Longitudinal Coordination of Care Pilots WG Monday, September 30, 2013
Longitudinal Coordination of Care Pilots WG Monday, September 30, 2013.
Mar 27, 2015
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Longitudinal Coordination of Care
Pilots WGMonday, September 30, 2013
Meeting EtiquetteRemember: If you are not speaking, please keep your
phone on muteDo not put your phone on hold. If you need to take a call,
hang up and dial in again when finished with your other call o Hold = Elevator Music = frustrated speakers
and participantsThis meeting is being recorded
o Another reason to keep your phone on mute when not speaking
Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know.o Send comments to All Participants so they
can be addressed publically in the chat, or discussed in the meeting (as appropriate).
From S&I Framework to Participants:Hi everyone: remember to keep your phone on mute
All Participants
Topic Presenter
Introductions and Purpose Lynette
Overview of CORHIO Pam
Overview of Pilot wiki and tools Lynette
Agenda
3
• Purpose– Provide tools and guidance for managing and evaluating
LCC pilot Projects– Create a forum to share lessons learned and best
practices– Provide subject matter expertise– Leverage existing and new partnerships
• Goals– Bring awareness on available national standards for HIE
and care coordination– Real world evaluation of parts of most recent HL7 C-CDA
Revisions Implementation Guide (IG)– Validation of ToC and Care Plan/HHPoC datasets
Pilot Work Group Purpose and Goals
4
LCC Pilot WG Timeline: Aug 2013 – Sept 2014
Mile
ston
es
Updated HL7 C-CDA IG
Complete
HL7 Fall Ballot Close
LCC Pilot Monitoring & Evaluation
LCC Pilot Proposal Review
HL7 Ballot Publication
LCC Pilots Close
HL7 Ballot & Reconciliation
LCC Pilot WG Launch
IMPACT Go-Live
NY Care Coordination Go-Live
HL7 C-CDA IG Revisions
LCC Pilot Wrap-Up
LCC Pilot Test Spec. Complete
HL7
Bal
lot
LCC
Pilo
t WG
LCC Pilot WG Tasks
6
Target MM Pilot WG Tasks (Agenda) WG Homework
Sept 13 • Launch LCC Pilot WG• Review Pilot Planning Tools
• Review and submit LCC Pilot Documentation Templates
Oct 13 • Present MA IMPACT Go-Live Plan• Review Pilot Requirements Traceability Matrix (RTM)• Review Pilot Proposal Criteria Matrix• Present Pilot Proposals
• Review: LCC Pilot RTM• Submit LCC Pilot Proposals• Evaluate Pilot Proposals
Nov-Dec 13 • Present NY Downstate Go-Live Plan• Present and evaluate Pilot Proposals• Present IMPACT Pilot Status• Present NY DD Pilot Status
• Review: Pilot Evaluation Template
Jan-Feb 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for IMPACT & NY DD Pilots
• Gather Pilot Performance Data
Mar-Apr 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for NEW* Pilot Sites
• Gather Pilot Performance Data
May-Jun 14 • Present LCC Pilots Status• Review Phase 1 Performance Metrics for NEW* Pilot Sites• Review Phase 2 Performance Metrics for IMPACT & NY DD Pilots• Review recommended revisions to C-CDA IG
• Gather Pilot Performance Data• Submit recommended C-CDA
revisions
July-Sept 14 • Review Phase 2 Performance Metrics for NEW* Pilots• Review and consolidate recommended revisions to C-CDA IG• Close out Pilots• LCC Pilots Open House
• Gather Pilot Performance Data• Review recommended C-CDA
revisions
Longitudinal Coordination of Care Pilots WG
CORHIO-LTPAC Transitions Program
September 30, 2013Pamela Russell, LTPAC Program
Agenda
• About CORHIO
• Initial Outreach through surveys and letters
• Participating LTPAC Providers
• Milestones and Measures
• Statistics on Usage and Queries
• Lessons Learned
• Q&A
About CORHIO
Goals for 2015• Health information exchange deployed in
every community• 85% of providers are meaningful users of electronic
health records (EHRs)
Health Information Organization
Care Transitions: Care Transitions: Long-Term & Long-Term &
Post-Acute CarePost-Acute Care
Medicaid EHR Medicaid EHR Incentive Incentive Program Program OutreachOutreach
Behavioral Behavioral Health Health
IntegratioIntegrationn
Regional Extension Regional Extension CenterCenter
Assist providers with EHRs & Meaningful Use
CORHIO
Health Information Health Information Exchange (HIE)Exchange (HIE)
CORHIO By the Numbers
Office-Based Physicians/ProvidersConnected or in Implementation
Hospitals Connected or in Implementation(30 are already connected to the HIE)
Unique Patients With Clinical Data in the HIEData current as of Aug 20, 2013
Long-Term, Post-Acute Care, Home Health Facilities Connected or in Implementation
4545
111199
1,8001,800++
2,582,6752,582,675
Labs Participating in HIE
• Cedar Diagnostics
• Colorado Lab Services
• LabCorp
• Quest Diagnostics
• Schryver Medical
Bold = Connected to HIE (Live)
Non-bold = Under agreement, in implementation
LTPAC Program –The Beginning• What’s HIE?
• Initial Outreach – Survey letters to LTPAC Providers
• Community Meetings in targeted communities– Area Agency on Aging– CFMC – state QIO– CHA – Colorado Hospital Association– CHCA – Colorado Healthcare Association
• Collaborations with hospitals, physician practices, care coordinators and care transition community groups
• Participant Agreement Milestones and Measures
What is HIE in Colorado?
The ability to electronically exchange patient health information including:
Lab/pathology resultsImaging/radiology reportsScheduled OrdersADT’s, H & P’s Discharge Summaries
Transcribed notesContinuity of Care Documents (CCDs)
…when it’s needed for patient care.
CORHIO HIE
• CORHIO, as SDE, manages the State Medicaid Health IT Plan and has a strategic roadmap for statewide HIE projects
• CORHIO currently supports HL7 2.5.1 transaction level information, Human readable CCDs in PDF directly from HIE.
• CORHIO is actively working on extracting structured CCDAs from CEHRT and publishing CCDAs into the HIE by Spring 2014.
• CORHIO will align with Colorado OIT recommendations supporting commercial technical solutions utilizing industry standards including Direct, Blue Button, HL7, etc.
• These developments will support PHR implementations throughout Colorado
It Takes a Community…
CORHIO Helps All Providers in the
Community Share Info & Coordinate
Care
CORHIO Helps All Providers in the
Community Share Info & Coordinate
Care
LTPAC Program Outreach
• Survey letters sent to 350 long-term and post-acute care providers
• Gathered information on IT readiness, internal resources and interest
• Participant Agreements completed and sent• Business Associate Agreements completed and sent –
Revised Sept. ‘13– Policies and Procedures - HIPAA– Opt Out language– User Request Forms with user name and password– Auditing Reports
• Workflow Process both internal and external assessed
Internal LTPAC Resources
• Internal CORHIO staff– LTPAC Program Manager– Finance/Contract Manager
• PA’s• BAA’s• Milestones and payments• AARA Report
– Surveys – all three– MarCom – video, collaterals– Ops – Implementation and Training including
• Policy and Procedures• Opt Out language• User Request Forms
External LTPAC Resources
• Core Users tied to milestones– Admission Coordinators– Health Information Managers/Medical Records/IT– Nursing Staff – especially night and week-end– Clinical Liaisons– Medical Directors
• Users – Therapists– Nurse Practitioner/Physician Assistants– Charge Nurses
LTPAC Milestones
• Milestones included:– Implementation and Training
• 30-45 days to train LTPAC Users• One hour training can be one on one or group
setting• Implementation “refresher” webinar training
accessed through CORHIO’s 24/7 Help Desk – Core Usage and Monthly Utilization Reports
• Manual Process with goal to be automated– Surveys
• Pre-Work Flow/Baseline• Satisfaction Surveys• Qualitative Survey
Participating LTPAC ProvidersSkilled NursingAssisted LivingHome HealthHospice and Palliative CareLabs
LTPAC Participants
And Many More!
Long-Term, Post-Acute & Home Health Care
LTPAC Users - Quick Stats
© 2013 Colorado Regional Health Information Organization (CORHIO) - All Rights ReservedCORHIO Proprietary - Not For Redistribution 23
April 2012 - Nov 2012
Dec 2012 - August 2013
Grand total
# Users 487 1090 1,577# Logged In 218 2,363 2,581# Queries 71,994 414,277 486,271# CCDs created 110 308 418# CCDs viewed 55 129 184# CCDs printed 24 81 105# CCDs exported 13 101 114
Patient Care 360® LTPAC Customer Satisfaction Survey Results
• Has PatientCare 360® improved your patient care transitions? 100% of participants polled answered “YES.”
“We are able to obtain more current information and to obtain additionally requested information more quickly.”
• Has PatientCare 360® made your job easier?100% of participants polled answered “YES.”
“I get access to info more promptly than before.”
• Do you believe that PatientCare 360® helps you provide better care to your patients?
100% of participants polled answered “YES.”
“Information needed is often readily available improving response time to physician inquiries.”
04/10/2324
© 2010 Colorado Regional Health Information Organization (CORHIO) - All Rights ReservedCORHIO Proprietary - Not For Redistribution
LTPAC Challenge Grant Measures
• 80% of transitions to and from targeted LTPAC providers include electronic exchange of standard health information– Pre-Work Flow Surveys documented 0% to 10%– Post GO LIVE survey documented 100%
• 70% of transitions to and from targeted LTPAC providers include transmission of information within 2 hours of discharge – Pre-Work Flow Surveys averaged 32 hours (see
slide)– Post GO LIVE Surveys shows 6 minutes
Workflow Improvement
Average Time Spent Locating Patient Health Records
Average Time Pre-HIE
Average Time 30 days Post-HIE
Average Time 60 days Post-HIE
29 hours 46 minutes
11 minutes 42 seconds
6 minutes 30 seconds
HIE saves LTPAC practices an average of 29 hours per admission
LTPAC Challenge Grant Measures, continued
Providers in targeted communities respond to 100% of patient requests for copies of care summary information
– All LTPAC providers have the ability to create and print CCD’s for their patients/family members upon request
– CCD’s are documented on a monthly basis • Manual process to show # created, viewed, printed
and exported• Need to further drill down for usage
Lessons Learned
• LTPAC Staff Resources– Turnover– Able to update resume with IT experience– Competing IT efforts
• Work Flow Process – Faxing for Data Senders (hospitals) - positive
• Hospital Discharge Flyers– Faxing for LTPAC Data Receivers - negative
• Impact on their ability to “market” to DC Planners
• EHR/HIE Integration– HL7 capability and ability to receive and send
ADT’s and CCD’s
Standard HIE – PatientCare 360Clinical InboxReportsTestsCCD Exchange
How Query-Based HIE Works
30© 2013 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved
CORHIO Proprietary - Not For Redistribution
Community Health Record
Hospitals
Public Health Departments Laboratories
Radiology Centers
Hospital ADT Info
Lab Results Pathology Reports
Radiology Reports
Consult Reports
Transcription Notes
Public Health Alerts
Immunizations
Diagnostic-Quality Medical
Images (with CTN)
Medications lists
Data Analytics
Pharmacy Information
CCD
CCD Upload
OrdersFuture
CIIS
Newborn Screening
Results
Reportable ConditionsImmunizations
Lab/Rad
Immunizations
Break the Glass
04/10/23 © 2011 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary – Not For Redistribution 31
Depending on your security settings, you may not be able to
get into the patient chart without “Breaking Glass,” establish a relationship, to view a record
Depending on your security settings, you may not be able to
get into the patient chart without “Breaking Glass,” establish a relationship, to view a record
Click on Break Glass Link…
Click on Break Glass Link…
Establishing a relationship…
04/10/23 © 2011 Colorado Regional Health Information Organization (CORHIO) - All Rights Reserved CORHIO Proprietary – Not For Redistribution
32
If a user were going to break glass – they would be presented with this Confidentiality Alert. Staff must be associated with a
provider in order for Long Term Access to function.
If a user were going to break glass – they would be presented with this Confidentiality Alert. Staff must be associated with a
provider in order for Long Term Access to function.
CCD
CCDs allow you to compile historical summaries of the care that a patient has received through the community.
04/10/23 33
Select in the upper right corner of any
patient chart
Select in the upper right corner of any
patient chart
Previewing CCD
04/10/23 34
Click SaveClick Save
LTPAC Initiatives
• Regional and statewide meetings to encourage HIE adoption for LTPACs
• Multi-state meetings to share LTPAC experience• Collaborating with HCPF on the TEFT (Testing Experience and
Functional Tools in Community-Based Long Term Services and Supports)
– Demonstrate use of personal health record (PHR) systems with beneficiaries of CB-LTSS
– Identify, evaluate and harmonize an electronic Long Term Services and Supports (e-LTSS) standard in conjunction with the Office of National Coordinator’s (ONC) Standard and Interoperability (S&I) Framework
• CORHIO’s Consumer Engagement Strategy and PHR• State Innovation Model (SIM) Grant• CFMC/CORHIO Patient Transfer Form in Northern Colorado• True North EMS and LTPAC Providers
04/10/2335
© 2010 Colorado Regional Health Information Organization (CORHIO) - All Rights ReservedCORHIO Proprietary - Not For Redistribution
CORHIO Making an Impact
Click image to view video; Internet access required.
Other Participating Providers
Visit www.corhio.org
and select “Participating
Providers”
Interactive Map
Full List of Providers Below
For More Informationwww.CORHIO.org
Click on Long-Term Care
UnderFor Providers
Click on Long-Term Care
UnderFor Providers
LTPAC
video
LTPAC
video
Pamela RussellManager
Business Development & Outreach Long Term Care
Contact Info at CORHIO
• http://wiki.siframework.org/LCC+Pilots+WG
How Can You Participate in the LCC Pilot SWG?
40
Summary of Documentation Templates & Reference Materials (Pilot Materials)
41
Document Name DescriptionPilot Overview Document
An overview of the LCC Pilots Workgroup including a Value Statement for Participating Entities, Benefits of Participation as an LCC Pilot Site and steps for How to Get Started.
Work Group Planning Presentation
A Reference presentation for potential pilots that provides an overview of the Transition of Care and Longitudinal Coordination of Care Problems, the Role of Standards for Problem Resolution, and Overviews of the IMPACT and Downstate New York Care Coordination Projects.
Pilot Documentation Template
A PowerPoint template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot.
Pilot Plan TemplateA word template for potential pilots to use to present their Pilot Team; Goal of the Pilot; C-CDA of Interest; Use Case Scenario and Actors/Systems; Minimum Configuration; Timeline; Success Criteria; In Scope/Out of Scope; and Risks & Challenges details of their pilot.
• Homework Assignment:– Complete Pilot Survey– Sign up as an LCC Committed Member– Submit Pilot Documentation Templates
• Available on the LCC Pilot SWG Wiki: http://wiki.siframework.org/LCC+Pilots+WG
• Email to Lynette Elliott ([email protected])
• NO Meeting next week due to HL7 WGM in Boston, MA
Next Steps
42
• LCC Leads– Dr. Larry Garber ([email protected])– Dr. Terry O’Malley ([email protected]) – Dr. Bill Russell ([email protected]) – Sue Mitchell ([email protected])
• LCC/HL7 Coordination Lead– Dr. Russ Leftwich ([email protected])
• Federal Partner Lead– Jennie Harvell ([email protected])
• Initiative Coordinator– Evelyn Gallego ([email protected])
• Project Management– Pilots Lead: Lynette Elliott ([email protected])– Use Case Lead: Becky Angeles ([email protected])
LCC Initiative: Contact Information
43LCC Wiki Site: http://wiki.siframework.org/Longitudinal+Coordination+of+Care
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