Longitudinal Coordination of Care (LCC) Pilots Template

1. Longitudinal Coordination of Care (LCC)Pilots Template IMPACT 8/19/2013

2. Pilot Team

3. Full Disclosure? We have no apparent or real conflicts of interest to disclose

4. 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

5. Which of the 5 C-CDA Revisions isbeing Piloted

6. Relevant Scenario (from the Use Cases) supported by Pilot Exchange of Clinical Information from Provider to Provider

7. 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)

8. Configuration – SEE sites CCD+ = Transfer Summary PCP CCD+ CCD+ KeyHIE Transform SEE CCD+ MDS Hospital Billing Program MDS Nursing Facility

9. CCD Document Outbound LAND Transformations “Transfer of Care”CDA Document XML Document HL7 v2.5.1 ORU LAND Converter CCD Document MDS XML Document OASIS XML Document

10. Converter Inbound Configurations

11. Text Document Inbound LAND Transformations HL7 v2.5.1 MDM  CDA Document CCD   LAND Converter Non-CDA Document HL7 v2.5.1 ORU   XML  Non-CDA Document 

12. Timeline

13. IMPACT Success Criteria

14. Out of Scope Incorporating discrete data elements into EHR beyond those in the CCD

15. 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

16. Questions / Needs None

17. 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

18. Appendix A: LCC Timeline LCC WG Timeline: Mar 2013 – Dec 2013 LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS LCC & HL7 Care Plan Coordination LCC Care Plan Use Case 2.0 Development & Consensus ToC IGs Development (Transfer Summary, Referral Note, Consult Note) HL7 Ballot & Reconciliation Care Plan/ Home Health Plan of Care IG Development HL7 Ballot Package Development Pilot Site Identification & Engagement IMPACT ToC Pilot Monitoring NY Pilots Monitoring FACA LCC WG Briefings ToC C-CDA Revisions Complete Care Plan C-CDA Revisions Complete HL7 Fall Ballot Open HL7 Project Scope Statement Due HL7 Ballot Publication Milestones HL7 Intent to Ballot Due NY Care Coordination Go-Live IMPACT Go-Live HL7 Final Ballot Due