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HL7 FHIR DevDays 2020, Virtual Edition US, June 15–18, 2020 | @HL7 @FirelyTeam | #fhirdevdays | www.devdays.com/us

PACIO Project and Interoperable Transitions of Care

Sean Mahoney, MITRE Nancy Lush, Patient Centric Solutions

Agenda• Discuss Post Acute Care (PAC)

• Introduce PACIO Project

• Discuss assessments used in PAC

• Review the PACIO-eLTSS use case

• Highlights from the Connectathon

• Next Steps

Why is Post-Acute Care Important?H

ospitaliz

ation

PAC (45%)

HHA (47.8%)

HHA Only (72.3%)

Acute (24.5%)

SNF (2.5%)

IRF (0.4%)

LTCH/ LTCH SN (0.2%)

SNF (42.1%)

SNF Only (38.7%)

HHA (42.2%)

Acute (18.8%)

IRF (0.3%)

LTCH/ LTCH SN (0.1%)

IRF (8.4%)

LTCH/ LTCH SN (1.7%)

No PAC services (55%)

• APPROXIMATELY 33,000 PAC PROVIDERS IN THE U.S. CARE FOR 6.9 MILLION BENEFICIARIES COSTING OVER $73.8 BILLION ANNUALLY

• AFTER A HOSPITALIZATION, 45% OF PATIENTS REQUIRED PAC SERVICES. HHA AND SNFS WERE THE MOST UTILIZED SERVICES AFTER A HOSPITAL ADMISSION

Primary goal:

Kicking off on February 24, 2019, the PACIO Project endeavors to establish a framework for the development of a Fast Healthcare

Interoperability Resource (FHIR) technical implementation guide and Reference Implementation that will facilitate HIE through

standards-based application programming interfaces (APIs) 1

Purpose:

Consensus-based approach to advance interoperable health information exchange (HIE) between post-acute care providers, patients,

and other key stakeholders across health care and to promote HIE among policy makers, standards organizations, and industry, through

open source FHIR IGs and vendor-based reference implementations

Problem Statement:

Care coordination, when a person transitions between healthcare settings, including ambulatory care, acute care, Long term post-

acute care (LTPAC), and home & community-based services (HCBS), is often fragmented and can lead to poor health outcomes,

increased burden and increased costs. Interoperable health information exchange has the potential to improve patient and provider

communications and supports access to longitudinal health information that enables improved efficiencies, improved quality of care,

and improved health outcomes. Data should be usable across the continuum of care, and beyond the traditional healthcare system –

into the community.1

1https://github.com/paciowg/PACIO-Project

PACIO Project

PACIO Project Participants

http://pacioproject.org

PAC Patients Have Complex Situations

Source: CMS DCPAC 5

Potential Points of Failure during Transitions of Care

•Poor communication across care providers, including outpatient

•Increased Cost and Provider Burden

•Reliance on patient recall during periods of high stress

Background: CMS AssessmentsCMS requires Post-acute care (PAC) providers to complete and submit assessments at specified intervals. The assessment instruments that collect this data are:

• Long-Term Care Hospital CARE Data Set (LCDS) for LTCHs

• Minimum Data Set (MDS) for SNFs

• Outcome and Assessment Information Set (OASIS) for HHAs

• Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI) for IRFs

• Functional Assessment Standardized Items (FASI) for HCBS

Primary goal:

The ultimate goal is to leverage HIT standards and electronic information sharing to improve the delivery and coordination of community-based

care provided under programs such as Medicaid Waivers.

Purpose:

This effort aims to provide guidance to access and exchange community-based service information alongside the medical interventions for a

comprehensive picture of a person’s care.

Problem Statement:

The adoption and use of Health IT and quality measurement for community-based long-term services and supports is limited. Limitations

include:

• lack of uniformity in the terminology and definitions of data elements, including those important to the beneficiary, needed for assessments

and service plans used across and between community-based information systems, clinical care systems and personal health record systems;

• insufficient business and/or financial incentives for service providers to acquire and use Health IT to support coordination of services;

• minimal national standards for quality measurement in LTSS outcomes;

• lack of consensus on the inter-relationships between a beneficiary’s plans across care, services and supports; and

• lack of evidence and understanding of how Health IT may benefit the beneficiary and encourage their adoption and use of Health IT.

• lack of established best practices for complying with legal security and privacy requirements when electronically exchanging data between

covered clinical entities and non-clinical entities providing community-based services.1

1 https://wiki.hl7.org/ELTSS:FHIR_IG_Proposal

Background: Electronic Long-Term Services and Support (eLTSS)

PACIO-eLTSS Use Case Diagram

Scene 1

Scene 2

Scene 2

Scene 2

Scene 3

Scene 3

Scene 3

Scene 4

Scene 5

Scene 6

PACIO-eLTSS System Diagram

Scene 1 – At HomeMs. Betsy Smith Johnson receives home community-based services (HCBS) services at home. A social worker documents eLTSS data including care plan and goals. eLTSS data is pushed to the Data Hub.

Server Viewer Push to Data Hub

Scene 2 – Hospital AdmissionBetsy experiences a fall at home and is admitted to the hospital for surgery. After the surgical intervention, physical, occupational & speech language pathology therapists (PT/OT/SLP) assess Betsy and recommended to continue her therapy in a skilled nursing facility (SNF). Cognitive and functional assessments completed and documented in the hospital EHR are pushed to the Data Hub.

Selects the EHR Patient for the PAC Assessment

Queries the pseudo-DEL for the list of available PAC Assessments

Converts the completed PAC Assessment QuestionnaireResponse to Structured Data Capture (SDC)

Sends the converted SDC QuestionnaireResponse to the EHR

Scene 3 – Skilled Nursing FacilitySNF admits for PT/OT/SLP services for 14 days. The SNF retrieves the eLTSS data and assessment data from the Data Manager to inform her care. Functional and cognitive status is assessed on admission and discharge and pushed to the Data Hub.

Scene 4 – CMS Data Element LibraryAssessment application pulls the standardized assessment data from the CMS DEL and presents forms to the clinician performing the assessments.

Scene 5 – Home and Community Based ServicesAfter 14 days, Betsy is ready for discharge back home. The HHA agency coordinator reviews the patient's data from the Data Manager as part of the triage process.

Scene 6 – Family CaregiversAs she moves across the continuum of care, Betsy and her authorized family caregiver access the eLTSS care plan and assessment data through a patient web application.

Data follows the Patient

• Transitions of care requires care collaboration

• Read/Write FHIR endpoint• Relevant data exchange across the

continuum of care• Current record always available• Demonstrated Dynamic Seamless

Data Exchange across care providers

• Improved care for patient with multiple chronic conditions• Reduced provider burden in sharing data• Engage both the patient and their family in improving the

patient’s health

Results of Connectathon (1/2)• Over 60 participants attended the track

• Successfully integrated multiple IGs, developed by several independent organizations, each focusing on a different area of healthcare, into a single interoperable use case

•While prior large-scale demos have been done under a single organization umbrella (e.g. Da Vinci Project), this effort demonstrated:

• Some integration occurred successfully first time without testing prior to Connectathon, providing a testament to the interoperability of the IGs

• IGs can support both the reading and writing of data so critical information can travel with the patient so they can receive the best care

• Comprehensive data exchange across the continuum of care

Results of Connectathon (2/2)•Patient Centric Solutions’ and MITRE’s clients retrieved PACIO and eLTSS data from the Altarum server

•Altarum’s successful implementation using the PACIO/eLTSS server satisfies the requirement of a third implementation of the PACIO IGs for the September 2020 ballot

•Coordinated Care track exchanged PACIO data as it relates to:• Use of multiple FHIR resources and FHIR IGs used to conduct a social risk screening, eReferral,

functional assessment, and eLTSS plan query and exchange

• Completing and exchanging a functional & cognitive assessment status

• Exchanging an eLTSS plan

•Clinical Reasoning track calculated eCQM (CMS 149v9 Dementia: Cognitive Assessment) using PACIO data • Demonstrated the potential of analytics for PACIO data

Next Steps• Further collaboration opportunities for future Connectathons (e.g. Da Vinci Prior Authorization, Clinical Reasoning)

• More vendor participation (replace reference implementations with a real vendor systems)

• September 2020 HL7 Balloting of Cognitive and Functional Status IGs

• Extend use case to add more interoperability• Demonstrate at September 2020 HL7 Connectathon

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Join us at: pacioproject.org

The PACIO Project is a collaborative effort to advance interoperable health data exchange between post-acute care (PAC) and other

providers, patients, and key stakeholders across health care and to promote health data exchange in collaboration with policy makers, standards organizations, and industry through a consensus-based

approach.

Learn and share more about the PACIO Project at www.PACIOproject.org

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Background: Impact Act• In support of the 2014 Improving Medicare Post-Acute Care Transformation Act (IMPACT Act), CMS created the Data Element Library (DEL) to support standardization and interoperability of patient assessment data elements

• The DEL is the centralized resource for CMS assessment instrument data elements (e.g. questions and responses) and their associated health information technology (IT) standards; the DEL does not contain any patient level personal health information (PHI)

• CMS prioritized cognitive and functional status as an area of clinical importance in need of standardization

1 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures

System RolesRole Description

Data Element Library (DEL) • Provides CMS standardized assessment data elements via FHIR API

Case Management System/ Care Coordinator

• Long-Term Care Plan App - captures care plan and goals for the patient• eLTSS Server - FHIR-based HIT system that contains the eLTSS care plan and goals for the patient and

pushes that data to the Data Manager using the eLTSS IG

Care Setting A: Hospital • PAC Assessment Application - FHIR-based assessment application that retrieves the standardized assessment data elements from the DEL and captures the cognitive and functional status data for the patient

• "EHR"/Server/Database - FHIR-based HIT system that stores cognitive and functional status data from the assessment application for the patient and pushes that data to the Data Manager using the PACIO Functional Status and PACIO Cognitive Status IGs

Health Data Manager • FHIR-based HIT system that collects data from the Care Coordinator and Healthcare Setting A using the eLTSS and PACIO Functional Status and PACIO Cognitive Status IGs

• Authorization/Identity Server - handles authentication and identity management

Care Setting B: SNF • PAC Assessment Application - FHIR-based assessment application that retrieves the standardized assessment data elements from the DEL and captures the cognitive and functional status data for the patient

• eLTSS/PACIO Server - Client HIT system that receives patient’s eLTSS, cognitive and functional status data from the Data Manager system

Care Setting C: HHA • Care Coordinator System - updates the care plan and goals• eLTSS/PACIO Server - Client HIT system that receives patient’s eLTSS, cognitive and functional status

data from the Data Manager system, for display to receiving clinician

Patient/Family Mobile/Web Client

• FHIR-based web/mobile application that receives patient’s eLTSS, cognitive and functional status data from the Data Manager for display to a patient or family member

HL7 Connectathon OverviewWhat is a Connectathon?• An opportunity for multiple vendors to review Implementation Guides (IG), test the client and/or

server in a structured environment and provide constructive feedback

• A Connectathon can be described as a “test kitchen” and the Implementation Guide as a “recipe” to be tested and refined by participants

HL7 FHIR Connectathon 24• Hosted from Wednesday, May 13 till Friday, May 15th

• HL7’s first virtual Connectathon

• 667 people attended/participated, breaking the prior attendance record of 413 in September 2019

• PACIO Project hosted the PACIO-eLTSS Post-Acute Care Transition Summary Track• Collaborated with the electronic Long-Term Services and Support (eLTSS) group to demonstrate the use of Home and

Community Based Service (HCBS) and PAC data elements in one integrated use case, consisting of 6 scenes, spanning the health care continuum

• PACIO Project also participated in the Care Coordination Track and provided sample data to the Clinical Reasoning Track