LCC+Use+Case+Comments

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 * **Commenter** || **Comments** || **Dispositions** ||
 * Karen Utterback || Page 13, lines 1-6 - Individuals spend the vast majority of their time in the home and there is significant value in maintaining an accurate record or allergies, medications and problems that are not confined to the definition of longitudinal beging determined by an episode of care. My strong recommendation is that while this may be a starting point until the existence of a strong HIE network or Nationwide HIE but should not be accepted as the long term goal.

Page 13, lines 13 - 17, I believe purchasers of LTPAC systems need the assurances of Certification regarless of incentive dollars, however the reality is that until the ONC endorses a certification for this segment of hte market vendors will be reluctant to make the investment.

Page 13, lines 27 - 30, The ICFs should provide the standard for determining disability. This likely will need to follow the adoption of the ICD10s but we should push forward with that and not create another means outside of the ICFs if possible || Comments will be moved to parking lot for future discussion. The document itself will remain unchanged because the portions commented on are quoted directly from the Meaningful Use Stage 2 NPRM. ||
 * Rosemarie Namisato || - p. 32 lines 16-18 read, 'The HHA staff begins care and sends the approved HH-POC to the ordering Physician to review and electronically sign.'

- p. 33 lines 4-5 read, 'The updated HH-POC is sent to the ordering Physician EHR system to review and sign.'

- p. 33 lines 13-14 read, 'The HHA staff begins care and sends the approved HH-POC to the ordering Physician to review and electronically sign.'

Rationale: Orders sent to the physician from the HHA system have been agreed upon by the HHA clinician and the physician through a verbal order, and most likely have already been executed. These orders have to be signed FIRST before further changes to them are made. Further changes to the order can be considered an instance or another instance (in the case of an interim order)of an interim order. || All comments accepted ||
 * Teresa Mota || Page 8: “Any statements about actual cost savings really are not justified as there is no specific evidence that any of this saves money. Suggest revising the first sentence to more address the "triple aim" - "Information exchange to support a broad array of health transitions of care is essential to healthcare reform because its implemention will enhance care coordination, improve clinical outcomes, boost care efficiencies, and decrease adverse events, all of which may provide cost savings throughout the system."

Page 21: “8.0 Actors and Roles - Table: Why is Transfer of Care Summary not in this table for NFs? User Story 1 would support this, and page 25, lines 9-10 as well other pages, would support its inclusion in the table.” || - Corrected the typo pointed out - Page 8: - Page 21: Page 23: “Doesn’t putting the “Trusted Clinical Exchange” label there without an asterisk and a footnote indicating it MAY be used appear to conflict with the idea that “Direct” implementations may be developed and implemented that allow direct provider to provider contact?)” Page 33: “Does the HH-POC contain all the data from 1-4? “ Page 34: “(Note that in Medicaid-funded care transitions, the ordering practitioner can be an NP)” Page 47: Should this read “to support Medicare and/or Medicaid payment” – we have noted at the beginning that insurance is out of scope for the use case, yet here were are… Right now, commercial insurance hasn’t adopted this, so we should be specific because the HITECH Act relates specifically to CMS payments and documentation and metrics requirements for Meaningful Use payments (CMS-only payments).” Page 51: “Why is there a step 10 that seems to repeat Step 9 within the HHA. If anything, shouldn’t this be either trigger of nursing care plan or perhaps nursing orders (I’m a nurse but am a little unclear about how the concept of nursing orders are used in the nursing discipline. I was trained in Switzerland. Nursing orders may be a US-specific concept)." || - We largely accepted in line edits. - Page 15 in reference to Care Coordinators definition: - Page 23 in reference to Context diagram: - Page 33 in reference to overlapping data transactions: - Page 34: - Page 47: - Page 51: <span style="font-family: Arial,Helvetica,sans-serif;">- Datasets comments: For the reasons listed below, I disagree with the PASD being defined as “out of scope” (p.7-8): 1). Requirements and data sets for the PASD are being identified and defined in the PAS SWG. 2) The PASD SWG is collaborating w/ HL7 to advance the PASD as a document type in the C-CDA 3.) It could be that "Clinical Summary information and its basic data set(s) for the [TOC] to include the transfer of care and the exchange of clinical information between providers and between Providers and patients” could be the PASD. 4.) Ruling this out of scope could have implications for future MU requirements and EHR CC. 5.) The comment on p. 8, line 22-23 indicate that the PASD could be a solution for needed HIE. 6) The statement on p. 17 (lines 26-27) indicating that guidance may be provided re: use of assessment data. Based on the above, it seems that it is unnecessary, counterproductive, and confusing to determine the PASD as out of scope. I recommend that the statement be stricken, and the “in-scope” section (p.7) include the following: • Definition of requirements and data sets for Patient Assessment Summary Documents (PASDs) is in scope. The PAS SWG, in collaboration with HL7, is identifying the requirements for PASDs, taking into account content from federally required patient assessments, the CARE Instrument (which has been subject to CMS demonstrations, and from which data elements will be used to support quality measures in long-term care hospitals (effective 10/1/12)), and data elements needed to support the Transitions of Care described in this Use Case. || During initial scoping discussions last April, we agreed that the requirements for PAS document and data elements were out of scope for the LCC Use Case because these PAS requirements were being developed in a parallel project involving Keystone Beacon and HL7. While the PAS SWG would provide input to the PAS project, the LCC Use Case requirements would focus on summaries for 1) transfer of care from acute care to exemplar LTPAC, i.e., HHA, 2) consultation request, 3)shared care encounter and 4) the home health plan of care. These information exchanges, summary documents and data considerations were the primary output of the LCC Use Case as scoped.
 * Disposition: Added language above.
 * Disposition: Although the transfer of care summary can be used by Nursing Facilities, Home Health is the exemplary transaction for Use Case 1. This was a scoping decision made at the Face to Face in order to keep our user stories focused. Conversely, Nursing Facilities were selected as the exemplar for the shared care consultation summary. No change required. ||
 * Rich Brennan || Since PHR systems are mentioned in the use case but not under control of the Providers we would suggest including them in the Out of Scope section. Suggested language: PHR systems or any funcational aspects of end-point systems other than to identify sending and recieving systems. || Incorporated PHR into existing language. ||
 * Susan Campbell || Page 15: <span style="font-family: Arial,Helvetica,sans-serif;">“Should this be changed to Coordinators of Care”
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: Leave as is based and move discussion of care coordinators v. coordinators of care to group discussion parking lot to be discussed for later use cases.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: Dotted lines indicated optional presence of HIE. Direct is contemplated in diagram. No change needed.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: the language is overlap which does not imply that there is complete overlap. Users can reference datasets for a more detailed picture of data relationships. No change needed.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: Although ordering privileges may differ by program and state, for the purposes of functional requirements Physician is an adequate description. No change needed, but this will be move to the parking lot for discussion by the WG for future Use Cases.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: This distinction doesn’t enhance the functional requirements. No change needed, but will move to the parking lot for discussion by the WG for future Use Cases.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: 9 is the sending action and 10 is the receiving action. They are distinct. No change necessary.
 * <span style="font-family: Arial,Helvetica,sans-serif;">Disposition: Removed some commentary as this can be taken up during Harmonization. The basic comments were driven by the group and will serve as initial guiding thoughts that will be born out in the Harmonization process. ||
 * Jennie Harvell || Primary comment:

When finalized the LCC Use Case requirements will be handed to Harmonization. Harmonization evaluates existing standards to determine best fit to meet requirements, identifies gaps and produces implementation design. We anticipate that Harmonization will evaluate the PASD requirements and as available HL7 C-CDA PAS Document type including sections and data entries as suitable for fulfilling data requirements for any of the four LCC Use Case document requirements.

We believe that we had full agreement on the parallel work on developing requirements with the plan to harmonize solutions at the next step in the S&I process and that the out of scope language had been reviewed and approved in open meetings.

However, to further clarify, we propose the following language be added to Section 2.1 In Scope:

“While this Use Case does not define the detailed information exchange and data requirements associated with Patient Assessment Summaries, the Use Case recognizes that patient assessment is integral to transfers of care and care plans. Detailed PAS Document requirements are being developed in a parallel project by Keystone Beacon with input from the S&I LCC PAS Sub Work Group and HL7. It is anticipated that the PAS Document emerging from the Keystone Beacon work will also be useful in meeting the patient assessment and potentially other summary data requirements for transfers and plans of care. This work will be done in Harmonization. “

We would then delete the last entry in Section 2.2 Out of Scope. || 2.3.2 Background Specific to the HH-POC, Page 10: Insert "two": Throughout the Home Health episode, which may range from several days to many two months 2.3.2 Background Specific to the HH-POC, Page 10 Insert the following sentence at end paragraph starting on line 15: At the end of two months, if the patient continues to require HH service, the patient is re-assessed by the HH agency and a new plan of care is approved by the physician. 2.4 Policy Issues, Page 10: lines 36 and 37 Revise to clarify unclear terminology -- i.e.,longitudinal care record and longitudinal care plan :
 * Jennie Harvell || 2.3.1 General Background, page.8: Insert "ASPE" - The December 2011 LTPAC paper from ASPE/AHIMA cites the following advantages of using Patient Assessment information for clinical purposes, based on expert opinions:

2.4 Policy Issues, Page 11: lines 6-8: reword as follows: The Meaningful Use Stage 2 NPRM establishes more HIE requirements for HIE between LTPAC and providers eligible for EHR incentives, and some requirements related to care planning, but

11.1 User Story of Scenario 2, Page 33 line 6 Insert "iterative": The Iterative Exchange of Information

14.0 Dataset Considerations, Page 55-59: Suggested additions to data set considerations (see mark-up sent to Kris and Victor)

Appendix E. References Page 55: strating on line 4. Reference should reflect that the Opportunities Report... was an HHS/ASPE report, produced under contract and in collaboration with AHIMA. || Edit made

Is this two month requirement for recertification Medicare only?

Same is this a Medicare only requirement? If so should we note or explain this as a Medicare requirement?

Change language as follows:

The LCC WG seeks to inform the discussions of both the HITPC and the HITSC by defining interoperability standards applicable to LTPAC Providers as well as laying out a roadmap for supporting longitudinal care coordination that includes a longitudinal care plan.

Change text as follows:

The Meaningful Use Stage 2 NPRM establishes more health information exchange requirements for exchange between LTPAC and providers eligible for EHR incentives, and some requirements related to care planning, but. . . Unclear where to insert phrase or replace other language

We will send your recommended additions for Type 5 data to Larry Garber and Terry O’Malley for review.

Edit made || Page 26, Section 10.1.1 Line 27 In this story, it indicates that the Provider creates the order for Home Health Care before the provider sends the Transfer of Care Summary to the HHA. I want to clarify whether or not the Transfer of Care Summary will include the orders for Home Health Care or serve as sufficient documentation to account that the HHA has received orders to initiate the start of care. If not, I propose that the workgroup work to include the order in the transfer of care summary. There is considerable administrative labor spent ensuring a signed initial order from a physician or have a clinician available to receive and document verbal order for the start of care. Furthermore, there is considerable time by the physician to provide the initial order to the HHA to initiate care when a Physician has already presumably documented the order for Home Health in their own EHR System. By including the referral / order information in the Transfer of Care Summary document (e.g. Services Ordered & Frequency & Signature), we can reduce administrative labor within the Healthcare system during these transfers of care. || In discussion of user stories and of data requirements, the WG decided that actionable orders, specifically the orders for HHC, were out of scope for the specific document types identified (transfer of care summary and home health plan of care). These documents would contain supportive data.
 * Eric Thul || Comment: Clarification of Transfer of Care Summary vs. Initial Order for Home Health Initiation of Care

While no standard is selected by the Use Case, the working assumption is that Harmonization would leverage the Consolidated CDA to fulfill the UC requirements. The Standards Development Support function confirmed that the CDA is not used to convey orders. However, it can contain lists of orders that have been placed. See Order Listing in the Data Consideration table:

“Consider actionable/ Signed Orders versus a catalogue of existing or pending orders. The focus here is a list/ catalogue of what has been ordered to inform the care team.”

We agree with the importance of the initial order for HHC and that it may be created within an eligible provider’s EHR. Thus we believe this should be actively considered for in scope by the next Use Case || Page 55, LCC Use Case Data Set Requirements, “F2F – Medicare” In the data set requirements table, there is a line item for F2F – Medicare and it indicates that it is available for the Type 5 Transfer File. I want to know whether this means that the transfer of care summary will include the last face to face encounter with a qualified provider regarding the reason for home care. Furthermore, this documented face to face encounter, if occurring within the standard timeframes as necessitated by CMS, should serve as documentation for the F2F requirement and no other documentation should be required unless the encounter is non-compliant or not available in the Transfer of Care Summary.
 * Eric Thul || Comment: Clarification whether Transfer of Care Summary will include F2F Attestation

Comment: Clarification of Standardized Medication & Allergy Listings within the Transfer of Care / HH-POC Page 53, LCC Use Case Data Set Requirements, “Active Medications”, “Allergies and Intolerances”, Page 54 “Medications” Does this use case specify or intend to specify a common standard for exchanging Medications & Allergy listings across provider settings and within the LTPAC community? Medications and Allergies will be a great place to start in harmonizing data standards from the LTPAC community with the Physicians and Acute Care Hospitals to achieve Medication Reconciliation efforts. Additionally, why does the Med list on Page 53 inherit from the ToC use case, but the Med list on page 54 does not have any reference to the ToC Use Case? || The WG added the F2F – Medicare data requirement as you noted with the intent that it could be used to document Medicare requirement for “Homecare Diagnoses/Specific conditions requiring treatment”. However, the WG did not go into detailed data requirements for all F2F documentation, which will occur in Harmonization. This will determine if in fact whether these summaries are sufficient.

It is the intent of the WG to leverage existing harmonized standards for medications and allergies as defined by the original ToC initiative and now reflected in the Consolidated CDA for adoption by LTPAC community.

The Med list on page 54 should reflect the same reference to ToC. In fact Active is another attribute of Medications which could have been consolidated with other Meds. However, it is called out separately based on the Core Clinical Data that ToC called out for every transition. || Page 56-57 Does this use case specify or intend to specify a common standard for documenting care plans across provider settings and within the LTPAC community? The HH 485 represents a strong baseline of structured care plan data with the different locator fields. Will we attempt to pursue a path of standardizing a data model within and across the locator fields of the care plan? We recommend a common relational data model standard. Additionally, attempting to standardize the menu of specific Problems, Goals & Interventions available to every LTPAC provider may be more challenging. Additionally, many LTPAC providers develop proprietary protocols and pathways based upon goals & interventions which may be hindered by a common care plan menu. The plan of care ideally will be customizable by setting and location while allowing providers to develop proprietary protocols and innovation when appropriate.
 * Eric Thul || Comment: Clarification of Care Plan Elements & Level of Standardization within the HH-POC

Comment: Will Transfer of Care Summary be inclusive and negate the need for state specifics transfer forms?

The following items are historically not available in transfer documentation from hospitals and greatly impact Home Health needs. We hope that the transfer of care summary will include this info: • Wound Care Medications & Dressings • If patient has Feeding Tube • Living Wills • Clarification of Inpatient Discharge Date to allow for more accurate HH hospitalization rates • Clarification of which Provider will Oversee HH Orders & Plan of Care It will be important to include into Scenario 1 the Primary Physician to LTPAC Site Story i.e. “Community Referral”. || The WG decided to include a Plan of Care in the initial UC as foundational and informative to future work on a universal, longitudinal plan of care, which is being defined in a separate LCC White Paper. The WG chose the HH POC as the initial exemplar and based data requirements on the “485” with some additions and modifications.

Based on pilot implementations, we would expect to learn how readily POC data and exchanges can be extended to other LTPAC settings.

Underlying data requirements for transfer of care as well as referrals is based on collective work in Massachusetts for IMPACT. It is designed to support initiation of safe care by the receiving provider upon any transition. The data elements you listed are included in the Type 5 data set within data set concepts:

• Advanced directives • Assessments, Interventions and Orders • Care team information including physician

We anticipate further work in Harmonization to detail data for care team members and their roles including oversight.

If understood correctly, a direct transfer of care by the Primary Physician to LTPAC is out of scope. However, as the UC is foundational, future UC and or application of Harmonized transfer of care summaries might leverage the hospital generated transfer of care summary. ||
 * Teresa Lee || **<span style="font-family: "Calibri","sans-serif"; font-size: 14.66px;">Comment **<span style="font-family: "Calibri","sans-serif"; font-size: 14.66px;">: <span style="color: #000000; font-family: "Calibri","sans-serif"; font-size: 14.66px;">We have only the following comment: On page 54, the Admitting & Discharge Diagnosis and Discharge Medication data points are not included in the Home Health Plan-of-Care. These data points are important for the home health team to treat the patient and reconcile the patient's medications. || We interpret your comment to refer to admitting and discharge diagnosis and discharge medications of provider organization referring patient to HHC, correct?

<span style="font-family: "Calibri","sans-serif"; font-size: 14.66px;">These data would come to the HH Information System as part of the Transfer of Care Summary. However, we can add these data requirements to be included in the HH POC. ||

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