Longitudinal Coordination of Care

Agenda

• Confirm Community Work Streams• Use Case and Policy Whitepaper Approach• Recommendation for Use Case scoping

Matching Appropriate Artifacts to WG Needs

• Need 1: Advance interoperability for the LTPAC community.– S&I process (Use Case, Harmonization, IG) provides actionable implementation

path for the LTPAC community– LLC WG would like implementable specifications to support pilots before the end of

2012

• Need 2: Influence and impact ongoing policy discussions– LCC WG has a strong set of LTPAC interoperability policy stakeholders at the table– White paper would allow for the articulation of a vision and objectives that would be

in a format that is familiar to policy-makers.

• Need 3: Support specific WG objectives– Continue to use LCC WG as the working forum to support the Challenge, Beacon

and VNSNY project objectives– Project-specific deliverables

• Need 4: Serve as a platform for responding to important and related standards activities– CARE Tool work (C-CDA structure review, Data Elements Review)– Analysis-supporting deliverables

Driving the Use Case vs. Driving Policy

Use Case Principles• Stay focused on specific transactions• All sections directly support the

selected transactions• Document designed for business and

technical implementers (not policy makers)

• Get the best possible coverage of likely overall data elements with the least number of specifically defined transactions

Interop Policy Whitepaper• Detailed articulation of environment• Detailed articulation of current efforts• CARE Tool work implications• NPRM response and implications• Vision for Longitudinal Coordination

of Care• Articulate how S&I first LCC Use

Case supports vision and what will come next

Broad Array of Overall Transactions

• 169 Total Transactions across 13 identified trading partners

• 91 Priority Transactions identified (Green)• 20 Second priority identified (Blue)• 58 transactions out of Scope (Red)• Would represent over 91 user stories in Use Case• ToC Use Case 1.1 had 5 user stories and 4 defined

data exchanges (discharge instructions, discharge summary, clinical summary, specialist clinical summary)

Complex Longitudinal View of TransitionsTransitions to (Receivers)

Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/

From Acute Care Services In patient PCMH Community Based Family

(Senders) Hospitals Facilties Services Organizations

In patient

ED

Out pt services

BH Facilities

LTAC

IRF

SNF/ECF

HHA

Hospice

Office basedCliniicians

CommunitybasedBH sites

CBOs

Patient/Family

Out High Lesserof Priority Priority

Scope

Scoping Proposal for Discussion

• Initial Use Case reuses as much of the transition summaries as possible– Seven existing transactions (see next slide)– Only data necessary for receiving clinician to begin safe care and/ or data

available in current summaries– Examine Consolidated CDA document templates for discharge/instructions and

referrals (see next slide)• Review CEDD core data elements• Identify essential but missing data elements

– Reuse consultation request and consultation summary

• Focus on subset of Home Health Agency and SNF transactions with the goal of aligning to ToC

• Add a Scenario 3 to articulate 485 requirements• Continue to add incrementally improve and add transactions over time

Seven Initial Transactions

Transitions

1. Acute care to HHA (build on ToC Discharge Summary and Discharge Instructions)

2. Acute care to SNF (build on ToC Discharge Summary and Discharge Instructions)

3. HHA to acute care (build on ToC Discharge Summary and Discharge Instructions)

4. SNF to acute care (build on ToC Discharge Summary and Discharge Instructions)

5. HHA or SNF to SNF or HHA (build on ToC Discharge Summary and Discharge Instructions)

Referrals

6. HHA or SNF to specialist or outpatient services (build on Referral and Results Summaries for PCP to specialist)

Patient Communications

7. Copy all summaries above to patient/care giver PHR

Essential Data Elements

• Core data elements common to all transitions of care– Demographics/Patient Identifiers– Contact information for the Sending site and Clinician– Allergies– Medications– Current active problems– Alerts and Precautions– Advance Directives– Reason for transfer

• Receiving Site-specific data elements – Role-specific data elements required by designated receivers (MD, RN, Therapist, etc)– Reason for transfer

• Emergent evaluation and treatment– Ability to comprehend and consent to treatment– Baseline function and cognition with observed changes– Specific clinical issues requiring evaluation/treatment

• Elective evaluation and treatment– Sufficient information to manage an unanticipated change in clinical condition

• Permanent transfer– HHA specific data elements– Facility specific data elements

• Patient specific data elements with detail as required by each site

Proposed Scope of LCC Use CaseTransitions to (Receivers)

Transitions In Patient ED Out patient BH LTAC IRF SNF/ECF HHA Hospice PCP BH Community Patient/

From Acute Care Services In patient PCMH Community Based Family

(Senders) Hospitals Facilties Services Organizations

In patient

ED

Out pt services

BH Facilities

LTAC

IRF

SNF/ECF

HHA

Hospice

Office basedCliniicians

CommunitybasedBH sites

CBOs

Patient/Family

Out High Lesserof Priority Priority

Scope

Scenario 1:7 (?) User Stories

Scenario 2:7 (?) User Stories running in parallel to Scenario 1

Scenario 3:Transactions and functional requirements identified based on Homecare Use Case (485)

Does this strategy promote the LCC WG Vision?

Vision

• Support and advance interoperable electronic health records systems across the long-term and post-acute care spectrum with the ability to electronically exchange clinical information with other providers

• Support and advance patient-centric interoperable health information exchange across the long-term and post-acute care spectrum

• Promote Longitudinal Care Management between all relevant sites and providers built around the needs and experiences of the patient

• LTPAC influences in Meaningful Use Stage 3