meaningful use workgroup subgroup 3 – improving care coordination may 24, 2013

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Meaningful Use Workgroup Subgroup 3 – Improving Care Coordination May 24, 2013. Charlene Underwood, Subgroup Chair Paul Tang, MU WG Chair. Schedule. May 8 th Follow-up on referral loop (SGRP305) Follow-up on notifications (SGRP 308) Care summary (SGRP303) May 24th - PowerPoint PPT Presentation

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Meaningful Use WorkgroupSubgroup 3 Improving Care CoordinationMay 24, 2013Charlene Underwood, Subgroup ChairPaul Tang, MU WG Chair1ScheduleMay 8thFollow-up on referral loop (SGRP305)Follow-up on notifications (SGRP 308)Care summary (SGRP303) May 24th Follow-up on care summary (SGRP303)Care plan (SGRP304) Reconciliation (SGRP302)June 4thInterdisciplinary problem list (SGRP127) Med adherene/PDMP (SGRP125)Follow-up on referral loop (SGRP305)Follow-up on notifications (SGRP 308)2Longitudinal Coordination of Care (LCC) Workgroup (WG)LCC Standards Update for the HITPC MU - #3 Care Coordination

May 8, 20133MU3 C-CDA Template Gaps4175325483CCD Data ElementsIMPACT Data Elements for basic Transition of Care needsData Elements for Longitudinal Coordination of CareMany missing data elements can be mapped to CDA templates with applied constraints20% have no appropriate templates483 data elements vs CCD 175E.g. EF for CHF, or 3 INRs for Coumadin4Five Transition DatasetsReport from Outpatient testing, treatment, or procedureReferral to Outpatient testing, treatment, or procedure (including for transport)Shared Care Encounter Summary (Office Visit, Consultation Summary, Return from the ED to the referring facility)Consultation Request Clinical Summary (Referral to a consultant or the ED) Permanent or long-term Transfer of Care to a different facility or care team or Home Health Agency5Transition Data Sets and Use Cases65 Transfer of Care Summary4 Consultation Request Clinical Summary3 Shared Care Encounter SummaryCare PlanHH POC (CMS-485)Home Health Plan of Care Care PlanTransition Data Sets and Use Cases3. Shared Care Encounter Summary:Office Visit to PHRConsultant to PCPED to PCP, SNF, etc5. Transfer of Care:Hospital to SNF, PCP, HHA, etcSNF, PCP, etc to HHAPCP to new PCP4. Consultation Request:PCP to ConsultantPCP, SNF, etc to EDIncluding coordinating with esMD/CMS engagementBallot through Structured Documents Workgroup6LCC WG TimelineLCC WG Timeline: Mar 2013 Dec 2013MilestonesPilot Identification & EngagementCare Plan IGs CompleteLantana Contract AwardedHL7 Project Scope Statement DueHL7 Intent to Ballot DueHL7 Fall Ballot OpenNY Pilots MonitoringLCC Care Plan Use Case 2.0 Development & ConsensusIMPACT ToC Pilot MonitoringIMPACT Care Plan Pilot MonitoringHL7 Ballot PublicationToC IGs Development (Transfer Summary, Referral Note, Consult Note)ToC IGs CompleteHL7 Final Ballot DueLCC Stakeholder Engagement: Lantana, IMPACT, ASPE, NY, CMSCare Plan/ Home Health Plan of Care IG DevelopmentHL7 Ballot Package DevelopmentHL7 Ballot & ReconciliationFACA LCC WG BriefingsLCC & HL7 Care Plan CoordinationIMPACT Go-LiveNY Care Coordination Go-LiveOne Ballot Package to address:Update to C-CDA Consult Note

New Referral Note

New Transfer Summary

4 New Care Plan document type7This timeline serves to illustrate all the various activities (TOP THREE ROWS) and milestones (BOTTOM ROW) the LCC WG is engaged in for this year to ensure the availability of standards for ToC and exchange of Care plans/ HHPoC to support MU3. All activities serve to ensure that consensus driven ToC and Care Plan/ Home Health Plan of Care IGs are balloted through HL7 during the Aug/Sept ballot.

Lantana, S&I LCC, ASPE, and NY engagement (past and future) to create standard datasets (including esMD/CMS engagement). Recall that LCC is a community-led initiative with multiple private and public sector partners. LCC WG leads established partnerships (funding) with Lantana, ASPE, ONC, NY, CMS;NY Downstate Care Coordination WG participants and vendors plan to implement LCC Care Plan standards in SeptemberLCC is also engaging with HL7 Patient Care WG to ensure both WGs are working towards complimentary Care Plan standardization activities. LCC WG plans to comment and vote on HL7 Care Plan Domain Analysis Model that will be balloted through HL7 in MayLCC is working towards development of an LCC Care Plan Use Case which serves to define the functional requirements and user scenarios and stories for Care Plan exchange. This UC will serve to define requirements for the development of the Care Plan Implementation Guide. We expect the Care Plan IG work to begin in mid AprilIMPACT Project go-live is scheduled for May; ToC datasets will be piloted in the field; expect to pilot Care Plan datasets in SeptAdditional pilot sets are being identified7Care Summary - 3038ID #Stage 2 Final RuleStage 3 RecommendationsProposed for Future StageQuestions / Comments303EP/EH CORE Objective: The EP/EH/CAH who transitions their patient to another setting of care or provider of care or refers their patient to another provider of care provides summary care record for each transition of care or referral.

CORE Measure: 1. The EP, eligible hospital, or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions of care and referrals. Data Sets 3, 4, 5 2. The EP, eligible hospital or CAH that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10% of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the nationwide health information network.3. An EP, eligible hospital or CAH must satisfy one of the two following criteria: (A) conducts one or more successful electronic exchanges of a summary of care document, as part ofwhich is counted in "measure 2" (for EPs the measure at 495.6(j)(14)(ii)(B) and for eligible hospitals and CAHs the measure at 495.6(l)(11)(ii)(B)) with a recipient who has EHR technology that was developed by a different EHR technology developer than the senders EHR technology certified to 45 CFR 170.314(b)(2); or (B) conducts one or more successful tests with the CMS designated test EHR during the EHR reporting period.EP/ EH / CAH Objective: EP/EH/CAH who transitions their patient to another setting of care or refers their patient to another provider of care Provide a summary of care record for each site transition or referral when transition or referral occurs with available informationMust include the following four for transitions of site of care, and the first for referrals (with the others as clinically relevant): 1. Concise narrative in support of care transitions (free text that captures current care synopsis and expectations for transitions and / or referral)2. Setting-specific goals3. Instructions for care during transition and for 48 hours afterwards4. Care team members, including primary care provider and caregiver name, role and contact info (using DECAF (Direct care provision, Emotional support, Care coordination, Advocacy, and Financial))Measure: The EP, eligible hospital, or CAH that cite transitions or refer their patient to another setting of care (including home) or provider of care , provides a summary of care record for 65% of transitions of care and referrals (and at least 30%* electronically).Certification Criteria: EHR is able to set aside a concise narrative section in the summary of care document that allows the provider to prioritize clinically relevant information such as reason for transition and/or referral.Certification criteria: Ability to automatically populate a referral form for specific purposes, including a referral to a smoking quit line.Certification Criteria: Inclusion of data sets being defined by S&I Longitudinal Coordination of Care WG, which and are expected to complete HL7 balloting for inclusion in the C-CDA by Summer 2013:1) Consultation Request (Referral to a consultant or the ED)2) Transfer of Care (Permanent or long-term transfer to a different facility, different care team, or Home Health Agency)*What would be an appropriate increase in the electronic threshold based upon evidence and experience?

Discussion topics:2. Setting-specific goals (free text permissible)3. Instructions for care during transition and for 48 hours afterwards (free text permissible)4. Care team members, including PCP and caregiver name, role and contact info (remove DECAF reference)

Certification criteria: Problems, meds, allergies, PCPRemove criteria from S&IList of data elements required for the templateAdd order tracking for results into test tracking objective 122Consider defining types of transitions in terms that reference data sets and corresponding use cases.

Transitions: Office Visit to PHR; Consultant to PC; ED to PCP, SNF, etc.Referral requests: PCP to Consultant; PCP, SNF, etc to ED Transfers of care: Hospital to SNF, PCP, HHA, etc SNF, PCP, etc to HHA; PCP to new PCP

8Care Summary 303 (II)9Stage 2 Care Summary ItemsStage 3 AdditionsMust include the following information if the provider knows it: Patient name. Referring or transitioning provider's name and office contact information (EP only). Procedures. Encounter diagnosis Immunizations. Laboratory test results. Vital signs (height, weight, blood pressure, BMI). Smoking status. Functional status, including activities of daily living, cognitive and disability status Demographic information (preferred language, sex, race, ethnicity, date of birth). Care plan field, including goals and instructions. Care team including the primary care provider of record and any additional knowncare team members beyond the referring or transitioning provider and the receiving provider. Discharge instructions (Hospital Only) Reason for referral (EP only)In circumstances where there is no information available to populate one or more of the fields listed previously, the EP, eligible hospital or CAH may leave the field (s) b

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