Longitudinal Coordination of Care Pilots WG

Longitudinal Coordination of Care Pilots WG Monday, June 9, 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 • Hold = Elevator Music = frustrated speakers and participants This meeting is being recorded • 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. • 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

ReminderJoin the LCC WG & Complete Pilot Survey • http://wiki.siframework.org/Longitudinal+CC+WG+Committed+Member+Guidance • http://wiki.siframework.org/LCC+Pilots+WG ** If your contact information has recently changed, please send your updated information to Becky Angeles at becky.angeles@esacinc.com

Agenda

Pilot Work Group Purpose and Goals • 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

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://iatric.webex.com/iatric/j.php?ED=211779172&UID=0&RT=MiMxMQ%3D%3D • Dial In: 770-657-9270; Access Code: 310940 • ALL 1013 comments have been reconciled. Ballot reconciliation package was voted on 4/10. • Draft version of final CCDA R2.0 specification has been distributed to the SDWG list serv. Final publication is slated for end of June. • Currently discussing CCDA R2.0 Template OID versioning issues and approaches.

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 • Currently Reconciling May 2014 Ballot Cycle Comments • Current working documents found here: http://wiki.hl7.org/index.php?title=Coordination_of_Care_Services_Specification_Project • Meetings every Tuesday 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 • Currently Reconciling May 2014 Ballot Cycle Comments for the updated Care Plan Domain Analysis model and story boards. • Current working documents found here: http://wiki.hl7.org/index.php?title=Care_Plan_Project_2012 • Meetings every other Wednesday from 4:00 – 5:30pm ET • Next meeting is June 18th • 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 • Currently working on Health Concern DAM for September HL7 Ballot Cycle • 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 June 19th • Meeting Information: • Web URL: https://meetings.webex.com/collabs/#/meetings/joinbynumber • Meeting Number: 236424669 • 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. Next meeting scheduled for July 7th • Meeting Information: • 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

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

FACA Meeting Reminders (see end of deck for updates) HIT Policy Committee Certification and Adoption WG Next meeting scheduled for June 18thfrom 2:30pm – 4:30pm ET http://www.healthit.gov/FACAS/calendar/2014/06/18/policy-certificationadoption-workgroup HIT Policy Committee Meaningful Use WG Next meeting scheduled for June 20th from 10:00am – 12:00pm ET http://www.healthit.gov/facas/calendar/2014/06/20/policy-meaningful-use-workgroup HIT Standards Committee Next meeting scheduled for June 17thfrom 9:00am – 3:00pm ET http://www.healthit.gov/facas/calendar/2014/06/17/hit-standards-committee HIT Policy Committee Next meeting scheduled for June 10thfrom 9:00am – 1:15pm ET http://www.healthit.gov/FACAS/calendar/2014/06/10/hit-policy-committee HIT Quality Measures Vendor Tiger Team Cancelled until further notice HIT Policy CommitteeAccountable Care WG Workgroup has been retired as of 05/29/14 meeting

LCC Pilot WG Timeline: Aug 2013 – Sept 2014 LCC Pilot Proposal Review LCC Pilot Monitoring & Evaluation LCC Pilot WG LCC Pilot Wrap-Up HL7 Ballot & Reconciliation HL7 Ballot HL7 C-CDA IG Revisions LCC Pilot WG Launch Revisions for HL7 CCDA IG Complete HL7 Ballot Publication HL7 Fall Ballot Close IMPACT Go-Live LCC Pilots Close LCC Pilot Test Spec. Complete Milestones GSI Health Go-Live NY Care Coordination Go-Live

Upcoming LCC Pilots Meeting Presentations June 23rd meeting CANCELLED due to AHIMA Upcoming presentations: • IMPACT Updates • GSI Health Pilots Follow-up • CMS Chronic Care Management Services Proposed Rule comment period • NQF Care Coordination Measures • VA Care Plan FHIR demo

ONC Updates

ONC Re-Organization Kelly Cronin Joy Pritts Lisa Lewis Dr. Doug Fridsma Judy Murphy, RN Seth Pazinski Dr. Karen DeSalvo Jody Daniel Kim Lynch Nora Super Steve Posnack

Call to Action: Nationwide Interoperable Health IT Infrastructure The ONC recently published “Connecting Health and Care for the Nation: A 10-year Vision to Achieve an Interoperable Health IT Infrastructure” Describes ONC’s broad vision and framework for interoperability Call for all health IT stakeholders to join in developing a defined, shared roadmap to help achieve interoperability as a core foundational element of better care at a lower cost Paper ascertains Interoperability is a national priority ONC will be offering several opportunities in the coming months for the public to provide their feedback

Nationwide Health IT Infrastructure: 5 Critical Building Blocks Core technical standards and functions Certification to support adoption and optimization of health IT products and services Privacy and security protections for health information Supportive business, clinical, and regulatory environments Rules of engagement and governance Building blocks are interdependent and progress must be incremental across all so that the Interoperability vision can be achieved over the next decade.

SAVE THE DATE: eLTSS Initiative

CMS TEFT LTSS Program • In March 2014 CMS awarded planning and demonstration grants to qualified states for Testing Experience and Functional Tools (TEFT) in Medicaid community-based long term services & supports (LTSS) • Total grant program ~$42M, up to 4 years • Purpose is to provide national measures and valuable feedback on how HIT can be implemented in this component of the Medicaid system • 8 of 9 states confirmed to participate in S&I Framework: • AZ, CO, CT, GA, KY, LA, MD, MN http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Grant-Programs/TEFT-Program-.html

CMS TEFT Components: S&I Focus States have selected to participate in ONE or more of following components: • Test a beneficiary experience survey within multiple CB-LTSS programs for validity and reliability • Test a modified set of CARE functional assessment measures for use with beneficiaries of CB-LTSS programs • Demonstrate use of PHR systems with beneficiaries of CB-LTSS • Identify, evaluate and harmonize an eLTSS standard in conjunction with the ONC S&I Framework

S&I Components: PHR demonstration • States that elect to demonstrate use of PHR systems must also participate in eLTSS S&I process • States that chose to test additional quality measures as part of the use of PHR systems are expected to share those measures with CMS • Measures from Medicaid Adult Health Quality Measure core set and other State-specific quality measures for relevant populations

PHR demonstration Requirements • PHR System functionality must enable: • Collection of Medicaid adult core quality measures • Collection of CB-LTSS information • Collection of “Treatment” outcomes identified through eLTSS record • Dissemination of this information among individuals, their families/guardians, case managers and providers • States can choose to use the following PHR systems: • DoD provided PHR Systems: • iPHEMS (Information Personal Healthcare Exchange Management System): PHR data broker • DoD HERMES: PHR data engine for survey administration • Pre-specified Commercial PHR • State-sponsored and developed PHR (i.e. State HIE Patient Portal)

PHR demonstration Requirements (cont’d) • For commercial or state developed PHR systems, States encouraged to use PHRs that meet ONC VDT certification criteria or that include equivalent functionality • States can use TEFT grant funds to customize and connect the PHR system with the eLTSS record and state IT systems • Beneficiaries/Caregivers and Providers must be included in state’s process to plan, customize and implement the PHR system

S&I Components: eLTSS Standard • States are required to identify and provide participants for S&I eLTSS Initiative • Once eLTSS standard is identified, states must test and validate standard with CB-LTSS providers and with beneficiary PHR systems • Will be initiated through Pilot Phase of S&I Framework process • States will be provided with scoring incentives for participating in eLTSS initiative • CMS expects states participating in this component to have higher cost for planning and implementation

Next Steps for eLTSS Initiative • eLTSS Initiative will be launched as NEW workgroup under the existing S&I Longitudinal Coordination of Care (LCC) Initiative • CMS TEFT grantees will participate in eLTSS Initiative as part of their grant program requirements • eLTSS Initiative will also be open for other stakeholder groups to participate: • Other States and State Medicaid Offices • LTSS system vendors • Other HIT systems • LTSS Providers and Facilities • Consumer Engagement Organizations • Timeline: eLTSS Initiative will launch Fall 2014 and will run for duration of CMS TEFT grant program (3 years)

Next Steps • 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 (Lynette.elliott@esacinc.com) • If you would like to learn more about participating in the eLTSS Initiative, please email Evelyn Gallego (evelyn.gallego@siframework.org)

LCC Initiative: Contact Information • 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 Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care

FACA Updates • As of 06/09/2014

FACA Updates: HITPC Accountable Care WG 05/29/14 This meeting was for a review of final recommendations, which will be submitted to the HITPC for action on July 8th. The workgroup has been retired as of this meeting. Focus areas included the following: • exchanging data across the health care community • See next slide for workgroup recommendations • data portability • scaling the data infrastructure for value-based programs • clinician use of data and information to improve care • streamlining the administration of value-based programs. Each contained a section on background, strategy and priority recommendations.

FACA Updates: HITPC Accountable Care WG 05/29/14, cont’d… Exchanging data across the health care community recommendations included the following [verbatim]: • HHS should specify within hospital survey and certification standards that institutions must electronically transfer discharge summaries to treating providers in a timely manner. • Increase public transparency around hospital and health system performance on measures related to health information exchange. • Provide additional shared savings incentives to accountable care organizations that include partners who are not eligible for EHR incentives. • Issue additional guidance around sharing of information protected under 42 CFR Part 2 across participants in an accountable care organization. • Drive progress on standardization and capture of social determinants of health data elements that are most critical to accountable care delivery models.

FACA Updates: HITPC Cert/Adoption WG 05/28/14 This workgroup session was used to Review Public Comments from the Blog and Listening Session as well as to review Proposed Recommendations for “Some” LTPAC/BH Providers Comments were abbreviated and presented on slides for discussion during the meeting • See following the slides for comments relevant to LCC and LTPAC (highlighted in red)…

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… General Comments from Blog • Vendor effort will be significant but achievable • Significant time and effort needed for workforce training and education related to workflow changes • Starting the admission process from the CCD data will reduce the number of fields that need to be filled, which may result in time savings and reduced errors. • Some existing EMRs are having trouble with consuming outside CCDs, feel very strongly this capability is key • Need for clear directions on which modules are required to support various use cases (e.g. interacting with EHRs for the attending physician or behavioral health staff) • Capability of LTPAC vendors to receive CCDA today is low (e.g., one vendor noted, “only 1 known LTPAC vendor with this capability”). • Challenge of using the Direct protocol to exchange CCDAs across multiple states is overwhelming

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… Care Coordination Comments from Blog • Support for certified EHR technology provisions that demonstrate the ability to send and receive transitions of care and referral summaries • Support provisions allowing patients and their caregivers’ access to their medical records in order to be an active partner in the management of their own health and wellness • Support for certification of EHR modules based on care coordination • Must be able to meet the transitions of care and clinical information reconciliation and incorporation standards. • An EHR module designed to support care coordination must have the ability to transmit and receive data to support this goal.

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… Clinical Reconciliation • Reconcilable data is key to care collaboration, critical for LTPAC physicians and other ambulatory providers LTPAC Patient Assessments • Support promulgation of standards which are necessary to establish any ‘cross cutting’ quality measures. Standardized data elements are needed to implement ‘shared’ clinical decision support between the facility and attending physicians. Patient Engagement • Maintaining Direct connections with many separate locations is beyond one group’s administrative capacity. Currently providers resort to fax messages because they can enter/store a phone # without external support. Advanced Directives • Support documentation of Advanced Directives using ‘standard’ free form text that corresponds to the particular State’s language. Lack of a national standard for Advanced Directives makes it impossible to treat this as a structured data element. Advanced Directives should be an Adult eCQM.

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… Listening Session General Comments • LTC physicians and nursing facilities 'share care’ for the patient concurrently. • Orders need to be synchronized with nursing facility EHR systems to be actionable (e.g., clinical documentation such as MD note, history and physical need to be in MD and facility EHR). • RxNorm missing over the counter meds, LTC pharmacies not ready for RxNorm. • Certification process has brought additional structure, beyond narrative notes for certified vendors. Allows for data analytics. • Certification that incorporates more BH data elements would be helpful. • One vendor on the panel is currently certified to ONC 2011 edition, another vendor is considering ONC 2011/2014 edition interoperability certification.

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… During the discussion of the Listening Session comments in the previous slide, a suggestion was made to split LTPAC away from BH and not continue to “bundle” them into the same discussions, as they are separate problems to solve. • General consensus agreed and this point will be added to the slides for presentation. • A distinction between the two will be made stating that part of what makes them different is that there are different sets and classes of providers who would be accessing an LTPAC record versus a BH record.

FACA Updates: HITPC Cert/Adoption WG 05/28/14, cont’d… Proposed Recommendations for “Some” LTPAC and BH Providers (see next slide for graphic depiction) • Recommendations in this category are based on ONC 2014 edition certification criteria • Modular approach • Functionality may be of value to SOME care settings depending on care delivery needs and scope of practice • May be programmatic reasons for adopting certification functionality, certification may make sense in those instances • Workgroup discussion focused on added value of certification for these functions; no consensus reached

Organizing Principles for Recommendations • LTPAC Setting-Specific • Patient Assessments • Survey and Certification • BH Setting-Specific • Patient Assessments • Consent Management (included under Enhancements to Privacy and Security) For ALL Providers • Transition of Care • Privacy and Security • Enhancements to Privacy and Security • For some LTPAC and BH Providers • Clinical Reconciliation • Clinical Health Information • Labs/Imaging • Medication-related • CPOE • Clinical Decision Support • Quality Measures • Patient Engagement • Advanced Care Planning • Data Portability • Public Health - Transmission to Immunization Registries

FACA Updates: HITPC MU WG Listening Session 05/27/14 This listening session was a continuation from May 20th Panel 3: HIT Support of Advanced Models of Care panelist comment highlights: • Urged that meaningful use move as fast as possible and approve the use of penalties; exchange in local community is key • Interoperability and the standards for it do not actually exist. Most vendor systems cannot interact with each other. States have not built the systems needed. • Providers should be allowed to select from a list of clearly delineated core measures. The pass or fail concept is not fair because a provider can fail on one technicality of a single measure. • In the future, additional and more stable funding to support the public health informatics infrastructure will be critical to sustaining the public health gains from meaningful use.

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Panel 3: HIT Support of Advanced Models of Care panelist comment highlights, cont’d: • Knowing which public health agencies to report to, their relative readiness and priorities for public health data, and how to get into an onboarding queue and anticipate wait times is a challenge. • Lack of physician compliance with laws that require them to notify public health authorities of patients with reportable health conditions remains a national problem. • It is crucial that meaningful use provide a framework that incentivizes the development of EHR functionalities that are necessary for case reporting. • Patients overwhelmingly believe that EHRs are useful across the range of clinical and patient-facing functions; portals should provide access in preferred language and interoperability with assistive devices.

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Panel 3: HIT Support of Advanced Models of Care panelist comment highlights, cont’d: • State implementation funds should be used to deal with artificial barriers to information flow across states and to build exchanges to public health agencies.

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Panel 4: Vendors • Stage 3 must be designed to avoid and reverse many of the unintended consequences manifested during Stage 2 and eliminate development burdens that limit innovation. • Concern that efforts to measure meaningful use often require more work than the actual use of the EHR itself. Consistent with comments the EHRA has previously submitted to CMS, ONC, and the HITPC, it is essential that at least 18 months are allowed before a new stage of meaningful use takes effect. • Urged establishment of a 90-day or quarter reporting period for the first year of each new stage, allowing upgrades to be spread out during the first year of a new stage. • Tight timing has led to concerns with Stage 2 certified product availability and implementation. Complexity affects vendors and providers and hinders ability to plan for orderly development and implementation. Also requires substantial diversion of resources to understanding and communicating the meaning and intention of specific meaningful use provisions. Complexity of the program expands exponentially with each additional objective or measure.

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Panel 4: Vendors • Accelerating use of audits has further complicated the program and tended to create a focus on provider compliance rather than true meaningful use and associated patient and clinician benefits. • The 13-24 month timeline is too short and the proposed 2017 Edition timeline does not yet accommodate that learning. The final set of standards was incomplete and required considerable updates and clarifications, thus further constraining the timeline. Providers underestimated the scope of impact, which further exacerbated the timeline • Although the perception was that approximately 30% of providers were substantially impacted in the 13 months allotted, in actuality 100% of providers bore more than 80% of the impact in the immediate timeline. Stage 2 underserved the urgency of CQM and Core 6 process analysis and (re)design in 2013 and CEHRT upgrades needed for the market as a whole

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Panel 4: Vendors • One panel vendor made the following recommendations: • Provide no less than 18 months from the final specifications and reporting requirements where final specifications are defined as complete, high quality, consistent, and unambiguous information. • Align reporting and interoperability priorities among all program(s) participants and stakeholders (i.e., states). • Avoid prescriptive requirements for collecting lists of data, measuring processes, and/or designing software. • Ensure appropriateness and maturity of selected standards • Certification of technology that cannot communicate across vendors is unacceptable. Hardship exceptions are unnecessary. • More than 90% were ready before the onset of the 2014 Edition requirement. A cloud-based system makes it work. The timeline problems are the fault of vendors, not providers. Public funded investments in underperforming products must cease.

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Q&A • What is the most important action to take to achieve interoperability? • Stopping the subsidization of systems that (sometimes deliberately) fail to interoperate and are basically closed systems • Align privacy and security with state requirements and implementation • Closer examination of the value of the listener and receiver • Each stage should be less granular than the preceding one • What policy levers would equal the playing field? • Someone needs to ensure that ACOs connect outside their own systems as well as with non-ACOs. Regulatory agencies must be vigilant in preventing patient lock-ins. Interoperability requires significant investment, which payment models should take into account • Stark and anti-kickback restrictions should be re-thought to make waivers and exceptions more available

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Q&A, cont’d… • What are some of the collaborations to address patient matching and other issues? • FDASIA draft report and the public private HIT Safety Center are examples • Although the EHRA previously pointed out many problems with meaningful use, no one paid attention. Being forced to do things that do not work will not promote exchange of information

FACA Updates: HITPC MU WG Listening Session 05/27/14, cont’d… Closing Remarks • Comments that had occurred frequently in public input forms: • misguided focus on the letter rather than the spirit of meaningful use • proprietary business interests impede exchange • employers’ use of ACO-like incentives can be used • rely on payment reform initiatives; avoid being so prescriptive • align CQMs • make policy on exchange across state boundaries and patient matching • prioritize information exchange for care coordination and patient engagement • Several members added the following: disagreement about timing and delays, making information on public health readiness available, and erroneous assumption that requirements for interoperability are in place

Next Steps • 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 (Lynette.elliott@esacinc.com)

Longitudinal Coordination of Care Pilots WG