Longitudinal Coordination of Care

1. Longitudinal Coordination of Care

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

3. 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

4. Driving the Use Case vs. Driving Policy 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 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

5. 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)

6. Complex Longitudinal View of Transitions

7. 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

8. Seven Initial Transactions Transitions • Acute care to HHA (build on ToC Discharge Summary and Discharge Instructions) • Acute care to SNF (build on ToC Discharge Summary and Discharge Instructions) • HHA to acute care (build on ToC Discharge Summary and Discharge Instructions) • SNF to acute care (build on ToC Discharge Summary and Discharge Instructions) • HHA or SNF to SNF or HHA (build on ToC Discharge Summary and Discharge Instructions) Referrals • HHA or SNF to specialist or outpatient services (build on Referral and Results Summaries for PCP to specialist) Patient Communications • Copy all summaries above to patient/care giver PHR

9. 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

10. Proposed Scope of LCC Use Case Scenario 2: 7 (?) User Stories running in parallel to Scenario 1 Scenario 1: 7(?) User Stories Scenario 3: Transactions and functional requirements identified based on Homecare Use Case (485)

11. Does this strategy promote the LCC WG Vision?