Longitudinal Coordination of Care (LCC)

Pilots Documentation

GSIHealth: Health Home Data Exchange via Direct01/06/2013

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

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Name Role Email

Vincent Lewis Architect Vincent.lewis@gsihealth.com

Parag More Technical Lead Parag.more@gsihealth.com

Lee Jones Internal Stakeholder Leroy.jones@gsihealth.com

Sandeep Subramanian Integration Lead Sandeep.Subramanian@gsihealth.com

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

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Goal of the Pilot

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GSIHealth Connect Dashboard

Patient List

Progress Notes

Assessment List

Assessment Sample

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

Care Plan Mental Health

Home Health Plan of Care Mental Health

What Relevant Scenario (from the Use Cases) does your Pilot support?

• Exchange of Clinical Information from Provider/System/Careteam to Provider/System/Careteam

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

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

Timeline• What is your proposed timeline given we want to wrap-up Pilots by

Q4 2014

Milestone Target Date Responsible Party

Pilot with email recipient Jan 30, 2014 GSIHealth (Vince Lewis)

Pilot with EHR RecipientMarch 30 2014 (maybe earlier if HIMSS is involved)

unknown

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.

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.

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.

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.