: (http://www.hl7.org/Special/committees/structure/docs.cfm?).
•Comments were accepted until July 11th.•Currently discussing CCDA R2.0 Template OID versioning issue
HL7 Patient Care WG Meeting Reminders
• Coordination of Care Services Specification Project– Provide SOA capabilities/models to support coordination of patient
care across the continuum– Reconciling May 2014 Ballot Cycle Comments – Current working documents found here:
http://wiki.hl7.org/index.php?title=Coordination_of_Care_Services_Specification_Project
– Tuesdays from 5:00 – 6:00pm 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
HL7 Patient Care WG Meeting Reminders, cont’d...• Care Plan Project
– Reconciling May 2014 Ballot Cycle Comments for the updated Care Plan DAM and story boards.
– Current working documents found here: http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012
– Every other Wednesday from 4:00 – 5:30pm ET • Next meeting is September 24th • Meeting Information:
– Web Meeting URL: https://intermountainmeetings.webex.com/intermountainmeetings/j.php?J=621920971
– Phone: 770-657-9270, Participant Code: 943377
HL7 Patient Care WG Meeting Reminders, cont’d...• Health Concern Topic
– Developing Health Concern DAM for September HL7 Ballot Cycle– Current working documents found here:
http://wiki.hl7.org/index.php?title=Health_Concern– Thursdays from 4:00 – 5:00pm ET
• Next meeting scheduled for September 25th • Meeting Information:
– Web URL: https://meetings.webex.com/collabs/#/meetings/joinbynumber
» Meeting Number: 233 955 026 » Phone: 770-657-9270, Participant Code: 943377
HL7 Patient Care WG Meeting Reminders, cont’d...• Patient Care FHIR Resources and Profiles
• Reviewing/Finalizing storyboards for the HL7 Sept WGM FHIR Clinical Connectathon
• Developing FHIR Resource for Referral and Transition/Transfer of Care
• Current working documents found here: http://wiki.hl7.org/index.php?title=FHIR_Patient_Care_Resources
– Thursdays from 5:00 – 6:30pm ET• Next meeting scheduled for September 25th • Meeting Information:
– Web URL: www.webex.com – Meeting Number: 198 139 396
» Phone: 770-657-9270, Participant Code: 943377
HIMSS Health Story Roundtable
• Why attend?– Advocate and build support for the Health Story Project– Collaborate and network with Health Story Project supporters– Engage with industry leaders in monthly meetings– Participation is open to any HIMSS Members at no additional cost
• Meets monthly on the 1st Monday from 4pm-5pm ET. Upcoming meetings scheduled for October 6th – Web URL: Click here to view agenda and download the calendar
invitation (this link will also work to join the meeting)– Meeting Number: 927 311 214– Meeting Password: meeting– To receive a call back, provide your phone number when you join
the meeting, or call the number below and enter the access code.• Call-in toll-free number (US/Canada): 1-866-469-3239• Call-in toll number (US/Canada): 1-650-429-3300
FACA Meeting Reminders
HIT Standards Committee• Next meeting scheduled for November 18th from 9:00am – 3:00pm ET• http://www.healthit.gov/facas/calendar/2014/11/18/hit-standards-committee
HIT Policy Committee• Next meeting scheduled for November 4th from 9:00am – 3:00pm ET• http://www.healthit.gov/FACAS/calendar/2014/08/06/hit-policy-committee
LCC Pilot WG Timeline: Aug 2013 – Sept 2014
Mile
ston
es
Revisions for HL7 CCDA IG
Complete
HL7 Fall Ballot Close
LCC Pilot Monitoring & Evaluation
LCC Pilot Proposal Review
HL7 Ballot Publication
LCC Pilots Close29SEP14
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
Upcoming LCC Pilots Meeting Presentations
• Upcoming presentations:• September 29th:
• LCC Pilots Initiative Closing Ceremony
June 2014
GSI Health LCC Pilot Reflections
All contents are CONFIDENTIAL.Do not cite or circulate.
Topics
• LCC Pilot Overview• Care Plan CDA Thoughts
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LCC PILOT OVERVIEW
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LCC Pilot Overview
• Premise: Care plans authored by individual providers should be accessible to the provider community via system interoperability
• Care coordination and planning is meant to be collaborative, and not just transparent
– Data exchange gets at transparency to see what others are doing– Coordinated care unites care providers to build a unified path forward for the
patient, and empowers them to execute their respective responsibilities in that plan– Hence, we have a centralized care-planning model
• In our “pilot” (really a technical proof-of-concept), we demonstrated how we– Mapped health-home community care plan elements to the LCC CDA document for
care plan interoperability– Extracted coordinated care plans and sent them to other technology platforms
using Direct protocols
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LCC Pilot Architecture Overview
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CARE PLAN CCDA THOUGHTS
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Our Use CasesWe have two use cases:•A provider in the community wants to contribute some care planning content from his/her EHR into the community care plan (whether that is an update or new content), and the community will merge it in•A provider in the community wants to update his/her local view of the patient’s care plan with the community one, and needs an export from the central care plan.
In both cases, the content on the systems needs to be reconciled, not just exposed
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Care Plan CCDA DocumentLevel 1 , Sections
• Current Section are:• Goals Section (NEW)
• A goal is a defined outcome or condition to be achieved in the process of patient care. Goals include patient-defined goals (e.g., alleviation of health concerns, positive outcomes from interventions, longevity, function, symptom management, comfort) and clinician-specific goals to achieve desired and agreed upon outcomes.
• Health Concerns Section (NEW)• The Health Concerns section contains data that describes an interest or worry about a health
state or process that has the potential to require attention, intervention or management.
• Health Status Evaluations/Outcomes Section (NEW)• This template is a section that contains Health Status Evaluations and Outcomes. Health Status
Evaluations and Outcomes represent status, at a point in time, related to established care plan goals and/or interventions.
• Interventions Section (V2)• Interventions are actions taken to maximize the prospects of achieving the patient’s or provider’s
goals of care, including the removal of barriers to success. Interventions can be planned, ordered, historical, etc.
Relationships maintained
through pointers across
sections. Sometimes
specific, sometimes
generic
Relational Integrity(?)
• Relational ambiguity cannot be introduced in creation of document (i.e., document less specific than internal representation)
• Data loss (i.e., document accommodates subset of system’s data) is not desirable, but less critical
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System 1 System 2
Care Plan A
Care Plan A
System 1's consumption of Care Plan A results in semantic equivalence of
its original export of Care Plan A
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2
Observation #1:Association of Related Historical Encounters
• There is no explicit allowance for an Encounters Section in the Care Plan Document.– Some encounter history that can be related to elements of the
care plan (e.g., encounter that led to care plan update) should be allowed
• Unclear how history of care-plan encounters (i.e., encounters that fulfill care plan goals & interventions) is handled– Maybe thought is to list as planned encounter then update the
status to show completion, but that is a little circuitous, and also may result in past encounters retrospectively being listed as “planned” when they weren’t
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Observation #2:Association of Related Notes
• The transition from documentation via notes (e.g., progress notes, case conference notes, etc.) to documenting in care plans is not complete.– Notes are used in conjunction with the care plan and associated
with care steps
• If Notes Sections were allowed in the document, they could be attached to care plan content by reference
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Observation #3:Cross-Reference of IDs
• The purpose of care-plan interoperability in the community context is more about “replication” than “exchange”– Need to synch disparate instances of local care plans with
centralized shared care plan
• Need to disambiguate care-plan specific elements (e.g., interventions, goals, etc.) for reconciliation, revision history, etc.– Not sure if this is to be done with local implementation guides, but
direct support in the standard would be better
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Observation #4:Handling of Domains for Concerns
• There are many kinds of concerns and activities that may be logged, and the standard tries to enumerate them at all levels (concern, goal, intervention), with a catch-all for things unclassifiable– The catch-all’s are likely to be used extensively in our use cases
• In shared care plan for complicated patients, the plan grows fast. Need customizable “domain” attribute associated with the health concern to allow for classification, filtering, etc.
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Concerns are Classified by Domain
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Domains Can Be an Extensive List
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Observation #5:Filter Criteria on Document Content
• In a shared care plan for complicated patients, the plan may grow fast, and filtering is used to pare down the space of relevance to a given user of the care plan– In replicating care plans across systems, sometimes the entire
care plan is not fetched, and the constrained content needs to be indicated
• Filters may be done on a number of dimensions, and a way to describe what was done must be versatile.
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Our Use of Filters
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Observation #6:Candidate vs. Final Care Plan Content
• In community care planning, there is consensus on what the shared picture is for both patient data and care plans.– Some elements of a care plan may be nominated, but are not
accepted as formal care plan elements by designated approver
• Distinction must be apparent between candidate care plan content, and final care plan content– Status is probably not a good place for this designation
since that likely indicates progress, not state– Other attendant information is useful (approver,
proposer, relevant dates of proposal/acceptance, etc.)
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Observation #7:Annotation of Evidence/Authority Source
• Some care steps (goals / interventions) are supported by evidence from the literature, or are part of “approved” protocols from the authoritative entities in the community. Such care steps should be distinguished from free-form care steps
• The source of the evidence or authority should be indicated– This is a different concept than the author participant which
indicates the person/entity that included the care step in the care plan, though the author may also be said entity
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Observation #8:Indication of Gaps in Care
• When care steps (goals / interventions) are not met as planned, they may be designated as gaps in care. This designation is important to represent.
• Seems different in nature than the content intended for Outcomes section since this is not an outcome.
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Observation #9:Clarification of Author Participant
• The community’s shared care plan has a revision history of all authors that have made changes and what changes were made. This document could at least accommodate the historical authors– It’s unclear if the “author participation” is meant to be the person
with current responsibility, or the author, or both.– There is a concept of participants in a review for the care plan that
may get at this, but reviewers aren’t editors, so it is unclear if this is a legitimate use of that feature
• Accommodation of auto-population of health concerns (and designating it as such) is desired– Also related to earlier point re: candidate content
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Observation #10:Vocabulary for Interventions, etc.
• The community is allowed to enter free-text issues, goals, and interventions, given the breadth of provider types (social services, medical, etc.) and associated activities. – Semantic interoperability would be helped if there was a registry of
same that encodes them (a la OIDs) so that the vocabulary of intervention concepts can be leveraged and interpreted universally
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Care Plan CDA Implementation
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Care Plan CDA Implementation
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Care Plan CDA Implementation
• First actual implementation currently in Test
– Transfer of C-CDA Care Plan document to a Clinical Decision Support engine
– Transfer via SOAP using OASIS/NHIN Notification framework
– Real-Time Decision Support Alerts relayed back to users
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Care Plan CDA Implementation
• Different from the “CCD World”
– Lack of formal terminologies– Needs to be adaptable as terminologies come on-line– Needs to handle large amounts of free text – How do we get the best of both worlds ?
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Care Plan CDA Implementation
• CDA Release 2 provides guidance on how to correctly include free text.
– Cases include when no coded terminologies are available and to enhance codes with descriptions
– Reference http://motorcycleguy.blogspot.com/2011/03/use-cases-for-links-from-entries-to.html (thanks Keith Boone)
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Care Plan CDA Implementation <title/>
<text>
<content ID="Blob1">...procedure/code original text...</content>
<content ID="Blob2">...act/text uncoded text blob...</content>
</text>
<entry>
<procedure>
<code code="12345" codeSystem="2.16.840.1.113883.19.1"/>
<originalText><reference value="#Blob1"/></originalText>
</code>
</procedure>
</entry>
</section>
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Care Plan CDA Implementation
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Care Plan CDA Implementation
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• When no codes are available
Care Plan CDA Implementation
• Some creativity may be necessary– Example: create a parseable structure for transfer of
multiple fields
<content ID="issue2">CREATED_DATE_TIME|ISSUE_TITLE|ISSUE_STATUS|UNIT| ISSUE_DETAILS</content>
<content ID="issue2">20100101000000|Mary is experiencing pain due to pressure sores.|In Progress|Private Home|Mary has been experiencing pain due to pressure sores for the last 2 weeks. Her PCP is informed of the issue. She has been referred to the Local Wound Center for in-home skilled nursing.</content>
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Brooklyn Health Home Model
Key Feature of the BHH
model: Virtual co-location of providers
and services enabled by
health IT and coordination
of services
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Clinical Decision Support – Design
• Brooklyn Health Home worked with GSIH and MedCPU to:
– Design protocols for managing specific patient issues
– Develop prompts within the CareBook App to alert CM/CN when a task or intervention is impending or
has not been completed within the appropriate time
– Integrate Prompts into User Workflow
– Define Escalation to Supervisors and Managers as appropriate
– Define management Reporting
• Protocols, Prompts, and Workflow have been designed for:
– General/Administrative Tasks
– Initial Assessment
– Hospitalization
– Housing
– Domestic Violence
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Category Time Rapid Cycle Evaluation and ImplementationCDS (MedCPU) Background Pilot Phase I Q2'14 Pilot with Hospitalization Protocol
Generate Care Prompt reports for Analysis
Define Revisions and Enhancements for next iteration
CDS (MedCPU) Background Pilot Phase II Q4'14 Revise and Enhance Protocols and Functionality
Implement new and revised Care Protocols and Functionality
Generate Care Prompt reports for Analysis
Define Revisions and Enhancements for Go-Live
CDS (MedCPU) User Interface (UI) Rollout Q1'15 Revise and Enhance Protocols and Functionality
Implement new and revised Care Protocols and Functionality
Alignment with general UI and workflow improvements
Deliver with live User Interface Functionality and Reporting end of Q1'15
Clinical Decision Support – Implementation
LCC Pilots WG meetings are held every Monday from 11am-12noon ET
Webinar: siframework1.webex.com
Dial-in: 1-650-479-3208 | Passcode: 665 643 961
Key Use Cases:Crisis Intervention – a Patient in crisis presents at an ED
• Is this a Health Home Patient, if so, which one?• Who is on the Care Team, how do I contact them?• What is the most critical information about the Patient?
Provider Process Integration in the Technology Platform• Simplify Workflow, access to information• Eliminate “double entry” • Support multiple legacy output requirements
Transitions of Care• Long and Short Term• Temporary and Permanent
Approach:Provide community wide platform, e.g., GSIHealthCoordinator (Health Home Dashboard)Leverage Healthix/SHIN-NY infrastructure and ONC DirectAdvancement of structured information exchange standards to:
• Coordinated Care Plan - LCC Initiative• Medical and Psycho-Social Assessments
Critical Success Factors:Definition and Adoption of StandardsTechnology Partner SupportPayer, Regulatory, Provider Process Simplification and Standardization
Interoperability Opportunities and Challenges
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• Homework Assignments:– Sign up as an LCC Committed Member
• Members will receive invite to join upcoming eLTSS Initiative (start November 2014)
• If you would like to learn more about participating in the NEW eLTSS Initiative, please email Evelyn Gallego ([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
52LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care