Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting August 6, 2013 1.

Longitudinal Coordination of Care (LCC) Workgroup (WG)

LCC All Hands Meeting

August 6, 2013

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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 Participants 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 Participants

Agenda

• Summary of LCC WG Accomplishments for June and July 2013

• LCC WG Timeline

• LCC Use Case 2.0

• HL7 Ballot Tiger Team

• eLCC – Transition of Care C-CDA Revisions

• Care Plan C-CDA Development

• Next Steps

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Summary of LCC WG Accomplishments• Achieved consensus voting on LCC Use Case 2.0: Care Plan

Exchange• LCC HL7 Tiger Team developed and submitted recommendations

on Care Plan DAM to HL7 Patient Care WG• HITPC MU3 SWG Meetings

– MU3 recommendations for Care Summary reference IMPACT ‘Transfer of Care’ dataset: consult note, transfer summary and consultation request

– Recommendations to be presented to HITPC on August 7th

• Lantana C-CDA Revisions Project (Transitions of Care and Care Plan/ Home Health Plan of Care)– Developed draft Implementation Guide/ Ballot Package for ‘Transfer of

Care’ and ‘Care Plan/HHPoC’– Ballot Package to be submitted for HL7 Balloting on August 15th

Summary of LCC WG Accomplishments (cont’d)• Continued LCC Stakeholder & Pilot Engagement Activities

– Participated in LTPAC HIT Summit June 16 to 18

– Call for Pilot Participation! New wiki site and pilot planning documents posted at: http://wiki.siframework.org/LCC+Pilot+Plan

– Conducted Pilot Overview Session for ONC State HIE LTPAC CoP (Community of Practice)

Longitudinal Coordination of Care

Workgroup

Longitudinal Coordination of Care

Workgroup

Patient Assessment

Summary (PAS SWG

LTPAC Care Transition SWG

Longitudinal Care Plan SWG

• Engage directly with HL7 to establish the standards for the exchange of patient assessment summary documents

• Inform the development of the Keystone Beacon PAS Document Exchange

• Identify the key business and technical challenges that inhibit LTC data exchanges

• Define data elements for long-term and post-acute care (LTPAC) information exchange using a single standard for LTPAC transfer summaries

• Identify standards for an interoperable, longitudinal care plan* which aligns, supports and informs person-centric care delivery regardless of setting or service provider

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LCC Sub Workgroups (SWG)

*Care Plan standards will enable providers to create, transmit and incorporate care plans and needed content for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers.

COMMUNITY-LED INITIATIVE

HL7 Tiger Team SWG

• Educate the LCC Community on related HL7 processes, framework and evolving standards relevant to LCC

• Gather and generate comments for HL7 Care Plan related evolving standards (Care Coordination Services & Care Plan Domain Analysis Model (DAM))

Work Group SchedulesLCC WG

SWG Meeting LCC Leads Date/ Time Projects

LTPAC SWG Larry GarberTerry O'Malley

Weekly Mondays11am - 12pm EST

C-CDA: Transfer Summary, Consult Note, Referral Note

LCC HL7 Tiger Team

Russ Leftwich Weekly Wednesdays 11am - 12pm EST

LCC WG comments for HL7 Care Plan DAM

LCP SWG Bill RussellSue MitchellJennie Harvell

Weekly Mondays AND Thursdays 5pm - 6pm EST

C-CDA: Care Plan, Home Health Plan of Care

HL7 WGSWG Meeting HL7 Lead Participating LCC

MembersDate/ Time Projects

HL7 Patient Care WG Russ LeftwichElaine Ayers Stephen Chu Michael Tan Kevin Coonan

Susan Campbell Laura H Langford Lindsey Hoggle

Bi-weekly Weds5pm - 6pm EST

Care Plan DAMCare Coordination Services (CSS)

HL7 Structured Documents WG

Bob DolinBrett Marquard

Sue MitchellJennie Harvell

Weekly Thursdays10am - 12pm EST

CDA (various)

HL7 SOA WG CCS Project Jon Farmer Enrique Meneses (facilitators) Stephen Chu

Susan Campbell Weekly Tuesdays 5pm - 6pm EST

Care Coordination Services (CSS)

HL7 Patient Generated Document

Leslie Kelly Hall Weekly Fridays12pm - 1pm EST

Patient-authored Clinical Documents

LCC WG Timeline: Mar 2013 – Dec 2013

Mile

ston

es

Pilot Site Identification & Engagement

Care Plan C-CDA Revisions Complete

HL7 Project Scope Statement Due HL7 Intent to Ballot Due

HL7 Fall Ballot Open

NY Pilots Monitoring

LCC Care Plan Use Case 2.0 Development & Consensus

IMPACT ToC Pilot Monitoring

IMPACT Care Plan Pilot Monitoring

HL7 Ballot Publication

ToC IGs Development (Transfer Summary, Referral Note, Consult Note)

ToC C-CDA Revisions Complete

HL7 Final Ballot Due

LCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMS

Care Plan/ Home Health Plan of Care IG Development

HL7 Ballot Package Development

HL7 Ballot & Reconciliation

FACA LCC WG Briefings

LCC & HL7 Care Plan Coordination

IMPACT Go-Live NY Care Coordination Go-Live

LCP SWG LCC Use Case 2.0 –

Interoperable Care Plan Exchange

Use Case 2.0 – Interoperable Care Plan Exchange• Focus on the functional requirements for an Interoperable Care Plan

exchange

– Will feed into the Care Plan component of the work Lantana is doing for the Aug/Sept HL7 Ballot

• Achieved Consensus on July 24, 2013

– 28 total votes (LCC has 111 Committed Organizations)

• 19 Yes

• 8 Yes with Comments

• 1 Objection with Comments

• LCC Use Case 2.0 Wiki Page: To view Consensus and Votes (http://wiki.siframework.org/LCC+WG+Use+Case+2.0)

– Final Use Case Available here

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LCC HL7 Tiger Team SWG Update

Lead: Dr. Russ Leftwich

Overview

• Tiger Team Objectives

• Importance of LCC Engagement with HL7

• Harmonize Care Plan DAM and provide comments

• Care Plan DAM has been submitted for ballot

Tiger Team Objectives

• Educate the LCC Community on the HL7 processes and framework

• Educate the LCC Community on the HL7 Ballots relevant to LCC

• Generate comments to the Care Plan Domain Analysis Model (DAM) for September 2013 ballot to align LCC Objectives with HL7 Work Products

Importance of LCC and HL7 Coordination

• Shared glossary of terms• Alignment of the various care plan components between LCC and

HL7 (Health Concerns, Goals, Interventions, Risks, Barriers, Associations, Priorities, etc.)

• Recommendations of data elements/components to be added to or updated within DAM in order to support care plan exchange across multiple disciplines

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• The Domain Analysis Model (DAM) was created by the HL7 Patient Care WG (PCWG)

• The goal of LCC was to review the DAM and provide input from a provider perspective and to harmonize elements that overlap with LCC efforts around care plan exchange and workflow• LCC Tiger Team presented ongoing recommendations and comments

during PCWG meetings prior to ballot submittal• The majority of comments/recommendations presented by the LCC

Tiger Team were implemented in the DAM by the PCWG

Harmonize Care Plan DAM

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• Review of final balloted Domain Analysis Model:

Wednesday, Aug. 14 at 11am ET (NOTE: This will be the final LCC Tiger Team meeting)

• Overview of final DAM recommendations made to PCWG available on LCC Tiger Team wiki:

http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG• Past Meeting Artifacts available on the LCC Wiki:

http://wiki.siframework.org/LCC+-+Meeting+Artifacts

Balloted DAM Review

LTPAC SWGeLCC – Transitions of Care C-

CDA Revisions

Leads: Mike Tushan & Zabrina Gonzaga (Lantana)

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Objective

• Develop national data standards for information exchange of a Longitudinal Coordination of Care Dataset.

• Expand on the document types and templates to include HL7 Implementation Guides (IGs) for new and enhanced document types:

• New: Transfer Summary

• New: Consultation Request

• Enhanced: Consult Note

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Background

• Improving Massachusetts Post Acute Care Transfer (IMPACT) project

• Resulted in a Transfer of Care Dataset: 500 data elements that are necessary during a patient transfer of care

• Data set is organized into 5 groups: • Transfer of Care• Consultation Request • Shared Care Encounter Summary• Care Plan • Home Health Plan of Care

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Stakeholders and Participants

• NYeC: New York eHealth Collaborative• CCITI NY: Continuum of Care Improvement Through Information

New York • Healthix, Inc• ONC S&I Framework • IMPACT Project team• HL7 International Structured Documents Work Group/ Patient Care

WG• ASPE (Care Plan)

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Deliverables

• Project Scope Statement (approved by Structured Docs WG)• Functional Specification• Templates: create up to 30 new CDA templates • Sample Files: sample files to accompany each document type• Schematron: validation rules• HL7 CDA IG(s): final implementation guide(s) for DSTU*

• HL7 Ballot Package • HL7 Ballot Reconciliation• Published HL7 CDA IG

*Draft Standard for Trial Use

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Project Timeline

AprTask 1: Background

Analysis• S&I stakeholder meetings• Identify relevant precedentTask 2: Functional

Specifications/Setting Specific Rules

• S&I stakeholder meetings• Develop mapping sheet• Define setting specific

rules

May Jun Jul Aug Oct Nov DecSep

Task 4: Templates• Develop templates

Meetings

Deliverables

LEGEND:

Task 6: Ballot Material• Produce schematron

validation rules• Develop IG• Review IG with Tiger Team• Deliver IG to S&I• Update and submit IG and

materials for ballotTask 7:

Reconciliation/Publication

• Develop ballot comment tracking table

• Lead reconciliation meetings

• Publish IG

HL7 Reconciliation meeting frequency and dates TBD

DraftDraft

© 2011 Lantana Consulting Group, www.lantanagroup.com23

LCC LTPAC Meeting Timeline

Jul 22: Nutrition & Plan of Care Artifacts

Jul 29: Documents-Transfer, Consult, Referral

Jul 29: C-CDA to Technical Writers (Lantana)

Aug 5: Highlight Incorporated Feedback

Aug 8: Post to C-CDA to HL7 List-Serv for review (HL7)

Aug 12: Ballot “How to”

Aug 15: Approval to go to ballot (HL7)

Aug 16: Ballot cycle opens(HL7)

LCP SWGCare Plan C-CDA

Development

Leads: Sarah Gaunt & Gaye Dolin (Lantana)

Overview

• Care Plan Document Type (NEW)– Goals Section (NEW)– Health Concerns Section (NEW)– Health Status Evaluations/Outcomes Section (NEW)– Interventions Section (V2)

• Discussed the following NEW Entry-Level Templates:– Act Reference– Author Participant– Goal Observation

• Patient Priority Preference• Provider Priority Preference

– Health Concern Act– Intervention Act– Outcome Observation– Prognosis Observation– Progress Toward Goal Observation

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IS CAUSE OF

HAS SU

PPORT

HAS

REA

SON

Relationships (Happy Path)

Health Concern

[mood EVN]

Goal [mood GOL]

Outcome Observation [mood EVN]

Intervention [mood: INT/ RQO/ etc.]

[mood: EVN]

Observation [mood EVN]

REFERS TOREFERS TO

HAS COMPONENT

EV

ALU

ATES

Progress Toward Goal Observation[mood EVN]

SUPP

ORTS

REFERS TO EVALUATIONS/OUTCOMES

HAS COMPONENT


• The following slides give a high level overview of the Care Plan templates that have been developed

• For further details, please see the latest C-CDA IG

Care Plan templates


• Care Plan

Care Plan Document-Level Template

Contained By: Contains:

Goals Section (NEW) Health Concerns Section (NEW) Health Status Evaluations/ Outcomes Section (NEW) Interventions Section (V2)


• Goals Section

• Health Concerns Section

• Health Status Evaluations/Outcomes Section

• Interventions Section


Care Plan (NEW) (required)

Outcome Observation (NEW)


Care Plan (NEW) (required)

Health Concern Act (NEW) Health Status Observation (V2)


Care Plan (NEW) (required) Goal Observation (NEW)

Care Plan Section-Level Templates


Care Plan (NEW) (required) Progress Note (V2) (optional)

Intervention Act (NEW)


• Goal Observation

Care Plan Entry-Level Templates


Goals Section (NEW) (required) Intervention Act (NEW) (optional) Outcome Observation (NEW) (optional)

Act Plan (V2) Author Participant (NEW) Encounter Plan (V2)

Health Concern Act (NEW) Observation Plan (V2) Outcome Observation (NEW)

Patient Priority Preference (NEW) Procedure Plan (V2) Provider Priority Preference (NEW)

Substance Administration Plan (V2) Supply Plan (V2)


• Health Concern Act (truncated – see C-CDA IG for full list of Contained templates)



Health Concerns Section (NEW) (required)

Goal Observation (NEW) (optional)

Act Reference (NEW) Allergy - Intolerance Observation (V2) Assessment Scale Observation

Author Participant (NEW) Caregiver Characteristics Characteristics of Home Environment (NEW)

Cognitive Abilities Observation (NEW) Cognitive Status Observation (V2) Cultural and Religious Observation (NEW)

Current Smoking Status (V2) Diet (NEW) Encounter Diagnosis (V2)

Family History Organizer Functional Status Observation (V2) Highest Pressure Ulcer Stage

Hospital Admission Diagnosis (V2) Mental Status Observation (NEW) Number of Pressure Ulcers Observation

Nutritional Status Observation (NEW) Patient Priority Preference (NEW) Postprocedure Diagnosis (V2)

Pregnancy Observation Preoperative Diagnosis (V2) Problem Concern Act (Condition)

Problem Observation (V2) Provider Priority Preference (NEW) Reaction Observation (V2)

Result Observation (V2) Result Organizer (V2) Self-Care Activities (ADL and IADL) (NEW)

Sensory and Speech Status (NEW) Social History Observation (V2) Substance or Device Allergy - Intolerance Observation (V2) Tobacco Use (V2)

Vital Sign Observation (V2) Wound Observation (NEW)


• Outcome Observation



Health Status Evaluations/ Outcomes Section (NEW) (required) Goal Observation (NEW) (optional)

Act Reference (NEW) Author Participant (NEW) Goal Observation (NEW) Progress Toward Goal Observation (NEW)


• Intervention Act (truncated – see C-CDA IG for full list of Contained templates)



Interventions Section (V2) (optional)

Act Plan (V2) Act Reference (NEW) Advance Directive Observation (V2)

Author Participant (NEW) Encounter Activity (V2) Encounter Plan (V2)

Goal Observation (NEW) Immunization Activity (V2) Instruction (V2)

Medication Activity (V2) Non-Medicinal Supply Activity (V2) Nutrition Recommendations (NEW)

Observation Plan (V2) Procedure Activity Act (V2) Procedure Activity Observation (V2)

Procedure Activity Procedure (V2) Procedure Plan (V2) Substance Administration Plan (V2)

Supply Plan (V2)


• Blog post by Grahame Grieve

• Identifiers in CDA Documents

• Act Reference template

Referencing Objects internally

LCC WGNext Steps

Initiative Coordinator: Evelyn

Next Steps

• Lantana to publish Transitions of Care and Care Plan C-CDA Implementation Guide for HL7 Ballot Voting

– Fall Ballot Opens August 16th

– Ballot Reconciliation starts end of September

• Launch LCC Pilot WG on Sept. 16th

– LCC Committed Pilots: MA and NY

– Continue to conduct outreach to potential pilot sites: MD, CT, TN

• Monitor IMPACT Project Go-Live in September

• Monitor NY Downstate Care Coordination Project Go-Live in October

• Review final Patient Care WG Care Plan DAM and submit any necessary ballot comments

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Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting August 6, 2013 1.

Documents

Transcript of Longitudinal Coordination of Care (LCC) Workgroup (WG) LCC All Hands Meeting August 6, 2013 1.