Workflow, Longitudinal Care, Transitions of Care, Care Coordination (Content from 2/29/2012 Revision)

ONC **Goal I:** Achieve Adoption and Information Exchange through Meaningful Use of Health IT


Objective #1: Support and advance care coordination and workflow improvements through the use of health IT and electronic health information exchange on behalf of persons receiving LTPAC services.

Strategies:
  1. Support workflow analysis and refinements to advance health IT-enabled care coordination and transitions in care:
  • Describe potential workflow considerations for and impacts on care coordination and transitions in care that arise with the acquisition and use of health IT and electronic health information exchange for these activities on behalf of persons who receive LTPAC services. This strategy will identify three (3) key activities that require health information exchange (e.g., the exchange of: summary documents, care plan information; and medication information) and describe:
    • Task completion (including current tasks to support care coordination and transitions in care and changes to these tasks through use of health IT and electronic health information exchange)
    • Internal and external roles and responsibilities associated care coordination and transitions of care enabled through the use of health IT/health information exchange
    • Documentation needed to support transitions in and instances of shared care and methods by which such data is collected in a Health IT enable environment
    • Expected benefits and costs of acquiring and using health IT/electronic health information exchange to improve care coordination and transitions in care, including initial and on-going staff training requirements, downtime when transitioning from manual to electronic care coordination processes; and costs of getting work done in facilities with tight budgets.

  • Develop and advance implementation of LTPAC use cases that uses health IT/electronic health information exchange to support care coordination and transitions in care. Findings from such use cases would allow early adopters to share information about the costs and benefits that were achieved through use of Health IT and electronic health information exchange. Lessons learned though these implementations could include:
    • How workflow efficiencies can be enhanced with the use of electronic reminders, alerts, or reports
    • Descriptions of positive and negative workflow impacts arising from changes in administrative decisions and work/job design
    • Impact on staff satisfaction and retention
    • Impact on provider to provider and provider to patient interactions as a result of changes to workflow, including the ability to share data with all members of the care team when and where needed.
    • Effective and efficient interface designs for LTPAC systems that are usable by LTPAC staff
    • Impact on tThe content and format of care summaries, care plans, and other documents that are exchanged.
    • Impact on exchange of summary documents and interdisciplinary care planning activities through the use of Health IT

  • Propose benchmarks to measure the impact of the use of health IT and electronic health information exchange on care coordination and transitions in care on behalf of persons who receive LTPAC services by engaging in several activities, including:
    • Respond to the CMS request for comments on the need for quality measures to support health information exchange on behalf of persons who receive LTPAC services.
    • Evaluate the applicability of and proposed approaches to fill gaps in the Medicare and Medicaid EHR Meaningful Use metrics to support the exchange of summary documents, care plans, medication reconciliation, and other information on behalf of transitions in and coordination of care for persons receiving LTPAC services.
    • Review measures endorsed or under development by NQF and in the National Quality Strategy to identify whether there are endorsed/other measures that could be advanced as metrics for the use of health IT/health information exchange for transitions and coordination in care that include persons who receive LTPAC.
    • Propose to the ONC and the Health IT Policy Committee measures that are needed to assess the impact of health information exchange for care coordination and transitions in care on behalf of persons who receive LTPAC.
    • Shape and support the standardization (using health IT vocabulary and document exchange standards) development of the CMS’ Continuity Assessment Record and Evaluation (CARE) instrument data library from which data elements could be used for different purposes CARE is a standard set of data elements that captures health and functional status data for beneficiaries across care settings, over time, regardless of payer or provider type.


Objective #2: Support development and adoption of health IT standards, implementation guides, and EHR Certification for LTPAC that will support interoperable health information exchange in LTPAC for purposes of continuity of and transitions in care.

Strategies:
  1. Play an active role in policy and regulatory development of EHR Systems for LTPAC
  • Provide comments on the ONC Proposed Rule regarding the need for standards, implementation guides, and EHR Certification for LTPAC.
  • Participate in the S&I LCC Workgroup and the HL7 SDWG to assist in the identification of standards needed to support continuity and transitions of care on behalf of persons receiving LTPAC services.
  • Participate in designing and implementing pilots that will test identified HIE standards and disseminate findings from such pilots.
  • Provide comments to the ONC and the Health IT Policy and Standards Committees regarding actions needed to advance the meaningful use of interoperable EHRs and health information exchange on behalf of persons who receive LTPAC service.

  1. Showcase health information exchange activities being implemented in federal, state and private-sector programs that engage LTPAC providers in HIT, EHR, and HIE activities
  • ‍ONC Challenge Grants
  • ONC Beacon Communities
  • Other noteworthy State and private sector HIE activities that include LTPAC providers.

Objective #3: Address ‍HIT Standards Issues Requiring Further Consideration: Functional Status, Cognitive Status, and Pressure Ulcers
At present there is not a uniform definition, assessment method or scale for functional status, cognitive status, and pressure ulcers. This creates challenges for representing and exchanging functional status cognitive status, and pressure ulcers content to support continuity of care, information exchange and re-use. This information is important to assessing an individual’s needs and providing appropriate and needed health and supportive services. Functional status, cognitive status, and pressure ulcers impacts the individual’s quality of life, wellness, and ability to care for self, and is often a factor in public and private payment methodologies as well as in quality management and clinical outcome measurement. Work is underway at the Standards and Interoperability Initiative: Longitudinal Care Coordination Workgroup and the HL7 Structured Documents Workgroup (SDWG) to address these critical gaps. Specification of the health IT vocabulary and document exchange standards will enable the exchange of critical information to support continuity of and transitions in care. The HL7 SDWG is collaborating with the S&I Initiative in the identification of standards needed to support interoperable exchange of functional status and other information needed at times of transition in care. The HL7 SDWG plans to publish a draft standard for trial use in time to be recognized under the next stage of EHR Meaningful Use program.

Strategies:
  • Participate in the S&I LCC Workgroup and the HL7 SDWG to assist in the identification of standards needed to represent critical content needed to support continuity and transitions of care on behalf of persons receiving LTPAC services. Specifically, work to fill gaps in representing and exchange content related to: functional status, cognitive status, and pressure ulcers.


Objective #4: Provide Mechanisms for ‍Certification of LTPAC EHR Products
The Certification Commission for Health IT (CCHIT) has developed comprehensive EHR criteria for LTPAC providers. Core criteria exist for skilled nursing facilities, certified home health, hospice, inpatient rehab facilities and long-term acute care hospitals. Full criteria exist for both skilled nursing facilities and certified home health[D1] . LTPAC EHR vendors have begun achieved ing CCHIT Certified ® 2011 Program certification for LTPAC, which includes the same security and interoperability requirements as hospital and physician EHRs[D2] . CCHIT LTPAC certification supports care coordination by requiring the Continuity of Care Document (CCD), medication reconciliation and many other functions that facilitate care coordination. For more information: http://www.cchit.org/certify/2011/cchit-certified-2011-long-term-post-acute-care-ltpac-ehr

At this time the ONC has not established a specialty EHR certification program (e.g., a certification and testing program for EHR products for LTPAC providers (or other specialty providers)) or identified EHR certification criteria that are needed to support the workflow requirements in LTPAC or other specialty providers. However, a number of LTPAC vendors have received modular certification from ONC (ONC-ATCB Certified 2011/2012) for both eligible providers and hospitals. For more information: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_and_certification/1153

An objective of the S&I LCC Workgroup is to “develop certification requirements for EHR & LTPAC vendors in anticipation of LTPAC pilots.”

Strategies:
  • Provide comments on the ONC Proposed Rule regarding the need for standards, implementation guides, and EHR Certification for LTPAC.

Objective #5: Provide information and outreach to LTPAC providers and vendors regarding health IT enabled transition in care and care coordination.

Strategies
Gather information from LTPAC providers and health IT/EHR vendors about the awareness and readiness of providers and vendors to use HIT/HIE products for interoperable HIE for transitions in and coordination of care. Develop and implement an educational campaign for LTPAC providers and vendors to increase their awareness of and readiness to adopt health IT/HIE solutions to improve care coordination and transitions in care.

[D1]Clarify the difference between core and full criteria.
[D2]What does this mean? Are you saying the same security and interoperability requirements as is required for EPs and EHs under the CMS EHR Meaningful Use Incentive Program? Clarify what this clause if referencing.


Priorities/Recommendations: Longitudinal Care/Transitions of Care/Care Coordination (original draft)

Section X: Introduction


Objectives
  • Define Care Coordination in today's context
  • Describe how Care Coordination fit into health reform
  • Align our statements with MU Stage II.

Coordination of care involves: activities to promote, improve, and assess integration and consistency of care across primary care physicians, specialists, and acute and post-acute providers and suppliers, including methods to manage care throughout an episode of care and during its transitions; for instance, during a discharge from a hospital or transfer of care from a primary care physician to a specialist (CMS ACO Final Rule, ONC national Grantees meeting slides). A definition of care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care (AHRQ, 2007). Stage II Meaningful Use documents break Care Coordination down into units including the care team, care summary, and care plan (R Brennan, email 2011).

Coordination of care includes:

  • Coordination within a setting
    • Shift handoff
    • Transfer from one unit to another
    • Across care team members

  • Coordination across settings
    • Discharge summary
    • Discharge plan
    • Transfer document

  • Coordination with patients/family members

This section of the LTPAC HIT roadmap will shape the issue of care coordination and its relationship to workflow. We provide an overview of current and future national efforts to increase standardization, interoperability, and potential certification efforts for LTPAC HIT systems that will impact workflow. Finally, we provide an overview of current national LTPAC HIT demonstration projects funded to promote care coordination efforts and workflow.

Section X: Framing IT and Care Coordination in LTPAC


Objectives
Frame the issue of Care Coordination into LTPAC workflow
  • Workflow and flow of information is extremely important for continuity of care and business strategies. Workflow issues needing consideration as use of technology emerges into LTPAC settings include those surrounding task completion, such as overlap of documentation by nurse aides and nursing personnel. Additionally, role responsibility can change as workflow shifts, for instance as nurse aides begin to document their episodes of care versus nurses episodes of care. Another workflow issue to appraise as HIT escalates includes time and cost of getting work done. Time variants which may be important for nursing home outcomes include additional training requirements, as well as time required for adjusting to implementations and upgrades of software. Cost of getting work done is also an extremely important variant for nursing homes with tight budgets. Use cases specific to the LTPAC setting should be developed to allow early adopters to share how increased effectiveness, efficiency, and satisfaction were achieved with LTPAC HIT. Important use cases to garner information from include how workflow efficiencies can be enhanced with the use of electronic reminders, alerts, or reports; descriptions of positive and negative workflows arising from administrative decisions and work/job design; consequences of patient provider interactions that affected workflow; interface design and content within LTPAC IT systems; effect of system integration on workflow; and how planning activities are supported by LTPAC HIT. One method to frame the issue of care coordination within workflow design would be to construct use cases for how care coordination is facilitated within LTPAC HIT systems. Use cases could be used to describe workflow successes and failures of LTPAC HIT during implementation and use. (Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wiscosnsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.
  • Evaluating how seamlessly LTPAC HIT supports care coordination processes is critical for achieving optimal outcomes for LTPAC staff and residents. Seamless integration of data within IT systems provides for transmission of data across units responsible for communicating care coordination activities, such as care team members, care summaries developed by care team members, and maintenance of interdisciplinary longitudinal care plans. Rich can you add more about meaningful use?
  • Benchmarks are needed to measure care coordination when LTPAC HIT is being used. Suggested benchmarks to measure workflow should include a mix of distal workflow and proximal workflow measures. Distal measures for LTPAC settings might include how telemedicine is used to support consultation services; furthermore, how these consultation services impact costs to the patient and facility or number of tests ordered. Other distal measures should include adherence to evidenced based guidelines and procedures, or nursing home quality measures without a full explanation of workflow change. Conversely, proximal measures might include more microlevel analysis such as workflow efficiencies among clinical settings, use patterns for LTPAC HIT, and/or processing time. Research is need to support the development of theoretical links and relationship between these distal and proximal measures and LTPAC outcomes.

Section X:

Objectives
  • Describe how Standards, Interoperability and Certification for LTPAC EHRs will drive future implementation efforts and care coordination processes
  • Describe what we know about certification efforts and standardization processes to further LTPAC EHR use and support for care coordination.
    • Include ONC S&I LCC WG

Recently enacted legislation, HITECH and the Patient Protection and Affordable Care Act of 2010 (referred to the Affordable Care Act) have[J1] established the use of health IT as a key tool to support needed improvements in health care quality, including improvements in continuity and coordination of care. The ONC Federal Health IT Strategic Plan 2011-2015 states that the “first priority in realizing the benefits of health IT is to achieve nationwide adoption of EHRs and widespread information exchange” (p.8).

Timely and complete health information exchange is critically important for persons who receive LTPAC services. A report completed for the Office of the Assistant Secretary for Planning and Evaluation (ASPE) by the American Health Information Management Association (AHIMA ) observes that, Individuals who receive long-term and post-acute care (LTPAC) services obtain care from a diverse group of physicians, clinicians, and specialists and experience frequent transitions between healthcare provider settings. The availability of health information to support and coordinate care is crucial for eliminating fragmentation and ensuring high quality, safe and efficient healthcare. Transitions in care are known to be particularly problematic because relevant information may not be communicated in a timely manner. Health information technology (health IT) and health information exchange have the potential to address the information gap and improve the overall quality and continuity of care of LTPAC patients, reduce rehospitalizations, and control healthcare spending” (Report: Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information”(p.4). Link:http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm)

Several health information exchange activities are being implemented in federal, state and private-sector programs that engage LTPAC providers in HIT, EHR, and HIE activities. A common goal across these efforts is to improve the quality, continuity, and coordination of care. Some of these activities are described below. The following summary is based on information in the report on Opportunities for Engaging LTPAC Providers in HIE described above (Link:http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm) and a January 24, 2012 presentation by ONC Challenge Grant recipients (need to include a link to that PPT).

ONC Challenge Grants

In January 2011, ONC made available $16 million in “Challenge Grants” to 10 states/state designated entities (SDEs) to focus on health information exchange in certain clinical areas, including “improving long-term and post-acute care transitions.” Through the Challenge Grant program, ONC awarded almost $7 million to four states to focus on health information exchange on behalf of persons receiving LTPAC services. These HIE programs are described below[J2] :

  • Colorado: Colorado Regional Health Information Organization (CORHIO) is focusing on connecting communities and developing tools to support the workflow for information exchange including LTPAC providers (including home health, hospice, skilled nursing facilities, assisted living, long-term acute care hospitals, and residential care facilities for the developmentally disabled). The goal of the CORHIO is to achieve broad- based adoption of electronic HIE for the LTPAC providers to improve care transitions and reduce hospital readmission rates. The CORHIO program is seeking to connect providers using a web portal that supports standardized information exchange and extends meaningful use to LTPAC.

  • Oklahoma: The Oklahoma Health Information Exchange Trust (OHIET) is focusing on the technology infrastructure across the state to facilitate the health information exchange workflow. The OHIET is focusing on two-way information exchange at times of care transitions between nursing homes and hospitals. The focus of the exchange is on the standardize exchange of key information needed to support transfers of care, including some data from the INTERACT [include link to INTERACT], presence or absence of advance directives, data regarding activities of daily living (ADLs), and some data from the nursing home Minimum Data Set (MDS). Several goals for the initiative have been indentified including enhancing workflow, improving documentation, improving availability of health data, and decreasing rates of hospital re-admissions and use of the ER.

  • Maryland: The Maryland Chesapeake Regional Information System for our Patients (CRISP) is seeking to advance HIE with LTC facilities using two approaches: (a) LTC facilities that are relatively mature in terms of their use of EHRs will be able to send and receive EHR data to/from[J3] the operational statewide HIE; and (b) less mature LTC facilities will be able to use a web portal to query for patient medication history, e-prescribing information, and laboratory and radiology reports. In addition, Maryland is considering how a statewide registry could maintain key documents such as advance directives based on the Medical Orders for Live-Sustaining Treatment Paradigm (MOLST). Maryland has identified several goals for this Challenge grant including: reducing hospital readmissions, increasing the completeness of data included in transition process, and increasing patient understanding of her/his care during transition.

  • Massachusetts: Massachusetts is leveraging its State HIE and implementing the IMPACT program -- Improving Massachusetts Post-Acute Care Transfers. The program is developing tools to support decision-making and information sharing at times of transfers in care to reduce unnecessary hospitalizations. IMPACT is identifying data elements needed for a “Universal Transfer Form” (UTF) that could be exchanged at times of transitions in care (e.g., to and from acute care hospitals and nursing homes, home health agencies, etc.). The IMPACT program anticipates re-using a subset of the MDS and OASIS assessment content to partially populate the interoperable UTF. The IMPACT program is working with the ONC Standards and Interoperability (S&I) Framework Transition of Care Initiative to identify the standards needed to enable the interoperable exchange and use of the UTF.

ONC Beacon Communities

ONC provided grant funding to 17 Beacon Communities to support building and strengthening their health IT infrastructure and exchange of information for improved care coordination, quality, and economic efficiency.[1] Some of the communities have specific initiatives to engage LTPAC providers, including Rhode Island, Maine and Pennsylvania. The Beacon Community Program in Pennsylvania merits particular attention as this health information exchange activity was cited in the press as including an important component for “solving the data exchange puzzle” for NHs and HHAs (http://www.informationweek.com/news/healthcare/interoperability/232400471).

  • Pennsylvania’s Geisinger Keystone Beacon Community is focusing on connecting nursing homes and home health agencies to on-going health information exchange activities by supporting the exchange of “Patient Assessment Summary Documents” that are comprised of a subset of data elements from federally-required patient assessment instruments, the MDSv3 and OASIS-C assessments. Nursing homes and home health agencies are required to complete and electronically transmit these instruments . The Patient Assessment Summary Documents are comprised of data elements that were identified by clinical and other subject matter experts as clinically useful to exchange at times of transitions in care or instances of shared care. The Keystone Beacon Community concluded that exchanging Patient Assessment Summary Documents would be a convenient starting point for engaging nursing homes and home health providers because this type of exchange: (A)builds upon federally required patient assessment instruments that are in an electronic format and are electronically transmitted by most nursing homes and home health agencies; and (B) re-uses accepted health IT vocabulary and exchange standards that have been applied to these instruments. While leveraging patient assessment content and making it interoperable might be a low-cost and opportunistic approach to engaging LTPAC provides in HIE activities, it is not perfect for summary information needed at transition of care. Nonetheless, experts indicated that: 1) having dated information was better than having no information; and 2) assessment documents include data elements that are likely to be stable over time and clinically relevant at times of transitions/ shared care. The Keystone HIE expects to supplement the Patient Assessment Summary Document with additional information (e.g., medication information). The ONC-sponsored Standards and Interoperability Framework/Longitudinal Care Coordination Workgroup/Patient Assessment Summary Sub-Workgroup has identified the exchange of Patient Assessment Summary Documents as its key focus and is working to identify health IT vocabulary and document exchange standards for this use case. (See the ASPE/AHIMA report: “Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information” http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm).

There are other noteworthy State and private sector HIE activities that are underway that include LTPAC providers.

  • Exchange of Home Health Plan of Care: The New York e-Health Collaborative is advancing work in collaboration with Visiting Nurse Services of New York (VNSNY), physician practice groups, health IT vendors, and other stakeholders to create an interoperable plan of care document for home care that would be continuously updated and shared between the home care agency and a physician. The plan of care document that will be exchanged in the NY project is the “CMS 485 form” formerly required by CMS and remains in widespread use by home health agencies. Although originating in New York, this project is gaining state and vendor support around the US. The project is advancing its work through the Longitudinal Care Coordination Workgroup of the ONC Standards and Interoperability Framework and will identify and harmonize vocabulary and exchange standards to support the exchange of the Home Health Plan of Care. The VNSNY anticipates reusing a subset of interoperable OASIS assessment content to partially populate the interoperable home health plan of care.
  • Detecting Potential Adverse Drug Reactions (ADRs): ADRs are common in nursing homes. The University of Pittsburgh in Pennsylvania developed and evaluated the use of a consensus list of laboratory, pharmacy, and Minimum Data Set (MDS) signals that could be used by EHR systems in nursing homes to detect potential adverse drug reactions (ADRs[J4] ). The system would alert the clinician when potential ADRs are signaled using the laboratory, pharmacy, and assessment data. Evaluation results indicate:

    • ADRs can be detected in nursing homes with a high degree of accuracy using an electronic clinical event monitoring that employs a set of signals derived by expert consensus. The overall PPV (Positive Predictive Value) of 81% is substantially higher than PPVs previously reported in the literature, which range from 3-50%

      • The study found that about one-third of the ADRs in nursing homes were preventable, and that of the preventable ADRs, 88% were associated with errors in the monitoring stage of the medication use process

While to study did not describe the impact on continuity and coordination care, the article stated, “Hospital studies indicate that these automated clinical decision support systems, which provide feedback to healthcare professionals based on information available in electronic format, are less expensive and much faster to use than manual chart reviews, and can identify events not often detected by clinicians during the course of routine care” [pX].

Meetings that include a Focus on LTPAC and Coordination in Care


There have been several meetings focusing on transitions in care, including transitions that include persons who receive LTPAC services, and the use of Health IT to support these transitions. ONC sponsored a five-year study with the National Governors Association (NGA) Center for Best Practices to better understand the States’ HIE needs with respect to LTC. NGA conducted a technical expert panel meeting and coordinated meetings with state HIT officials in conjunction with ONC Regional Extension Center and Beacon Communities meetings. NGA published an issue brief summarizing the findings[J5] and concluded that there is great promise for electronic exchange of health information for improving quality and potentially reducing healthcare costs once LTC facilities begin connecting to broader state HIE activities.//**[2]**// The NGA issue brief highlighted several common challenges identified by states to integrate LTC into HIE efforts ://**[3]**//, //**[4]**//Two challenges that were identified related to care coordination were:
  • Inaccessibility of Data: Inadequate information in an inconsistent structure is a significant barrier. Clinical data in LTPAC is often fragmented due to antiquated record systems that collect only a portion of a patient’s health information. Information such as the MDS is reported to CMS in real time, but that data cannot be shared across care providers and may not include all relevant information; and
  • Lack of Standardization of EHRs: There is a lack of standardized data collection methods in the various LTPAC settings that leads to challenges in care coordination functions such as treatment history, referrals and transfers. CCHIT has certified EHR programs unique to LTPAC but adoption by LTPAC vendors has been low.
In addition, a common challenge that was identified was that States are having to address multiple and competing State health initiatives that are running in parallel. States are coordinating multiple initiatives including sustaining Medicaid, implementing healthcare reform, and controlling healthcare costs. As a result, state health IT efforts have largely focused on the meaningful use incentive program for eligible providers and hospitals. The result has been fewer resources for ineligible providers such as LTPAC.

Despite these challenges, the NGA noted that states are taking steps to engage LTPAC providers and made several recommendations to States.//**[5]**// Two of the NGA recommendations were:

  • Understand the LTPAC Environment and Engage Stakeholders: NGA recommended that states conduct an environmental scan of LTC facilities, providers, care centers and others to understand their landscape and key challenges. For example, some states have conducted a survey of the LTPAC providers and their readiness/interest in HIE activities. States could bring LTPAC stakeholders into workgroups and planning efforts to identify specific actions for change; and
  • Incorporate LTC into Ongoing State Strategic HIT Plans: States could look for opportunities to establish goals and bring LTPAC into their state strategic and operational plans as well as their HIE outreach plans.

In addition, ONC has convened meetings to raise awareness about the need to exchange health information across the healthcare enterprise, including the LTPAC sector.
  • ONC convened a town hall meeting at the 2011 LTPAC HIT Summit//**[6]**// to make available information regarding State HIE activities that include LTPAC providers.
  • In October 2011, ONC and private sector foundations hosted a working meeting -- Putting the IT in TransITions//**[7]**// -- of innovators, policy makers, and health IT experts, providers, and others to identify how health IT could be used to support some of the challenges in transitions in care. In addition, in November 2011, ONC hosted a meeting for State Health IT Coordinators, Beacon Communities, and other entities. A session during this meeting was focused on increasing awareness of and opportunities and methods for engaging LTPAC providers in HIE activities.

ONC Standards & Interoperability Framework (S&I Framework)

The S&I Framework, an ONC sponsored collaborative community of volunteers from the public and private sectors focused on providing tools, services and guidance to facilitate the exchange of health information, was launched on January 7, 2011. The standards and implementation guides that emerge through the S&I Framework are expected to be used as EHR certification criteria and future EHR Meaningful Use requirements.

The S&I Framework uses a set of integrated functions, processes, and tools that enable execution of specific value-creating initiatives. Each S&I Initiative tackles a critical interoperability challenge through a rigorous process that typically includes:

  • Development of clinically-oriented user stories and robust use cases
  • Harmonization of interoperability specifications and implementation guidance
  • Provision of real-world experience and implementer support through new initiatives, workgroups and pilot projects
  • Mechanisms for feedback and testing of implementations, often in conjunction with ONC partners such as NIST[1]

Initial initiatives of the S&I Framework included:

  • Transitions of Care (focused on support for Meaningful Use Stage 1 summary of care (Eligible Provider, Eligible Hospital, and Critical Access Hospital) requirements for transition of care and transition of care to consumer;
  • Laboratory Results Interface; and
  • Provider Directories.

In October 2011, ONC launched a new S&I Framework initiative of significant interest to the LTPAC community. The Longitudinal Coordination of Care Workgroup (LCC WG) was created as a community-led initiative to support HIE on behalf of LTPAC stakeholders and to address potential gaps in the prior S&I Transitions of Care work products in order to support engagement of LTPAC providers in HIE activities.[2] The LCC WG has established the following three sub-workgroups:

  • Longitudinal Care Plan Sub-workgroup - The goal of the Longitudinal Care Plan SWG is to evaluate the best practices in technology enabled care planning and coordination and to document the associated information streams and processes as well as the current and emerging standards for care planning. The short term goal and deliverable is a standard for the Home Health Certification and Plan of Care (CMS 485 – see discussion of “Exchange of Home Health Plan of Care” on page _). Use Case analysis focused on coordinated interdisciplinary wound care will provide further insight into the collaborative and iterative processes fundamental to coordinated care. Finally, the long term goal of this SWG is to solidify the concept of the Longitudinal Care Plan, define the information model necessary to support its adoption, and complete a gap analysis of existing HIT standards to inform future efforts to implement a patient center longitudinal care plan.
  • LTPAC Care Transitions Sub-workgroup - The goal of the LTPAC Care Transitions SWG is to (1) develop a priority list of acute-post acute transitions based on volume, clinical instability and acuity of the required information; (2) develop standard clinical content defined by the receiving clinicians for all high-priority transitions; (3) develop resources to support interoperability of all clinical content across all sites of care; and (4) re-use of selected data elements from OASIS and MDS to populate the transitions data sets from HHAs and SNF/NFs (see discussion of Massachusetts’ IMPACT program on page _).
  • Patient Assessment Summary Sub-workgroup - The goal of the Patient Assessment Summary SWG is to identify the subset of MDS3.0 and OASIS-C data elements that can be usefully included in patient assessment summary documents. In addition to the identification of data elements, the SWG will identify the standards that can be used to support interoperable exchange of these assessment summaries between providers, and between providers and patients (see discussion of Geisinger’s Keystone Beacon Community on page _).


HIT Standards Issues Requiring Further Consideration


Individuals served by LTPAC providers often have chronic illnesses and disabilities resulting in physical and cognitive functional limitations. They interact routinely with multiple providers. The ability to communicate functional status between providers and caregivers is crucial to ongoing care planning and treatment.

Currently there is not a uniform definition, assessment method or scale for functional status to be communicated consistently across care settings. This creates challenges for representing functional status in a standardized vocabulary to support continuity of care, information exchange and re-use. Functional status information is important to assessing an individual’s level of functioning and providing appropriate and needed health and supportive services. Functional status impacts the individual’s quality of life, wellness, and ability to care for self, and is often a factor in public and private payment methodologies as well as in quality management and clinical outcome measurement.

Work is underway at the HL7 Structured Documents Workgroup (SDWG) to address critical gaps in representing functional status using health IT standards. Specification of the health IT content and messaging standards related to functional status will enable the exchange of critical information to support quality and continuity of care. [3] The HL7 SDWG will collaborate with the S&I Initiative in the identification of standards needed to support interoperable exchange of functional status and other information needed at times of transition in care. The HL7 SDWG plans to publish a draft standard for trial use in time to be recognized under the next stage of EHR Meaningful Use program.

Appendix I of the HHS/ASPE report “Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information” provides more specific suggestions for addressing the standards related to functional status.

Certification of LTPAC EHR Products


During a discussion at the 2011 LTPAC HIT Summit at the session on “Moving LTPAC Providers in the Nationwide Health IT Infrastructure,” providers and vendors concluded that there is likely a core set of EHR criteria that will be common across all EHR products (e.g., requirements related to privacy/security, medication reconciliation, problem list, etc[J1] .).

At this time the ONC has not established a specialty EHR certification program (e.g., a certification and testing program for EHR products for LTPAC providers (or other specialty providers)) or identified EHR certification criteria that are needed to support the workflow requirements in LTPAC or other specialty providers. There are several benefits that are frequently cited when considering the need for EHR certification criteria. EHR certification criteria are expected to “level the playing field” between providers and health IT vendors. Specification of EHR certification criteria that should be supported by EHR products used by providers is expected to create confidence on the part of the provider when making HIT/EHR investment decisions. EHR certification criteria should support efficient and cost-effective interoperable health information exchange and re-use across providers. These benefits are expected to support the acquisition and used of interoperable EHRs. However, establishing such a program or identifying EHR certification criteria is complex, could be costly, and requires careful consideration of the advantages and disadvantages.

As mentioned, an objective of the S&I in the draft roadmap of the Longitudinal Coordination of Care Workgroup is to “develop certification requirements for EHR & LTPAC vendors in anticipation of LTPAC pilots.”[4]


Conclusion


Objectives:
  • Explain how Care Coordination fits into current priorities and recommendations for the LTPAC HIT Roadmap 2010-2012
  • Reflect where the LTPAC community is today and where we want to be in the future in terms of care coordination.

Improving individual access to quality and cost effective health care is a major national goal – a critical priority that can be achieved, in part, through the adoption and meaningful use of health information technology. Electronically collecting and exchanging relevant health information between acute care hospitals, doctors, and post acute care providers in a timely manner are keys to improving the coordination of care and the appropriate delivery of health care services within a single setting, across multiple settings, and with patients and family members.

Up to now, government’s primary focus has been on acute care doctors and hospitals, incentive dollars to encourage them to adopt electronic health records and the means to begin sharing patient data through state or local health information exchanges. Government is supporting the development of these exchanges and the standards that will define that exchange of information.

Today, through the efforts of the LTPAC Collaborative and others, government interest in including the LTPAC sector has spawned in an array of programs to accelerate the expansion of health information technology. Clearly, the goal is ensure the quality of care is maintained through all patient transitions.

While LTPAC providers remain ineligible for federal incentive payments, federal dollars are flowing into a number of programs that are now inclusive of long term and post acute care. Such programs include the Office of National Coordinator’s (ONC’s) Challenge Grant and Beacon Community programs, the Standards & Interoperability Framework, and others. The work being done right now, in these programs, will govern the way care coordination is managed in the future.

Even though the ONC is calling upon LTPAC sector experts to become more engaged in this foundation building work, the response has been minimal. National policy makers are taking note and are fully prepared to build the future without LTPAC input.

Actions needed now:
  • The LTPAC HIT Collaborative must develop recruitment and retention programs to get providers and vendors more aggressively involved in HIT program development efforts at all government levels. Such programs can focus on:
    • Educating providers and vendors on the opportunities that exist;
    • Helping them get signed on to actively participate in current ongoing programs and, additionally, how to create new collaborative opportunities by building strong relationships on the state, local, and national levels; and
    • Providing ongoing support.

References


ACO Final Rule 2011

AHRQ Care Coordination Document 2007

Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.



[1] S&I Framework: What is the S&I Framework.
http://www.siframework.org/whatis.html
[2] “Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information” http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm).
[3] “Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information” http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm
[4] “Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities with Patient Assessment Information” http://aspe.hhs.gov/daltcp/reports/2011/StratEng.htm


[J1]Did the last roadmap call for EHR certification?





[1] ONC Beacon Community Program. http://healthit.hhs.gov/portal/server.pt?open=512&objID=1805&parentname=CommunityPage&parentid=2&mode=2&cached=true
[2] NGA Center for Best Practices. Issue Brief: health Information Technology Integration in Long-Term Care: Challenges, Best Practices, and Solutions for States. 2011.
[3] NGA Center for Best Practices. Issue Brief: health Information Technology Integration in Long-Term Care: Challenges, Best Practices, and Solutions for States. 2011.
[4] Summary Report from NGA State Alliance for E-Health Regional State Health IT Consultations July-August 2011.
[5] NGA Center for Best Practices. Issue Brief: health Information Technology Integration in Long-Term Care: Challenges, Best Practices, and Solutions for States. 2011.
[6] State and Regional HIE Initiatives Town Hall (June 2011) at the 2011 LTPAC HIT Summit.
[7] Putting the IT in TransITions. http://xnet.kp.org/newscenter/pressreleases/nat/2011/101111caretransitions.html

[J1]The following is the technically accurate description: Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act of 2009, and Patient Protection and Affordable Care Act of 2010, as amended by the Health Care and Education Reconciliation Act of 2010, (referred to collectively as the Affordable Care Act)
[J2]Before the Roadmap is published, these summaries should be cleared with representatives from the following programs.
[J3]Need to confirm the directionality.
[J4]Assessing the Performance Characteristics of Signals Used by a Clinical Event Monitor to Detect Adverse Drug Reactions in the Nursing Home
Steven M. Handler, MD, MS, et al. AMIA 2008 Symposium Proceedings Page – 278
[J5]Need to obtain a publicly available copy and link to this document
  • To what extent are there EHR solutions that support care coordination and interoperable health information exchange. (Summit speaker: Howard Degenholtz, University of Pittsburgh) (Steve Handler, University of Pittsburgh)

Types of Information and Tools Addressed in S&I Initiatives
Transitions of Care (ToC) Initiative
http://wiki.siframework.org/Transitions+of+Care+%28ToC%29+Initiative
  • Discharge Summaries
  • Discharge Instructions
  • Consultation Summary
  • Consultation Request
Longitudinal Coordination of Care Initiative
http://wiki.siframework.org/Longitudinal+Coordination+of+Care+WG
  • Transfer forms
  • Patient Assessment Summary documents
  • Longitudinal Care Plan including specific care plan use cases (e.g. exchange of plan of care between home care and physicians)
Other Relevant S&I Initiatives
http://wiki.siframework.org/
  • Electronic Submission of Medical Documentation (esMD)
  • Data Segmentation
  • Public Health
  • Query Health

Research
Definitions of Care Coordination
http://www.ncbi.nlm.nih.gov/books/NBK44012/table/A25899/?report=objectonly
Reference on Previous link:

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination)

Technical Reviews, No. 9.7
Investigators: Kathryn M McDonald, MM, Vandana Sundaram, MPH, Dena M Bravata, MD, MS, Robyn Lewis, MA, Nancy Lin, ScD, Sally A Kraft, MD, MPH, Moira McKinnon, BA, Helen Paguntalan, MS, and Douglas K Owens, MD, MS.
Stanford-UCSF Evidence-based Practice Center
Rockville (MD): Agency for Healthcare Research and Quality (US); June 2007.
Report No.: 04(07)-0051-7
ACO RULE
Coordination of care includes the ACOs having systems in place to identify high-risk individuals and processes to develop individualized care plans for targeted patient populations. We proposed that an individualized care plan be tailored to-- (1) the beneficiary's health and psychosocial needs; (2) account for beneficiary preferences and values; and (3) identify community and other resources to support the beneficiary in following the plan

Coordinate care across and among primary care physicians, specialists, and acute and post-acute providers and suppliers. The ACO must--
(i) Define its methods and processes established to coordinate care throughout an episode of care and during its transitions, such as discharge from a
hospital or transfer of care from a primary care physician to a specialist (both inside and outside the ACO); and
(ii) As part of its application, the ACO must:
(A) Submit a description of its individualized care program, along with a sample individual care plan, and explain how this program is used to
promote improved outcomes for, at a minimum, its high-risk and multiple chronic condition patients.
(B) Describe additional target populations that would benefit from individualized care plans. Individual care plans must take into account the
community resources available to the individual.

ANI Response to Notice of Proposed Rule Making EHR Incentive Program
Technology should be an enabler to support care coordination, enhancing the communication between care providers throughout the continuum of care. The health outcomes associated with this priority are focused on provider to provider data sharing and medication reconciliation. We would like to see language that clarifies and strengthens the responsibility of those who are responsible for prescribing medications to reconcile medication lists at key transitions of care. These transitions of care should be clearly articulated. ANI recommends future requirements should incorporate criteria on the use of electronic interdisciplinary education and care plans as well as multidisciplinary documentation flowsheets. The integration of data from these plans and flowsheets will enable higher standards of health information exchange across multiple providers and with PHRs. These standards should include the utilization of standard plan of care language and pathways, and standard terminology data sets.

Federal Health IT Strategic Plan

Several use cases presented on care coordination

Address quality measures and evolving clinical decision support opportunities that will promote appropriate exchange of health information in LTPAC and behavioral health care settings for optimal coordination of care

Build on meaningful use to adopt electronic standards for the exchange of clinical data among facilities and community-based LTPAC settings, including, where available, standards for messaging and nomenclature.

Recognizing that emergency care settings are essential places for patient care coordination. Explore ways to address the need for clinical data to be available in emergency care situations and identify policies and standards that are necessary to support these needs.

Patients managing illnesses or other ailments can use health IT to connect with other patients that share a similar condition, keep better track of their health care, receive health care solutions remotely, and participate in their care coordination.

VA’s Care Coordination Services uses health informatics, e-care, and disease management technologies to avoid unnecessary admission to long-term institutional care facilities. Technologies include videophones, messaging devices, biometric devices, digital cameras, and remote monitoring devices. VHA also has an award-winning PHR, "My Health eVet," which gives its patients access to their health information along with other VA information and services. DoD’s MiCare portal enables its patients to manage their medical information through a PHR of their choice. IHS is in the process of developing a PHR for its patients which will support meaningful use requirements. CMS is piloting free PHR options for Medicare recipients. "Medicare PHR Choice" gives people living in Arizona and Utah a choice among four vendors’ PHRs, and automatically updates their online record with Part A and Part B claims. "My Personal Health Record South Carolina" allows participants to see their medical history based on the past two years of claims. Additional information can be added manually, and the PHR provides helpful resources to understand diagnoses, conditions, and procedures.

Steps to focus care coordination (Owens, Southeastern Consultants, 2009)
http://www.pcpcc.net/files/owens_focusing-care-coordination_120809.pdf
1. Identify, quantify, and target patients with uncoordinated care
2. Incorporate targeting into care delivery models with actionable information
3. Direct provider/patient incentives with a patient-centered, shared accountability approach
4. Use HIT, clinical integration, and decision support tools
5. Review and validate efforts

HITSP Medical Home Interoperability Specification

The American Health Information Community’s (AHIC’s) 2009 Medical Home: Problem Lists & Practice-Based Registries Extension/Gap describes two main requirements:
• The ability to manage patient problem lists and provider information (from intra-organizational and inter-organizational sources) within the medical home to
support co-morbidity management
• The ability to utilize information to perform practice-based, patient population management and registry functions within the medical home for care coordination
to support individual patient needs

Care Coordination Measures Atlas

The health care community is struggling to determine how to measure the extent to which care coordination activities are being implemented. AHRQ’s new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlasis useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination.
http://www.ahrq.gov/qual/careatlas/
Prepared by: Kathryn M. McDonald, M.M.1; Ellen Schultz, M.S.1; Lauren Albin, B.A.1; Noelle Pineda, B.A.1; Julia Lonhart, B.S., B.A.1; Vandana Sundaram, M.P.H.1, 3; Crystal Smith-Spangler, M.D., M.S.1, 3; Jennifer Brustrom, Ph.D.2, Elizabeth Malcolm, M.D., M.S.H.S.4
Select for print version (PDF File, 2.2 MB). PDF Help.

Health Information Technology Toolkit for Home Health Agencies
The HIT Toolkit for Home Health Agencies consists of seven stages categorized into three main sections. Descriptions of the individual tools are available on the Web pages for each section. This toolkit was funded by Aging Services of Minnesota and its subsidiary Alliance Purchasing for use by home health agencies in Minnesota. Produced by Stratis Health.
All of the tools are listed below.
  • Section 1. Adopt: Assess - Plan - Select
  • Section 2. Utilize: Implement - Effective Use
  • Section 3. Exchange: Readiness - Interoperate
http://www.stratishealth.org/expertise/healthit/homehealth/hhtoolkit.html


Rationale:

Patient Centered Care Primary Collaborative
  • Lack of coordination can be unsafe, even fatal, when: abnormal test results are not communicated correctly, prescriptions from multiple doctors conflict with each other, or primary care physicians do not receive hospital discharge plans for their patients;
  • Uncoordinated care is also costly because of duplicated services, preventable hospital readmissions, and overuse of more intensive procedures.
  • Models of care coordination are demonstrating how health care can be delivered more smoothly and efficiently, particularly for people with chronic illnesses and complex needs. Though details differ, the best of these models share some common characteristics:
  • Individuals and families at the center of care planning and delivery;
  • Care continuity across medical and non-medical services and from acute to long-term settings;
  • Strong clinical and organizational support for effectively coordinating care;
  • Appropriate payment incentives for coordinating care and integrating benefits;
  • Systems for including the consumer voice in care design and plan governance.


Objectives:
  • Talking point for LTPAC engagement
  • Leverage models like ACCs (ACOs) and how longitudinal care fits in the care model
  • LTPAC can approach the hospital to reduce hospitalizations and financial incentives
  • Longitudinal Care Plan
  • Similarities with PCPCC Clinical Decision Support
  • For LTPAC to engage in clinical decision support – we should pick our quality measures very carefully – what we know well and create the related decision-support tools
– Compliance with benchmarks and practice guidelines (should establish a floor
– Need information on the current state of clinical decision support related to meds and med monitoring in LTC and the analytics that are being applied
  • Some of the consulting pharmacy package have the information
  • Meaningful Use
    • How LTPAC informs Meaningful Use and the strategy on the hospital side
      • Measure for stage 2 MU – ER receives a summary document from all patients being sent from a LTPAC provider
      • Standards Challenges
        • Functional status gaps
– Gaps in standards (content) and transmission (not a fit in current CCD/C32 structure)
  • LTPAC Providers need to decide if they will use a standardized approach to information exchange (won’t be incentivized)
  • Identification of standards needed for different document types of high value in health information exchange. Id through Standards Committee; Use S&I Framework; Have adopted by Secretary
– Home Care Plan of Care Document
– Universal Transfer Form
– Assessment and Assessment Summary
– Meds and Medication Reconciliation;
– Medication Monitoring (labs, meds, MDS and algorithms to detect and prevent medication errors)
– Advanced Directive
– Immunization
– Longitudinal care plan
  • Need to get the LTPAC community and vendors engaged in the standards communication
– Who will provide the leadership role to role to bring together the vendors?
– Be realistic about who will and should participate
  • CCD
  • Role of Certification

Strategies:

(ONC)
  • Transition of Care Event planned October 14th
  • Experts brought in to evaluate transition of care issues
  • S&I Framework LTPAC group launched
  • November LTPAC meeting is under consideration
  • Liz is looking at pulling together a HHS LTPAC workgroup to align activities

Suggested Speaker(s) at Summit:
##
Group Work Process Notes:

Introduction/Background
We need to provide a good definition for Care Coordination
Describe what we mean by Care Coordination.
Care Coordination has become a big concept in health reform and IT discussions.
Frame the issue of care coordination around topic areas such as workflow, transitions of care, care planning, shared care (interdisciplinary).
Describe how is Care Coordination facilitated with LTPAC HIT.

How health IT/HIE is important to support care coordination.


Evidence
Electronic health information exchange (bridging concept between paragraph 1 and 2)
Demonstrate through examples how hit has been shown to support care coordination

  • 12/1 Rich: will find AHRQ link and summarize study of information exchange between physicians and home health)

  • 12/1 Jennie: will find and summarize Steve Handler’s work (Integration of data to support care coordination, prevents errors, produces alerts, and communicated to health care providers (Steve Handler at University of Pennsylvania study on integration of data, clinical decision support, and alerts).

Current State of the Play

  • 12/1 Todd and Rich will reach out to NASL/HCTAA members and identify: what HIT/EHR solutions that support care coordination and interoperable health information exchange. For example:
    • What percentage of available EHR/HIT products support (i) interoperable HIE and (ii) non-interoperable HIE. For example:
      • Transfer documents
      • Physician E-prescribing
      • HIE with Pharmacies
      • Patient Assessment
      • Lab results
      • Identify Other HIE opportunities
  • 12/1 Dan Cobb: will summarize what CCHIT EHR certification criteria supports care coordination.


  • 12/1 Ask Liz if she can produce/obtain a brief description of the following initiatives and how they support care coordination that includes LTPAC providers:
  • Four ONC Challenge Grants: Massachusetts (UTF transfer form), Colorado, Oklahoma, and Maryland;
    • 12/1 Todd will also collect info re: what is going for all 4 Challenge Grants
  • ONC Beacon Community Programs: Geisinger Keystone Beacon, Maine (Rich will follow-up with ME);
  • ONC putting IT into transitions effort,

Standards and interoperability:
12/1 Sue will describe S&I LCC WG activities re: care coordination.
Other Public/Private Sector Initiatives:
  • ACO
  • Sec. 3026 (care coordination, AoA ombudsman) Jennie will get some info (hopefully) this week.
  • Other ACA provisions
  • Patient Center Medical Home
    • Jennie will describe: MN LTC Medical Home efforts

Workflow

12/1 Greg will work on this section: Workflow and flow of information is extremely important for continuity of care and business strategies.
Seamless fit of HIT with care coordination processes.

  • 12/1 Annessa will review past work:
  1. How does Care coordination fit into priorities and recommendations from the LTPAC HIT Roadmap 2010-2012?
  2. Review topic areas in the 2010-2012 Roadmap to identify care coordination/HIE areas/topics that need to be brought forward such as (b) Certify LTPAC Vendor Solutions and (c) Adoption and Use of Health IT and EHRs


12/1 Next step
  • Next meeting: Review the care coordination definition.



Action Items:
Look for a definition in the emerging roadmap.
Find references to help define
Obtain Provider article that lists all LTPAC HIT Vendor Solutions (Dan)