Longitudinal Coordination of Care (LCC) Pilots Documentation

1. Longitudinal Coordination of Care (LCC)Pilots Documentation GSIHealth: Health Home Data Exchange via Direct 01/06/2013

2. Pilot Team Identify 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

3. Goal of the Pilot GSIHealth provides a Care Coordination Software platform for Health Information Exchange especially in the Health Home and ACO continuum. We will be piloting the use of the NHIN Direct Protocol (http://wiki.directproject.org/home ) to transfer a C-CDA document containing Health Home Care Plan and Assessment Information Data will be sent from an Electronic Care Plan and Assessment Tool (TREAT) to an Email Client and possibly an EHR, via secure channels, demonstrating Provider to Provider Exchange. TREAT will demonstrate EHR-like maintenance of operational Care Plan and Assessment data, The LCC Enhanced C-CDA Document (Care Plan) sent to the Email Client will be human readable. If a Care Plan is sent to an EHR, we would like to demonstrate parsing the CarePlan elements into operational data. Diagram below shows overall architecture

4. Goal of the Pilot

5. GSIHealth Connect Dashboard

6. Patient List

7. Progress Notes

8. Assessment List

9. Assessment Sample

10. 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.

11. What Relevant Scenario (from the Use Cases) does your Pilot support? Exchange of Clinical Information from Provider/System/Careteam to Provider/System/Careteam

12. 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 • Receiving Entity Information System

13. Minimum Configuration • What is your current technical / infrastructure set up? See Diagram above • What systems / applications will you be using to conduct the pilot? • Electronic Health Record (EHR) system (optional) • Electronic Email Client • Electronic Care Plan and Assessment Tool • Health Information Service Providers (HISP) (2) • Existing interfaces • XDR as part of Direct • SMTP • IMAP/POP • New interfaces • well its not really new but not part of the widely known interfaces, the OASIS Notification interface

14. Timeline What is your proposed timeline given we want to wrap-up Pilots by Q4 2014

15. 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. • The pilot will be successful when • Human Readable C-CDA with Care Plan and Assessment Data reaches an email Client securely. • Human Readable C-CDA with Care Plan and Assessment Data reaches an EHR and is parsed into operational data. Since we already facilitate the exchange of Health Home data within the healthcare enterprise, it would be difficult to demonstrate further success at the organizational level. Rather we see the LCC effort as a way of standardizing our integration efforts, making the task of Health Home Data Exchange simpler and less risky.

16. In Scope / Out of Scope Our scope is defined by the boundaries of the Direct Project, using a Care Plan C-CDA document. We want health home providers, including Care Navigators to be immediately alerted to patient care plan changes and assessment data. This workflow may include Direct Messaging to an email client over a secure channel.

17. Risks & Challenges Finding an EHR who has Direct XD Capability and that can parse the new CarePlan elements in short order is the highest risk. Thus we have left that for a “bonus” feature.

18. Questions / Needs We are looking for an EHR vendor who has Direct XD Capability and is willing to try and parse out the elements of the Care Plan C-CDA document to obtain Care Plan and Assessment data.