longitudinal coordination of care (lcc) workgroup (wg) review of hitpc mu stage 3 request for...

Longitudinal Coordination of Care (LCC) Workgroup (WG)

Review of HITPC MU Stage 3 Request For Comments (RFC)

January 09, 2013

1

Overview

• S&I Longitudinal Coordination of Care (LCC) Overview• Key Accomplishments of the LCC WG• Care Plan & Meaningful Use• Health IT Policy Committee (HITPC) MU3 Request for

Comment (RFC)– RFC Care Plan Questions– S&I LCC WG Care Plan Considerations

• Summary & Discussion

• Next Steps:– Expanded collaboration and participation

2

S&I Longitudinal Coordination of Care (LCC) Workgroup

• Initiated in October 2011 as a community-led initiative with multiple public and private sector partners, each committed to overcoming interoperability challenges in long-term, post-acute care (LTPAC) transitions

• Supports and advances interoperable health information exchange (HIE) on behalf of LTPAC stakeholders and promotes LCC on behalf of medically-complex and/or functionally impaired persons

• Goal is to identify standards that support LCC of medically-complex and/or functionally impaired persons that are aligned with and could be included in the EHR Meaningful Use Programs

• Seeks to influence Meaningful Use Stage 3• Consists of three sub-workgroups (SWGs):

– Longitudinal Care Plan (LCP)

– LTPAC Care Transition

– Patient Assessment Summary (PAS)

3

Longitudinal Coordination of Care Workgroup

Longitudinal Coordination of Care Workgroup

Patient Assessment Summary (PAS SWG

LTPAC Care Transition SWG

Longitudinal Care Plan SWG

• Providing subject matter expertise and coordination of SWGs

• Developing systems view to identify interoperability gaps and prioritize activities, and align identified standards with the EHR MU Program

• 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

4

LCC Sub Workgroups (SWG)

*Care Plan will enable providers to create, transmit and incorporate goals, objectives, and outcomes for the benefit of medically complex and/or functionally impaired individuals, their families and caregivers.

COMMUNITY-LED INITIATIVE

Key Accomplishments

1. LCC Use Case. Outlines three scenarios for health information exchanges between LTPAC and acute care settings

2. LCC Whitepaper. Meaningful Use Requirements For: Transitions of Care & Care Plans For Medically Complex and/or functionally Impaired Persons.

3. Transitions of Care Data Set. Developed 480+ data elements needed by receiving clinicians to safely and appropriately care for patients at times of transitions of Care.

4. Stage 2 MU C-CDA Refinements. Supported and advanced, with HL7, refinements to C-CDA for interoperable exchange of Functional Status, Cognitive Status, & Pressure Ulcer

5. HL7 Balloted Patient Assessment IGs (avail. DEC2012)– CDA R2 Questionnaire Assessment – Consolidated CDA LTPAC Summary (formerly Patient Assessment

Summary)5

6

CARE PLANS & MU

Jennie Harvell, ASPEJennie.harvell@hhs.gov

Why Exchange of a Care Plan is Important

• The S&I LCC WG believes that:– The exchange of a care plan is needed to support coordination

and continuity of care, particularly on behalf of medically complex/functionally impaired persons; and

– The concept of “Care Plan” and its component parts needs to be unambiguously defined for interoperable exchange.

• The LCC WG has been considering advancing to the HITPC recommendations that MU3 include requirements for the interoperable exchange of a care plan and component parts

7

We need your input on care plan components necessary to support Transitions of Care and Coordination of Care.

Information Exchange Needs to Support Transitions and Coordination of Care

• HIE at times of transition in care (ToC) and referrals in care is critically important to support care coordination, particularly on behalf of medically complex/functionally impaired persons

• MU2 requirements identify some required data elements that should be included in Summary Care Records at times of ToC and referrals in care

8

MU2 Requirements and Exchange of Care Plan Content

MU2 includes requirements related to the exchange of care plans:•Care plan content, if known, is required in the Summary Care Record for each transition of care or referral•Care plan content required in the Summary Care Record includes:

– Care plan field, including goals and instructions.

– Care team including the primary care provider of record and any additional know care team members beyond the referring or transitioning provider and the receiving provider.

9

MU2 Requirements and Exchange of Care Plan Content cont.

The MU Stage 2 Final Rule also provides the following definition of “Care plan”:

For purposes of the clinical summary, we define a care plan as the structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome) (page 54001).

10

11

Health IT Policy CommitteeMU3 Request for Comment

Dr. Terry O’Malley, Partners HealthCaretomalley@partners.org

HITPC MU 3 RFC – Care Plans

• In section SGRP 304, four questions are posed related to Care Plans:– How might we advance the concept of an electronic shared

care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers?

– What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management?

– How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

– What data strategy and terminology are required such that the data populated by venue specific EHRs can be exchanged? How might existing terminologies be reconciled?

12

LCC WG Care Plan Considerations

• To help frame responses to the RFC, the LCC WG has developed definitions for key terms, structure, and components of a care plan to support transitions in and coordination of care

• These terms/components apply to both the ‘care plan’ and ‘plan of care’:– Health concern

– Goals

– Instructions

– Interventions

– Outcomes

– Team member

13

14

Term/Component: CARE PLAN

MU2: Not defined

HIT PC RFC: How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers?

LCC Proposed Definition:

The S&I LCC believes that the exchange of care plans is important to support collaboration across care settings and providers, and allows for and can encourage team based care.

The S&I LCC believes that a “care plan” considers the whole person and focuses on a number of health concerns to achieve high level goals related to healthy living.

In contrast, some clinicians use the concept of “plan of care” to focus on discrete problems, the specific interventions to address the problem, and achieve a certain goal related to the problem.

The S&I LCC WG believes that both the Care Plan and Plan of Care share the components: health concern, goals, instructions, interventions, and team member

15

Term/Component: HEALTH CONCERN

MU2: Health concern is not defined. “Problem” is defined as “The focus of the care plan”

HIT PC RFC: What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management?

How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

LCC Proposed Definition:

Health concerns reflect the issues, current status and 'likely course' identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member.  

“Problems” and “diagnoses” will capture medical/surgical diagnosis but are insufficient to capture the full array of issues that are important to individuals. Health concerns include:Medical/surgical diagnoses and severityNursing/Allied Health/Behavioral Health issues Patient reported health concernsBehavioral/Cognition/Mood issuesFunctional status, including ADL issuesEnvironmental factors (e.g. housing and transportation)Social factors including availability of support and relationshipsFinancial issues (e.g. insurance, eligibility for disability)

16

Term/Component: GOALS

MU2: The target outcome; target or measure to be achieved in the process of patient care (an expected outcome).

HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

How might we advance the concept of an electronic shared care planning and collaboration tool that crosses care settings and providers, allows for and encourages team based care, and includes the patient and their non-professional caregivers?

What are the most essential data elements to ensuring safe, effective care transitions and ongoing care management?

LCC Proposed Definition:

A defined outcome or condition to be achieved in the process of patient care. Includes patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes.

17

Term/Component:

INSTRUCTIONS

MU2: By clinical instructions we mean care instructions for the patient that are specific to the office visit. Although we recognize that these clinical instructions at times may be identical to the instructions included as part of the care plan, we also believe that care plans may include additional instructions that are meant to address long-term or chronic care issues, whereas clinical instructions specific to the office visit may be related to acute patient care issues. Therefore, we maintain these as separate items in the list of required elements later.

HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

LCC Proposed Definition:

Information or directions to the patient and other providers including how to care for the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines and a summary of best practice.

Detailed list of actions required to achieve the patient's goals of care.

18

Term/Component:

INTERVENTIONS

MU2: Not defined

HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

LCC Proposed Definition:

Actions taken to maximize the prospects of achieving the patient's or providers' goals of care, including the removal of barriers to success.

Instructions are a subset of interventions.

19

Term/Component: OUTCOMES

MU2: Target outcome; target or measure to be achieved in the process of patient care (an expected outcome).

HIT PC RFC: How might sharing key data elements actually improve the communication? Consider health concerns, patient goals, expected outcomes, interventions, including advance orders, and care team members.

LCC Proposed Definition:

Status, at one or more points in time in the future, related to established care plan goals.

20

21

Exchange of Care Plan & MU Standards

22

Summary & Discussion

Jennie Harvell, ASPEJennie.harvell@hhs.gov

Summary & Discussion

• The S&I LCC WG anticipates advancing to the HITPC recommendations that MU Stage 3 include requirements for the interoperable exchange of care plans and component parts:– Health concerns

– Goals

– Instructions

– Interventions

– Outcomes

– Team member

23

WE WANT TO HEAR FROM YOU! LET’S DISCUSS…

24

NEXT STEPS

• We welcome your thoughts on the need for these care plan concepts and definitions as a way to respond to the HITPC RFC due January 14 2013

• Please share with us!– Evelyn Gallego-Haag, S&I LCC Initiative Coordinator at

evelyn.gallego@siframework.org – Becky Angeles, S&I LCC Support,

rebecca.angeles@esacinc.com

25

Participate & Collaborate!

S&I Longitudinal Coordination of Care Workgrouphttp://wiki.siframework.org/Longitudinal+Coordination+of+Care

26

Appendix:SUBMITTING RFC

COMMENTS

• Comments will only be accepted electronically

• Follow the “Submit a comment” instructions at http://www.regulations.gov

• Attachments should be in Microsoft Word or Excel, WordPerfect, or Adobe PDF

• HIT PC requests that duplicate comments not be submitted

27

28

Search for "Office of the National Coordinator for Health Information Technology; Health Information Technology; HIT Policy Committee: Request for Comment"

29

1. Enter identification information

2. Type comments3. Upload files4. Submit comments

30

Appendix:HITPC RFC – CARE PLANS

31

32

33

34

35