October 22, 2015

© Copyright 2015 ADVault, Inc.

Agenda

IntroductionRole of ADVault in the pilot

Goal of PilotTier PilotingActivity to Pilot

Standards and Technologies Under Consideration

Logistics

Ecosystem

Defining Success

Resources/References

© Copyright 2015 ADVault, Inc.

Introduction: Pilot Team

Name Role Email

Scott Brown Team Lead – Project Coordinator sbrown@advaultinc.com

Paul Coyne Project Manager – Technology pcoyne@advaultinc.com

Others TBD Depends on Pilot Partners’ Needs

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Introduction: Organization

What MyDirectives does• Enable persons to create, store, update, retrieve and share personal emergency, critical

and advance (ECA) care plan information via internet and iPhone accessible applications • Help people express their goals, preferences and priorities for their medical treatment in

the event of a healthcare emergency. MyDirectives is involved in services and support• Serve as a blueprint to be shared by a person’s care team, with the individual at the

center• Help guide care if the person ever becomes a patient and cannot effectively

communicate with caregivers. • Capable of achieving interoperability with various EMR, EHR, PHR and patient portal

platforms, either directly or via an HIE• ECA care plan produced by MyDirectives can be shared with other systems that create

and manage eLTSS care plans.MyDirectives is currently supporting eLTSS activities• Various eLTSS stakeholders are already using MyDirectives for the purposes discussed

above.© Copyright 2015 ADVault, Inc.

Introduction: MyDirectives Role in eLTSS Pilots

MyDirectives is a tool that Beneficiaries, Advocates, eLTSS Plan Developers and eLTSS Plan Facilitators/Stewards can use to capture, store and share elements of the eLTSS Plan, including the following:• Personal Information (Demographics, Relationships, Choice &

Decision Making and Person-Centered Profile)

• Health, Wellness & Rights (Medications and Safety)

• Service Planning & Coordination (Payer Information)

• Family & Caregiver Information (Family Information)

• Cross-Cutting Sub-domains (Goals and Priorities)

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MyDirectives Pilot Introduction: Business Drivers

• Voice of all consumers – We do not focus exclusively on people who are elderly, frail, developmentally or physically

challenged, or chronically or terminally ill• Free to consumers

– Benefit offered by payers and a value-add, “meaningful use” certified EHR module licensed to providers.

– Anyone can go to MyDirectives.com or download MyDirectives MOBILE™ to create and share his or her ECA care plan

• VISION: “Person-centered healthcare” cannot exist without the voice of the person, and value-based payment systems will not work if providers and payers do not know what their patients and beneficiaries value.

• MISSION– Every citizen over the age of 18 should have a basic, high-quality ECA care plan that can be

accessed whenever and wherever needed.– Provider workflows must be adapted to make emergency, critical and advance care planning a

standard, normalized process for every patient encounter – just like measuring height, weight, blood pressure and temperature.

– Healthcare systems must leverage technology as much as possible to ensure that every person has an ECA care plan, that the plan is of the highest quality, and that the plan is accessible 24/7, anywhere in the world.

© Copyright 2015 ADVault, Inc.

User Story 1

MyDirectives is a tool for capturing, storing and sharing a wide variety of person-centered information, so we can be a part of either user story.

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User Story 2

• Personal demographics• Goals, preferences and

priorities• Contact information for

caregivers and members of the care team

• Messages for caregivers and members of the care team generated by the individual

• Medications and allergies• Physician orders• Multiple ways to share

information (hard copy, fax, email, Direct, XDR, XDS.b, etc.)

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Workflow

Current Status:• ECA care planning is largely reserved for the elderly, frail and sickest members of

society• Despite talk of “patient-centered” and “person-centered” healthcare, providers

and caregivers take little time to ask what the patient wants in the event they cannot communicate – then it is too late

• Providers assume that people do not want to talk about ECA care planning, cannot use technology, or “aren’t smart enough to understand” the process or the implications of their decisions

• Even when ECA care plans exist, the typically are inaccessible and/or of low quality

Pilot “Success”:• Change in provider workflows to normalize the capture of a person’s goals,

preferences and priorities, regardless of age or health status• Prove that technology can be leveraged to help beneficiaries, advocates and

caregivers create, store, update, retrieve and share ECA care plan elements, which will result in better healthcare

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Tiers

We hope to partner with eLTSS Pilot Sites and solution providers interested in working through all three pilot tiers.

We believe that the following the three-tier approach will allow pilots to work through all the issues that need to be considered when introducing technology in the delivery of long-term care services.

• Tier 1: develop, clarify, and normalize workflows that can support the use of paper ECA care plan documents that contribute the person’s goals, preferences, and priorities to the eLTSS care planning process.

• Tier 2: demonstrate improved workflows that support more efficient access to ECA care plan information generated by beneficiaries through exchange of digital information with consumer and provider facing systems.

• Tier 3: seek to demonstrate more effective workflows that support automated transfer of consumer-generated digital documents and real-time ECA care plan updates between beneficiaries, caregivers, providers and payers (subject to security and privacy requirements) when a person modifies his or her goals, preferences, or priorities for care, changes his or her healthcare agent(s), or changes other preferences relating to palliative and supportive care, organ donation or autopsy. We also hope to show how the data being shared can be used to support data analytics for clinical decision making, clinical quality management, and beneficiary and caregiver satisfaction with care received.

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Activities

• MyDirectives will pilot the following activities:– Create Plan– Approve/Authorize Plan/Services– Access, View, Review Plan– Update Plan

• MyDirectives will work with the following service providers:– Janie Appleseed (Consumer educator and advocate)– Coordinated Care Oklahoma (Health Information Exchange)– Seeking other partners (TEFT Grantees, Payers, Clinical and Institutional-based Providers,

EHR/EMR/PHR/patient portal and HIE platform developers, vendors and operators, eLTSS Plan Developers, etc.)

• Electronic systems currently in use are as follows:– We know that Coordinated Care Oklahoma and its member organizations have an electronic

system (Cerner HIE).– MyDirectives is interoperable with several platforms, and proving additional interoperability

would be a goal of the pilot.• The following sub-domains will be piloted:

– Choice & Decision Making, Relationships, Demographics, Person-Centered Profile, Medication, Safety, Payer Information, Family Information, Health, Goals and Priorities

© Copyright 2015 ADVault, Inc.

Standards Under Consideration

• Tier 1– Focus on collection of information and delivery of paper format ECA care plans or

scanned PDFs sent by fax (InterFax or GFI FaxMaker) or email– LOINC, VSAC managed value sets, and SNOMED-CT– VPN; SSL; HTTPS; 256-bit AES encryption

• Tier 2– LOINC and VSAC managed value sets; SNOMED-CT– HL7 C-CDA v2.1; HL7 v2– Blue Button Plus; InterFax or GFI FaxMaker; DIRECT; XDS.b– VPN; SSL; HTTPS; 256-bit AES encryption; OAUTH– API in a RESTful format returning an array in a JSON or XML format– HTML; CSS

• Tier 3:– LOINC and VSAC managed value sets; SNOMED-CT– HL7 C-CDA v2.1; HL7 v2– Blue Button Plus; InterFax or GFI FaxMaker; DIRECT; XDS.b; RFD; FHIR– VPN; SSL; HTTPS; 256-bit AES encryption; OAUTH; ATNA; XUA; SAML– API in a RESTful format returning an array in a JSON or XML format– HTML; CSS; Other content presentation options

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Logistics

• Timeline:– Milestones for completion of round one pilot by April 2016:

• Kick off: October 2015• Identification of Partners/Providers: November 2015• Completion of Requirement Traceability Matrix: March 2016• Completion of Round-One Pilot: April 2016

• Challenges:– Finding providers and payers willing to pilot and who have financial

resources and bandwidth available to do so.– Changing provider mindsets and workflows to prioritize and normalize ECA

care planning (e.g., resident/patient intake, ongoing customer/beneficiary/patient visits, etc.).

– Lack of technology or emerging standards are not a problem with ECA care planning.

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Ecosystem

• Current or potential partners/providers include the following:

– Clinical and institutional-based providers such as healthcare systems (Baylor Scott & White Health, HCA, Tenet, LTPACs, SNFs, ASLs, etc.)

– Federal, state, and private healthcare payers (Medicare, Medicaid, Humana, Aetna, BCBS, Kaiser Permanente)

– Community based LTSS providers

– EHR, EMR, PHR, patient portal and HIE vendors and operators (Coordinated Care Oklahoma, Chesapeake Regional Information System for our Patients (CRISP))

– Janie Appleseed

• MyDirectives can be interoperable with most EHR, EMR, PHR, patient portal and HIE platforms, including Cerner, Athenahealth, Allscripts, Epic and others.

• MyDirectives works with Microsoft, Rackspace Cloud, Mirth, Cerner HIE and others to carry out our work.

© Copyright 2015 ADVault, Inc.

MyDirectives Pilot Success

• Demonstrate that technology can be used to include the consumer’s perspective as the starting point or foundation for the eLTSS plan– Improve the quality of the plan and producing outcomes that more clearly

demonstrate “person-centered care” – Improve the person’s (and the caregiver’s, care team member’s, family’s, and payer’s)

experience when he or she becomes a patient– Improve population health management, and decrease per capita cost of care

• Additional performance metrics should include the following:– How many customers/beneficiaries/patients have ECA care plans that include high-

quality advance directives?– Are those ECA care plans readily accessible?– How often are those ECA care plans accessed, retrieved and reviewed, and by whom?– How often are the person’s goals, preferences and priorities expressed in those ECA

care plans able to be incorporated into the development of the person’s care plan or LTSS plan?

– What effect does such incorporation (if possible) have on the quality of care outcomes for the person, his or her family and caregivers?

• Additional Clinical Quality Measures may be required in order to record these metrics.© Copyright 2015 ADVault, Inc.

Helpful References

• www.MyDirectives.com• Research on advance directives and advance care planning:

– Advance Directives and Advance Care Planning: Report to Congress, prepared under contract #HHS-100-03-0023 between the U.S. Department of Health and the RAND Corporation (August 2008). See http://aspe.hhs.gov/basic-report/advance-directives-and-advance-care-planning-report-congress.

– Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. Institute of Medicine. Washington, D.C.: The National Academies Press (September 2014). See http://iom.nationalacademies.org/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx.

• Research on consumer attitudes towards ECA care planning:– Final Chapter: Californian’s Attitudes and Experiences with Death and Dying. California HealthCare

Foundation (February 2012). See http://www.chcf.org/publications/2012/02/final-chapter-death-dying.– Kaiser Health Tracking Poll: September 2015. The Henry J. Kaiser Family Foundation (September 30,

2015). See http://kff.org/health-costs/poll-finding/kaiser-health-tracking-poll-september-2015/.• Value-Based Payments Require Valuing What Matters to Patients. J Lynn, A McKethan and AK Jha. JAMA, Vol.

314, No. 14 (published online September 17, 2015). See http://jama.jamanetwork.com/article.aspx?articleid=2443231.

• A Better End of Life. D Kendall and E. Quill. Third Way Report (published online September 29, 2015). See http://www.thirdway.org/report/a-better-end-of-life.

© Copyright 2015 ADVault, Inc.