Standardized Nursing Care Plans

â»â» good afternoon. my name is jennie harvell. thank you very much for taking the time toparticipate in this presentation this afternoon. as described, dr. o'malley and i will be talkingabout the impact act and assessment data element standardization and interoperability. related to data element standardization andfocusing on the work that's underway to standardize the initial set of data elements in post-acutecare settings. and also to define interoperability and standardizationrelated to this work. we want to highlight the opportunities toreuse standardized data elements in quality

measurement and also to use reuse data elementsthat have been standardized and made interoperable to support health information exchange attimes of transitions and other instances of exchanging information. we want to be able to describe, for you, theintersection between policy, payment, technology to support the reuse of data elements thathave been standardized and made interoperable to improve service delivery including carecoordination on behalf of some of the most vulnerable individuals in our society. a couple of keynotes and caveats, to meetthe impact act requirements each of the four post-acute care settings will continue tocollect assessment data elements in-their

setting-specific assessment instruments. cms will not replace these instruments withthe care instrument. instead, cms anticipates reusing some of thecare data elements to support standardization of data elements across the four post-acutecare settings. cms also anticipates that setting specificdata elements will likely continue to persist to support the needs of the population inthose specific settings. the data element library which we'll be talkingabout in a bit will be a repository for the post-acute care assessment data elements andkey mapped relationships to each of those data elements.

however, i want to point out that the librarywill not include any personal health information. it's simply a repository of the assessmentdata elements and their mapped relationships. the impact act was a piece of bipartisan legislationthat was enacted in 2014. and there are several requirements in thatlegislation including that post-acute care providers submit standardized assessment data. and those submission requirements are satisfiedthrough the submission of your assessment instruments in the long-term care hospital,the lcds and the inpatient rehab facilities, the irf-pai, the skilled nursing facilities,the minimum data set, mds and the home health agencies the oasis, so as time goes on, dataelements will become increasingly standardized

and through your assessment submission processyou'll be satisfying your impact act requirements for the submission of standardized assessmentinformation. in addition the impact act requires that post-acutecare providers submit their standardized data elements to support the construction of qualitymeasures that are identified or quality measure domains that are identified in the impactact. and we'll be talking a little bit about that. in addition, the act also requires that assessmentdata elements be made interoperable. we'll be talking more about that. i want to just point out, there is no requirementin the impact act that post-acute care providers

use the interoperable data elements. it's a requirement for cms to make data elementsinteroperable. and it's an opportunity for providers andyour vendors to leverage the interoperable data elements to support improved qualityand coordination of care. so what are the driving forces behind theimpact act? as probably everybody is aware, post-acutecare costs have been increasing at a fairly rapid rate. and right now, in the absence of data elementstandardization, it's very difficult to be able to compare quality across the post-acutecare settings.

this limits cms's ability to make informedpolicy decisions regarding the quality comparisons across sites. it also limits the ability of consumers tomake informed decisions about which post-acute care setting might they be interested in receivingservices in. there's also growing awareness and recognitionand studies supporting the fact that through the use of interoperable health informationexchange and standardize information, that that type of information can support carecoordination, and as a result improve quality and reduce costs, particularly at times oftransitions. so post-acute care matters.

in 2014, there were almost 6 million medicarepost-acute care beneficiaries who cost -- on behalf of whom medicare spent close to $60billion. so it's almost 10% of medicare expenditureswere directed on behalf of this population. these individuals are the most vulnerableindividuals served in the medicare program-- multiple chronic conditions often with disabilities. and so, being able to support standardizedinformation and the exchange of information on behalf of these individuals who requireservices across an array of service providers, is very important to support their coordinationand continuity of care. so the impact act supports or is in alignmentwith the cms quality strategy.

the cms quality strategy focuses on improvingpatient care, improving population health, and increasing smarter spending by the governmentfor the services it covers. there are several goals in the cms qualitystrategy, and many of those goals align, also, with the goals of the impact act includingmaking care safer, strengthening person and family-centered caregiving, importantly promotingeffective communication and care coordination and making care more affordable. the cms quality strategy is built on severalfoundational principles, again which align with the requirements of the impact act, includingimportantly strengthening our infrastructure, and/or data systems.

and i think as we go through this presentation,you'll hear about how the impact act's requirements for data element standardization and interoperabilityare in line with those principles. so with standardization of post-acute caredata, this will allow beneficiaries to access the most appropriate care setting, will allowfor quality comparisons across the post-acute care settings, and will allow for paymentreforms to be based more on quality. standardization in interoperability is expectedto allow for a shared understanding of data as it's shared across provider settings andalso for the efficient exchange of this information as individuals transition across settings. so what is standardized data?

standardized data are data elements that havethe same meaning and have the same definitions across the post-acute care settings. by standardizing data elements across thesettings, it will allow information to be shared and seamlessly reused across the post-acutecare providers. and as you share this common understanding,when a patient might be discharged from the inpatient rehab facility into a skilled nursingfacility, when the information is transmitted regarding the individual's functional status,the receiving care provider will be able to have a shared understanding of what that functionalstatus data actually means. sharing information is expected to supportcare coordination and discharge planning across

the settings. what is interoperability? the office of the national coordinator hasestablished a definition of interoperability and it's important to note that the definitionof interoperability focuses on systems, rather than individuals consuming interoperable information. the definition established by the office ofthe national coordinator is that the ability of systems to exchange information electronically,and to be able to reuse that information to support caregiving without any special efforton the part of the user of those systems. i want to say now that, hopefully, one ofthe things that you'll learn through this

presentation is that, as clinicians, you'renot really expected to become fluent in health it standards, which is what will enable interoperableexchange. your vendors should understand health it standardsand be able to integrate those standards into their products. but from the clinician's perspective, it shouldbe very seamless. and you should be able to receive electronicinformation in a format that you're able to receive and understand, and interpret, anduse, and to be able to do so efficiently. so the benefits of standardized and interoperabledata include that the meaning of this data is shared, that the information can be sharedbetween computer systems, and reused between

systems for multiple purposes. and that this electronic information thencan -- one of the purposes is that it can be reused to support information exchangeas individuals transition across care settings or care is shared between multiple healthcareproviders. so this is a graphic that highlights a futurestate where data actually follows the person. and before we start talking about the future,i want you to think about the current state. the individuals that you are responsible forcaring for are, again, among the most vulnerable in the medicare program, having multiple chronicillness, often disabling conditions, being seen by multiple care providers, receivingmultiple medications.

before they come to your post-acute care setting,they're likely to be living in the community where they're seen by multiple physician specialists,perhaps receiving some home and community-based services to support their needs. then some acute event happens and they'retransferred to an emergency room, for attention. they might be admitted to the inpatient hospitalfrom which they're discharged to your setting. imagine from the individual's point of viewhaving to transfer information about their health status, their medications, at eachone of those transition points. that largely describes the current state oftoday. much of information exchanged today happensvia the individual.

it's person mediated. in the future, with interoperable health informationexchange and through standardized data, the future is one that systems enable the exchangeof this information regarding the individual's condition, regarding their medications acrossthe multiple care providers that are treating the individuals and the multiple care providersthat encounter the individual as the individual transitions across the care continuum. so the impact act requires that cms standardizeand make interoperable data elements. and there are two large buckets of requirementsin this regard. cms is to standardize and make interoperabledata in certain assessment categories.

and on the right-hand side, is a listing ofthe assessment categories that data elements must be standardized and made interoperablein. in addition, the act requires that cms developquality measures in certain quality measure domains. and you can see the quality measure domainslisted on the left. this slide highlights some of the qualitymeasure domains and the timelines that are established also in the legislation that cmsis required to develop the quality measures in. i think one of the things to take note ofis both for the quality measure domains and

the assessment categories, the timelines establishedin the impact act legislation are very aggressive, and relatively speaking, very near term. for the domain of functional status, cognitivefunction and changes in function in cognitive status, skilled nursing facilities and inpatientrehab facilities are to submit standardized assessment data beginning this october. long-term care hospitals are to begin submittingstandardized data for this domain and for this quality measure beginning october 1,2018. and home health agencies begin submittingthis data in january 2019. for the domain of skin integrity and changesin skin integrity the institutional post-acute

care providers are to submit the data elementsneeded to construct this quality measure beginning this october. in-home health agencies begin submitting thisdata in january 2017. for the domain of medication reconciliation,which is particularly important domain, all of these are very important domains, actually,but medication reconciliation is an instance where errors in the transfer of medicationinformation can result in a series of adverse events which are dangerous for the individualand very costly. this domain requires that home health agenciesbegin transmitting this data beginning in january 2017 and the institutional post-acutecare providers report this data to cms in

october, 2018. the act also requires quality measures inthe domain of incidents of major fall, and again the institutional providers begin submittingthat data in october, this october, 2016. and home health agencies begin submittingthe data in january, 2019. another quality measure domain in the impactact is related to the transfer of health information and care preferences. and this is another important quality measuredomain when you're thinking about health information exchange, going back to the notion of informationfollows the person from the acute care hospital, to the post-acute care setting and the home.

each of those instances or points of exchangeare called out in the impact act as being a focus of this particular measure. in terms of this measure, the institutionalpost-acute care providers begin submitting the data to support the construction of thismeasure in october 2018 and the home health agencies in january 2019. the act also requires that cms specify someresources and other measures including a measure on medicare spending per beneficiary, a dischargeto community measure, and also a measure related to potentially preventable hospital readmissionrates. those measures are particularly importantfor understanding the cost of care, as well

as the quality of care. this language here is from the impact act. and it pertains to the transfer of healthinformation and care preference measures. and again, as you can see from the languageon the slide, it talks about the measure is to focus on the transfer of individual healthinformation and care preferences of an individual to transfer that information to the individualand the care networks and service providers when the individual transitions from the acute-carehospital, critical-care access hospital or to another setting including post-acute caresetting or home. and when the individual transfers from thepost-acute care setting to another setting

such as the acute-care hospital, criticalcare access or home. it's a very broad measure and focused on theneed to transfer information and care preferences. in addition to establishing quality measurerequirements, the impact act requires that cms standardise patient assessment data andestablishes timelines by which the assessment data must be standardized. so, again, with more aggressive timelines. the legislation requires that assessment datain the categories listed at the bottom of the slide be standardized for the institutionalpost-acute care providers by october 2018, or that providers be begin reporting thatstandardized information by 2018.

and then home health agencies begin reportingthat information in january 2019. as i believe you all are familiar, the assessmentdata elements are often used for multiple purposes. they're sometimes used for both quality measurementand quality reporting programs, payment, quality improvement activities, care planning andcare coordination. cms is taking into account the various usesas it goes about the business of standardizing, that is aligning these data elements acrossthe post-acute care assessment instruments. so we're going to take a quick look at whatit means to be standardizing these assessment data elements and the relationship of thestandardization process with quality measurement.

this simple graphic just indicates that thereare data elements related to eating across each of the data instruments. on this slide you can see that the conceptof eating was standardized through the use of a data element that was laid out in thesection gg of the assessment instruments for skilled nursing facilities, inpatient rehabfacilities and long-term care hospitals. and so when you look at this particular dataelement across the instruments, section gg0130a you'll see, essentially, the same languagefor this data element on eating across each of the three post-acute care assessment instruments. in this instance this would be a standardizeddata element.

our next slide, which is hard to see, i'msorry for that. it indicates data elements that are standardized,whether or not a data element is standardized across more than one instrument, and if so,which instrument and how frequently that data element might be standardized. so this is the type of work that cms is presentlyundertaking to look at standardizing data elements for quality measurement purposesas well as standardizing data elements across the assessment instruments. so the goal of standardization is to supportthe ability to share information across multiple settings.

having a data element that uses the same words,has the same meaning, and used in multiple settings allows information to be shared andunderstood by the care providers across these post-acute care settings. that is the focus of the impact act, standardizingthe data elements in the post-acute care settings. but the vision for the future, and in fact,in some ways, the future is now, is to standardize beyond the post-acute care settings. and we'll talk about how some of the shareddata elements are being used in other settings beyond the post-acute care environment forexample, in home and community based services. and the purpose again of sharing data elementswith the same meaning is to support care coordination,

continuity of care, the ability to constructquality measures that allow us to compare quality across care settings, and to helpinform our thinking about policies. â»â» thanks folks. you're putting up with a long day here, sogood work. so far so good. so i'd like to -- well jenny went throughsort of the extent of the impact act which is really, really, very, very extensive andwill involve all of us in these really big changes. i want to bring it back to just how we'regoing to use this new standardized and interoperable

information. and really if you look down on this very busyslide let me just sort of parse this apart. we're going to be really having the benefitfrom exchanging and reviewing this information. that's where the real benefit is. so from a clinical standpoint, if you lookat the top three or four on the left side of the screen you can see these are the sitesof care that most people use now. these are the major players in healthcare. and here we're going to have data that theyare going to be able to use as interoperable exchange.

but if you move it down to the next levelto the home and community-based service providers and the "other" providers, including behavioralhealth, then you start to put the pieces together that are involved in the care of the mostcomplex individuals out there, the ones that jenny cited as being the most vulnerable. so those are two reasons. then you get to the health information exchanges. those are the ways -- that's a process bywhich we're going to move this information. but if you give the health information exchangesmore data that they can move and move it for more and different reasons; in this case it'sgoing to be around special services and treatments,

they're going to be able to involve more peoplein the spectrum of care that are engaged in the care of these very vulnerable people inthe exchange of information. so health information exchanges are goingto be benefiting from this. then you have reporting to public health organizations. and this is the reuse of information. farzad mostashari who was the director ofthe office of national coordinator used to call this "lazy data" and his big push was,you get data that somebody had collected, then put away in a cabinet that no one elsecould see. he wanted to free that data and let it movearound to anyone who needed to get it.

this is an example of taking lazy data thatmds, oasis, irf-pai which goes nowhere except to cms, it doesn't go to the rest us who aretaking care of the patients, and then freeing it up so we can begin to reuse this data. then finally, if you look on the right sideof the screen these are all the ways that the data can be recombined to have a clinicalimpact. that's around transitions of care, longitudinalcoordination of care, event and awe of care, longitudinal coordination of care, event andalert notifications. so these are -- this is how impact is reallygoing to change what we're doing. and i wanted to pull it back to this sortof clinical level of care.

and the next slide, the green button, therewe go. i'll just give you a case. alright. so this is a hypothetical case, victoria baylor. she happens to be from pennsylvania, wheregeisinger health system runs a health information and before this exchange was up and running,her case was one of a typical 75 year old ex-smoker. she ended up needing a hip replacement, wentto a skilled nursing facility and really had an uneventful skilled nursing facility stay.

she did all the usual things there. they got assessments. they completed the mds, which is hundredsof data elements for those of you who don't use mds including function and cognition anda lot of detail about what people can do and can't do. she had a 20-day stay, kind of average. and then went home and had a home visitingnurse the next day. nothing out of the ordinary. but the next day, when the home care nurseshowed up, ms. baylor had slurred speech.

that's unusual. there's no way to tell whether it had occurredbefore or not. and there's no description in the transferdata which really focused on her wound, and her functional status and what her weightbearing should be and when physical therapy was going to be in to see her. the home care nurse really had no significantbaseline data to tell whether this was news or old and something that needed to be actedupon. so he or she called the skilled nursing facilityand like any of you who have called other facilities for information, this always seemsto be a good reason why you can't get it.

the chart is down in coding, or it's in medicalrecords, or the nurses who are taking care of the patient are not on shift. be that as it may, there's no way to get theinformation quickly. the nurse then sent the patient to the emergencyroom and unfortunately the delay involved in getting this critical information broughtthe patient to the ed outside of the intervention window. so why and how can we make this outcome different? so that's sort of "pre." but to make an outcome different you reallyneed four pieces.

and impact is contributing mightily to thefirst two. you need standardized and interoperable datathat you can move from one place to another when you need it, get it to the people whoneed it to act on it. and you need to have quality measures basedon that data, which will help drive the adoption of that exchange. the two are related. so back to -- oops -- now we're going to againcontinue on with our case. and here we had problems finding the data,moving the data, making a decision about where the patient could go and when.

but in the new scenario, so this is the newgeisinger using a new set of tools for their health information exchange. and they're using a tool called the key hietransform. key hie because pennsylvania is the keystonestate. and hie because it's the health informationexchange. and they built a new tool called the transformwhich takes mds data and converts it into standardise interoperable data for healthinformation exchange. so the next day, under this new system now,home health aide, the home nurse comes in, still has slurred speech, unclear if it'sold or new but now can access the health information

exchange from his or her laptop and find outwhether or not this was something that was new or old. and the mds assessment instrument has a sectionon speech and it says, quite clearly in the document that the nurse was able to retrieveclear speech. there's no prior episode of slurred speech,representing a new and changed condition. the nurse calls the pcp, who suspects a strokewho also can see this information, sees the past history of stroke, alerts the emergencydepartment, sends the patient in. the ems folks are also aware of this databecause they can retrieve it on the home health -- on the health information exchange.

and the patient gets the ed in time for thestroke. it activated the stroke team who intervenessuccessfully. so this is sort of the, what interoperabledata available when you need it can do to clinical care. so again, back to the building blocks. the reason this data could work was becausegeisinger is a system that is actually paid to reduce total costs of care and incentiveto provide really thoughtful and efficient care. we'll come back in a bit to the infrastructurearound what's needed to exchange this data.

but probably the most important in geisingeragain, being paid on a new model of care, is that the payment models that we're alloperating under now are changing dramatically. we've got the old fee-for-service model beingreplaced by value-based payment, payment for outcomes which include quality and cost ofcare. so under fee-for-service which we all knowand, know. (laughter) the more you do, the more you getpaid. you get paid for unit of service. if you're a hospital, it's an admission. if you're a snf, it's a day in the bed.

if you're a home health agency it's a of 60day episode of care. but these are all units. and we all want to try under fee-for serviceto provide as many units as we can. that's our job. and so, that's what we do. and if we need more revenue, we provide moreunits. no one really is caring about the total costof care. we're all caring about our total units andwhat we get paid for. and it turns out that the information exchangethat has to happen between these different

sites of care was really driven more by meaningfuluse, the high-tech act which provided billions of dollars to provide incentives for hospitalsand physicians to acquire certified electronic health information systems, but didn't includethe post-acute care folks in that. and there is no, really, need to push thissupport to acquire this capability on to post-acute but now we have the new payment models. and these are very, very different. so you're no longer about driving volume. you're about providing an outcome and theoutcome is really lower cost. so the only way you can succeed under value-basedpayment, you can't get paid more for doing

more. you get paid more for having more people underyour care for whom you're responsible. so you're increasing your risk, but that'sthe only way you can increase your revenue is by increasing the population you care for. and if you want to provide more services,you're paying for them, someone else isn't. and if you provide the services at a highercost than what you're being paid to provide them, you get to accrue the loss. no one else is going to come back and sayoh we have to give you more money because you weren't successful.

and you also, if you don't meet the qualitymeasures, get paid less. because if you don't meet the quality measuresthen the quality measures actually subtract from your total payment. so the only way to win under this system isto provide efficient, effective high-quality and it turns out that the people in your populationthat drive that cost, there's a very small number of them who drive it. so what cms is doing is really a two-prongedattack on fee-for-service. and the first one is to provide what are called"alternative payment models ." these the at-risk models like accountable care organizationsor most recently, bundled payments.

a long time organization called medicare advantage,in which the payment is capitated and medicare advantage plans have a lot of incentives totry to coordinate care and meet the cost outcomes. but this again is a fairly aggressive timeline. so by the end of this year, cms wants 30%of all payments to be through these alternative payment models. and they're already ahead of that estimate. and by 2018, 50% of all payments. and for those payments that are not includedin an alternative payment model that come under medicare fee-for-service, medicare'sattaching quality outcomes to them like readmission

reduction, discharges to the community. so these are one way or another fee-for-serviceis going to be tied to outcomes. and that's part of the big strategy of cmsto move away from fee-for-service. so the new payment models went through medicareadvantage and acos, bundles are a new wrinkle in the cms arsenal. they are an all-inclusive payment for a diagnosisor a condition, the treatment of a specific condition. so the first bundle that we're out happensto be the care of patients going to post-acute these are elective bundles.

they came in four different categories. you could be in it or out of it, there's nopenalty. and this is a learning opportunity, the lastthree oh or four years that cms had these bundles available. the latest bundle which started in april ofthis year is the comprehensive care of joint replacement patients, ccjr. which was mandatory. if you were in one of the 60 metropolitanareas in the country, and you came under the new bundle, every patient who got a hip replacementor a knee replacement who is not part of an

alternative payment model, came under thebundle which meant the hospital's responsible for 90 days worth of care, including the surgery,and 90 days after for any patient with a joint replacement. meaning they're responsible for the home healthcare, they're responsible for the snf, outpatient physical therapy, anything. they're accountable for the complicationsof that surgery. this is a very different model. and now hospitals are on the hook to makesure that their payment, that their expenses are inline with what cms is going to pay them.

they'll learn this next april when cms willtell them whether cms will write them a check, or they're going to write cms a check. it will be interesting to hear what the responseto that is going to be. but the other important thing to know is thatin 2017 there are three more mandatory bundles coming down for acute mi, heart attack, forcoronary artery disease, bypass grafting and for fractures of the hip or femur. these are all going to be bundled. they're going to be different metropolitanareas. but here's another example of an alternativepayment model that's coming down that's going

to affect a great number of us. so what this means, this change to alternativepayment models is we really are into population health. we're going to be responsible as entitiesproviding care, we're either going to be part of an entity or we are the entity that isgoing to be responsible for total population. these are people who have been assigned tous because we've been taking care of them. and we no longer can ignore any people thatwe want to ignore. the folks that we used to like the high-cost,high-intensity people who required many, many, services -- remember under fee-for-servicewe're happy to provide those.

under an alternative payment model, we needto get our arms around these folks and provide all of the care they need when they need it,but really efficiently and at a lower cost than we're currently doing. and what this challenge will be for us is, as jenny eluded to, we'vegot bigger teams; there are more specialists, more docs, more sites, more places that needto be engaged in the management of these patients. how do we bring all these teams together? and then that's going to be one of our bigissues in how we build these new systems. i want to show you with these two graphs what,sort of, what the finances are behind this. you know, the costs of care are not evenlydistributed across the population.

so the four bars on the right, the red bars,those are medicare fee-for-service payments divided into four groups. groups with the smallest bar with 0-1, chronicconditions. and then 2-3, 4-5 or 6 or more chronic conditions. and you can see that obviously, it's no surpriseto this room, the folks with the most chronic conditions have the highest cost. the average cost for that six or plus groupis $32,000 a year. it's $2,000 for the ones 0-1%. you can see there's a huge skew of where costsare found in this population on that case

on the basis of conditions. the other graph is a -- called a populationcost curve. and this is what insurance companies use. if you start at that arrow on the lower left,it's at 0 population, 0 cost. costs go up as you go vertically. and the population from 0% to 100% as yougo along the horizontal axis. so as you go from that arrow on the left andyou get to the next vertical arrow that's at 50%. so that's 50% of the population.

and you see where that arrow crosses, thatline crosses the cost curve? cost is at a 2.7% meaning that half of thepopulation spent 2.7%. the other half spent whatever, 97.3%. keep moving. the next vertical arrow is at 95%. so 95% of the population, and you see wherethat crosses the cost curve, it crosses it that means that half the population, that95% of the population has spent half of the total amount of resources. that means that 5% spent the other half.

you go out to the next arrow, that's at 99%. that crosses the curve at 73% meaning that1% of the population accounts for 27% of the cost. this is why new organizations and new systemsof care are going to focus very, very much on this 1 or 5% at the top. and this is just more data. this is from the medicare chartbook in 2012. and this, again, just shows how the costs,in this case the percent of spending is changed depending on the number of chronic conditions.

some the purple group, those are the six ormore; 28 is 4 to 5. and you see this disproportional expenditure? and this is very striking. this is readmissions. so 70% of readmissions are accounted for bythose with six or more chronic conditions. 70%. and if you add the 4 to 5 chronic conditionsto that group, they together account for 90% of readmissions. it's really dramatic.

you see why we're going to need to focus onthis group, if we're at risk for total cost for care. so who's in this top 5%? it's really anyone who's got a complex mixof adverse social determinants, complex medical conditions, functional impairment, behavioralhealth issues. this is the group that generates the 5%. and they all share, they maybe different groups,but they all share common characteristics. they get care in multiple sites. they get admitted.

they go to irf. they go to snf. they go to home care or go back to the primarycare doctor. they frequently use emergency medical servicesand are in and out of the emergency room. so they are the group that is churning. they're the ones that are the busiest withinthe system. and they also need to be transitioned moreoften than anyone else. and as we all know transitions of care area fairly dangerous time in the episode of so, we need to build a new system.

so i love this slide. this is from john derr and larry wolf. and it's such a beautiful slide because itjust shows you what a lovely system we have out there. this makes perfect sense. it’s very reassuring. we start in the green and blue area wherehome-based services and outpatient physician office. then we go, as we go to the right, we're goingto more acute care.

and as we go up, we're going to the intensityof care. and we've ultimately arrived at the hospital's,acute-care hospitals. but it's lovely. you know, there's just a smooth transition. we're going from one to another. that's all well and good except that if youlook carefully, there's no connection between any of these pieces. there's white space between all of them. so this is not so much a system of care asit is a spectrum of care, and kind of an agglomeration

of care providers who are, really, each individuallyout to do what's best for them. it's not a system here. in fact, it's far from being a system. it's really more like this. everyone is acting in an informed self. and, you know, under fee-for-service, youdidn't have to be a system. it really didn't matter because all you neededto do with information exchange was to get referrals or make referrals, empty beds, fillbeds; depends on what your incentives were. you didn't have to share information.

you just had to share enough to get the nextadmission. but that's going to change. so how are we going to meet the challengeof this bigger team? multiple sites? then we're going to need to have interoperableinformation exchange, which is why impact is so important. and more communication. so i want to give you -- (phone ringing) excuseme -- someone wants to sell me a bahamas vacation. i'll take it.

so what do we have now? current care community, here's where we'reat right now. so we've got the individual and their caretaker. and i love this gliff because i'm never surewho is helping whom in this picture. and you have the primary care doctor, thecare coordinator, the hospital, skilled nursing facilities, home health agency, our usualplayers. but the new system is going to need more. you're going to have to bring emergency servicesin. you'd have to bring home and community-basedservices, pharmacists, dentists.

think of all of the resources that are outin the community that may bear on the health and welfare of complex folks. so currently, our health information exchangetoolbox is fax and phone. we use it well, it works great. keep using it. so somebody wants to go to the emergency roomthey call ems. ems transports them to the emergency room. the emergency room calls the physician whomay or may not call back and give information. a decision is made about the care for thepatient.

usually in admission, 60% of folks who showup in emergency, end up admitted to the hospital. so the hospital then calls the skilled -- eitherthe home care or the skilled nursing facility, who calls the physician for orders. everyone's calling back. so this is electronic health information exchange. faxes are electronic, phones are electronic. not quite. not quite the electronic health informationexchange we have in mind. so now let's connect this community.

let's wire them up. so down in our toolbox we now have ehrs. right. this is what meaningful use paid for. so hospitals and the physician groups haveehrs. no one ,really, other than those folks havethem. although we'll give credit to those nursinghomes and home care agencies that have, although they're in the minority. these folks can exchange -- well' go into the standard -- this is called a consolidated cda document;this is a standardized electronic document.

i'll talk a little bit more about that ina minute. but they can exchange it. and in massachusetts we've built a bear ofsoftware called land the other called see, because of paul revere's s ride, one if byland, two if by sea. and this is a software that you don't needan electronic healthcare information system to exchange. all you need is a browser, a web browser. we call it see, surrogate electronic environment. and you can pass these documents around withouta big investment.

this is the new toolbox and if you can putthose out with ems and home-based, community-based service providers, you now you have a networkthat's wired up and can begin to communicate. and you need one more piece, that's this bigpiece in the middle. this is the switchboard for health informationexchange. think of it as literally, as the old telephoneswitch board. we know who the physicians, who the providersare, we know who the patients are, we know what the relationship of the providers andpatients are, and that's all stored there. so if you sent a message and it says who belongsto this patient? you'll find out who the provider is.

and similar, you can take messages and dowhat's called an event notification. you can say if i receive a message like this,i'm going to do something about it. and this then sets the system that we're goingto have. and the new, sort of, messages you can senddown in the right-hand corner again, the adt message, a very simple, standardized message. insurance companies receive these, millionsof them a day, they're really as a request for coverage. so it tells you who the patient is, wherethey are, what services they're getting. but you can repurpose that to actually bean event notification message.

so let's put this in motion. so this time, the individual doesn't callanybody, they just go straight to the emergency room. in worchester, massachusetts what happens whenthey go to the emergency room, their emergency room, their ehr sends an adt message to thisswitchboard. the switchboard says, oh i know who this patientbelong to. they belong to this doctor, and sends a messageto that electronic health system, also to the care coordinator alerting the patient'sin the emergency room without the physician doing anything in the office.

although they're contacted. the ehr sends a care summary to the emergencyroom, medications, allergies, conditions, code status, a nice set of documents. and this arrives in the emergency room beforethe individual has actually gotten away from the front desk, before they're even in a,bed. this information is there in the ed. allows the emergency room to make a much moreinformed decision, and can get input from case management. and then often they found, since the groupthat's using this currently in massachusetts

isn't a medicare advantage group, that they'vesignificant reduced their emergency room admissions. important. so now again, let's just say they call ems. right, now we've wired ems now. so now what ems can is do is, they don't knowthis person. they just called. they send to it the switch board. the switchboard go to ehr and sends them theinformation that was just sent to the emergency room in the previous example.

now ems has that same information and theycan go to the patient's home and make an assessment, read in place, and make two determinations. one, they need to send the patient back tothe emergency room, in which case they can send documents before they arrive. or they can say, well, wait a minute. let's call the skilled nursing facility orthe home health agency in this case and see if they will show up the next morning. we'll send them the information. so an emergency room visit is averted as isthe admission.

the home health agency can then talk to thehome and community-based services people to say, you know, we need more services in thehome. and they can tell case management about it. the home and community-based service providerscan take a on observation of a change in medical status, they're not walking quite as well,they're not eating quite as well, they don't appear to be cognitively as sharp. and they can send that information, whichthey currently can't. talk about lazy data again. they can't.

they'll second that to the primary care docwho, in turn, can trigger a call to the skilled nursing facility, decide from admission. and so you see there's a new system of carethat's going to evolve because we can exchange standardized information. and the goal of that is going to be largelyto eliminate or reduce as much as possible hospital admissions, high cost stays. so that's the connected care community. and it matters to all of us. it may not be exactly like this but this iswhere we're going and the tools in place.

that example is actually being tested in massachusetts,this is not theoretical, this is actually undergoing use right now. but our challenge is how do we link togethermultiple sites, multiple teams for patients who are really complex? and we'll use this data to drive those newsystems. we'll use this same data to build qualitymeasures. our quality measures will be driven from ourclinical requirements, which is really a nice change. and we'll be able to reuse this informationfor public reporting.

and the system will be able to learn. because now we'll know what's happening andwhat interventions worked and what hasn't. no arrests on health information exchange. the thing about hit, i'm almost done withmy section, i wanted to circle back to, sort of, the standards. what does it mean to have standardized exchange? there are really, sort of, two kinds of standards. oops, i'm not -- i'm going to come back laterand tell you. jennie is going to tell you what onc is currentlydoing.

so stay tuned and i'll tell you about standards. â»â» so it's not just cms and the implementationof the impact act that's advancing standardized and interoperable data but there are a wholeseries of activities that are underway to support the standardized and interoperableexchange of information. and i'm going to talk about some of thoseactivities now. so the office of the national coordinatorfor health it is an office in the department of health and human services. and they are the office responsible for establishingrules and requirements related to health information technology and standards and certificationcriteria.

the office of the national coordinator recentlypublished its nationwide interoperability roadmap which links together public and privatesector activity to advance information exchange across the care continuum across america. and it defines a path for us in terms of movingforward in advancing interoperable health information exchange. the roadmap links together with the deliverysystems reform that dr. o'malley described, whether it's a movement towards alternativepayment models, or paying based on quality and linking quality to payment. and in the roadmap it defines periods of timeby which certain goals will be achieved.

in the near term, in 2015 to 2017, the focusof the roadmap is on sending and receiving electronic health information. and it includes a focus in this near-termobjective on long-term and post-acute care providers. in the midterm, the focus is on expandingdata systems and users of interoperable health and then in the longer term, the roadmap focuseson the ability to exchange information and support what's called a "learning deliverysystem" where information is no longer lazy, and we're able to use this information tohelp inform service delivery and inform our decision making regarding services.

the office of the national coordinator hasawarded several grants over time, and has recently awarded some grants to support healthinformation exchange. i'm going to talk very quickly about thesethree programs that onc has supported. this particular program is focusing on healthinformation exchange. and onc awarded 12 grants for about $30 millionto support health information exchange and technology with a particular focus on carecoordination. the next program that onc supported awardedgrants across these 12 states and those states with the asterisk next to their name includeda focus on long term care post-acute care. so i'm not sure if you're from any of thosestates.

but you might be interested in seeing if yourstate is on the list. in another grant program, onc supported healthinformation exchange in the community. and one of those -- this was a smaller grantprogram. and one of them, the first one on the list,altamed health services included a focus also on long-term post-acute care. this slide summarizes across each of thosethree grant programs how they're focusing on long term care and post-acute care. illinois, delaware and colorado are leveragingwhat dr. o'malley described as having been built in collaboration with the key hie, healthinformation exchange, under their beacon community

program, the long term post-acute care assessmentdocument. the long term post-acute care summary documentis a summary document, an interoperable summary document that reflects clinically relevantassessment data elements from either the minimum data set or the home health oasis that havebeen identified by clinicians as useful for those data elements have been linked withhealth it standards and captured in this interoperable document and then can be shared from the nursinghome or home health agency with their trading partner, whether it's the health and informationexchange organization, or the acute care hospital. and so, delaware, illinois and colorado areimplementing the use of that tool to support exchange by their post-acute care providersin their state.

rhode island and new jersey are leveragingadt messages, again going back to dr. o'malley's slide about how this is a commonly used toolfor insurers but is being reused for other purposes of alerting clinicians about transitionsin care. in addition, several states are focusing onexchanging transition of care documents to support the transition and coordination ofcare on behalf of their long term post-acute care patients. and utah is developing discharge summaries. so interoperable exchange is happening. it's still happening in pockets in terms ofthe long term post-acute care providers engagement.

but it is happening. and with the roadmap in the near term, theinstances of interoperable exchange are expected to increase. the office of the national coordinator alsoengages in other activities in addition to funding grants. it establishes rules related to health informationtechnology. it identifies the nationally accepted healthit standards. it establishes ehr certification criteria. so onc is involved in a variety of policy-settingactivities.

i described the roadmap a little while ago. and my next slide, i think it is, i'm goingto be talking about the onc certification rules. onc also has identified a federal health itstrategic plan, which identifies opportunities for the federal government across the variousfederal programs to advance information exchange, including opportunities for advancing informationexchange on behalf of long term post-acute in contrast to earlier strategic planningdocuments, for example, i was looking at one the other day about-- from about ten yearsago. ten years ago there was essentially no referenceto long-term and post-acute care providers

in the federal strategic planning documents. this federal strategic planning document recognizesthe criticality, the importance of including long-term post-acute care in our federal activitiesin order to achieve the goals and the visions established in the nationwide interoperabilityroadmap, the vision that dr. o'malley was describing about seamless information exchangeto support care coordination across the continuum. so in the recent 2015 onc hit certificationrules, this is a change from how onc has regulated health it in the past. prior to 2015 onc established requirementsrelated to electronic health records. those requirements for electronic health recordswere largely established to support the providers

who are eligible for the ehr incentive program,largely physicians and hospitals. and so the ehr requirements were about establishingthe standards and criteria that those electronic health records needed to support in orderfor physicians and acute care hospitals to achieve their meaningful use payments. well in 2015, in response to public comment,onc has modified its certification approach. and it will still certify and establish requirementsfor ehrs for acute care hospitals, and physicians and meaningful use program. but it also has certification criteria forhealth it applications. and that's in recognition that not all providerswill require a fully functioning ehr.

and instead, perhaps you will require a specifichealth it application to support a specific use case, for example, creating a transferof care document and being able to exchange that interoperably with your trading partners. so onc has established these modular certificationcriteria and a modular certification program. and that's too-- and that was in recognitionof long-term post-acute care providers, behavioral health providers and other providers who werenot eligible for the ehr incentive program. so this program is setting agnostic, and willsupport the use of these applications, these hit applications, across care providers includinglong-term post-acute care. so in addition to the impact act and someof the activities that you've already heard

about in terms of advancing standardizationand interoperability of data, there are other cms activities underway to further the useof interoperable information. one activity is the testing experience andfunctional tools, the teft demonstration, which is a medicaid demonstration happeningin eight states. and it is focusing on long-term services andsupport providers, home and community-based providers in medicaid. the demonstration consists of four parts,two of those parts are particularly relevant for this conversation today. one is the functional assessment standardizeditem set in the upper right-hand corner.

that is an assessment tool being tested inhome and community-based service settings in these eight states. and that tool incorporates some of the samedata elements that have been standardized under post-acute care. so again, going back to that earlier graphicof the vision of having shared information that has the same meaning across multiplecare settings, not just post-acute care, but across the care continuum. this is an instance where that vision is beingrealized now in these demonstration states. in addition, in the teft demonstration program,there are also testing and electronic long-term

service and support plan, to support planningand exchange on behalf of these home and community-based service beneficiaries. also, in february of this year -- and so,it's interesting listening to dr. o'malley's presentation, in february of this year, cms,the medicaid part of cms, cmso, published a state medicaid directors letter that announcedthe availability of an enhanced match rate to support information exchange on behalfof medicaid providers who were not eligible for the ehr incentive program. the enhanced medicaid match rate is availableto these ineligible medicaid providers if the match rate goes to support exchange activitiesbetween the eligible provider, the acute-care

hospital and the physician for example, andthe ineligible provider. one of the activities that is supported bythis enhanced match is the switchboard activity that dr. o'malley described identifying whothese providers are, what's their address, how do you exchange information between theacute-care hospital and the nursing facility, for example? so this onboarding activity is one of thetypes of activities that this enhanced match rate, 90% federal funding is available for. the state medicaid directors letter notesthat the funding cannot be used for paying for or subsidizing the cost of an ehr, orthe ineligible provider.

so cms is continuing to consider this guidance. about 20 states have come in so far and haveexpressed an interest in securing the enhanced match. and they are focusing on long-term care providers,home and community service provider, behavioral health providers and public health organizations,all of whom were not eligible for the ehr incentives. and states are considering how to supportinformation exchange with those ineligible providers with the providers who were eligible. so in addition, as i mentioned, the impactact requires that data elements be standardized

and made interoperable. and towards that end as largely a public service,cms is creating a data element library. actually i guess it serves multiple purposes. one it serves cms's business needs which i'lltalk about in a second. but also, as a public service, it will bemaking available information to providers and vendors to support their ability to participateand develop products for interoperable exchange. the library will help cms in managing thestandardization of data. on my earlier slide, i highlighted an exampleof the eating data element. so as cms goes forward in identifying whatdata elements need to be standardized, you

can come to the library and look at, wellwhat, are our current data elements related to eating or toileting or whatever the particularconcept is? what are the data element specifications forthat particular item? how are those specifications, what are thosespecifications across the post-acute care instruments? and how can we standardize? what are we going to standardize on for thesedata elements? in addition, the library will include notonly the data elements, the post-acute care data elements and information in terms ofwhether or not they're standardized or not

across the different instruments. but it will include mapped relationships tohealth it standards which we will be talking about the specific building blocks in termsof those hit standards in a minute. and that information can be used by providersin using interoperable health it products and also by their vendors in creating interoperabledocuments for purposes of exchange. this graphic basically depicts what i justsaid. on the right-hand side cms has a series ofbusiness needs for which it uses assessment it uses assessment information to constructquality measures, create it's quality reporting programs, support payment, regulatory compliance,survey and cert.

there's a variety of uses of these data elements. and cms needs a way to manage those needs,and the data elements. and as it goes forward under the impact act,in standardizing these data elements, it needs to keep in mind these different uses and beaware of the different uses as it's standardizing the data elements. because the impact act requires these dataelements to be made interoperable in making that information available to the public,it's a one-stop shop. the library will become a one-stop shop onthe data elements, and the linked health it standards associated with each of those dataelements.

and by being that one-stop shop, it can feedinto a provider's electronic health record, or other health it application to be ableto leverage that assessment content as well as other clinical information in the electronichealth record or health it application and the provider site. and by having this information linked to nationallyaccepted health it standards, supports information exchange, not only with your training partners,but with health information exchange informations, public health programs and states and otherentities. so the library database is under developmentand is being populated with the post-acute care assessment data elements and will map,as i said, the relationship of these data

elements across each of the four assessmentinstruments, will link the data elements to particular domains that are useful for searchingon, and will also link these data elements to health it standards. health it standards, that will be mapped tothe data elements, will be nationally accepted health it standards that have been establishedor identified under the rules published by the office of the national coordinator. and, for example, we'll include vocabularystandards. if you've heard of them, one is called loinc,another is called snomed. it will also include document exchange standards,one of which, is a major one of which, is

the consolidated cda that dr. o'malley referenced. the consolidated cda is a set of documenttypes. and it includes for example, discharge summaries,transfer of care summaries, referral summaries, care plans. and so, we will be linking the data elementsto these different document types, and the embedded templates so that when your vendors,or your hit staff or anybody who's interested in this content, can come to the library andsee how the data element on eating, what it's linked to in terms of a vocabulary standard,and what document exchange standards could be using the eating data element.

it might be a care plan document. it might be a summary document. and so this type of information could be usedby vendors to support their applications or summary documents, summary of care, transitionof care documents that then the provider can use in clinical care. the library content will be updated over timeas new data elements are added and data elements are retired and also as new hit standardsare added. so it's just like legos. again as i said, some time ago, clinical staffare not expected to become fluent in these

hit standards but you should make sure thatyour vendor is. and you should make sure that the productsthat you're using support the use of these national health it standards. and it would be useful if they are familiarwith the data element library. and cms intends to make available contentfrom the library that then could be accessed by your vendor or if the provider were interestedby the provider, or health services researchers, or anybody who wanted to go to the library. so it's a building block. and the idea is to be able to promote thereuse of these data elements to support information

exchange in a variety of instances. â»â» so i like the legos because that's aeasy way to understand what we're talking about with standardize. if you think of a lego, it's the ultimatestandardized toys. the prongs are certain height, they're a certaindistance apart, the legos are a different sizes and shape, but they come in lots ofdifferent colors. and you can put them together in thousandsof different ways. they're these little modular building blocks. and that's like standardized data.

think of it as just a bunch of legos. and you're building legos, you're puttingthem in a pile, you're assembling them to create a particular type of document. but when someone receives that document madeof all your legos, they can take that document apart, use your legos and build another document. that's more legos and build an even biggerdocument. so the standardize really starts the dataelements. once you standardize the data elements, thenyou can put them together in different ways. so that's the vocabulary standard, right?

we've got the lego that's green. it's got six prongs and is this high. that means something to loinc. don't ask me what is means, but it means somethingto them. and they'll tell you what it is and and youcan use that green lego to mean the same thing no matter where you are. that's the importance of standardization. but what a consolidated cda is, that's clinicaldata architecture, it's a type of document. it's a template.

it's really a blueprint. how do you put all of these legos togetherso that they mean something in a standardized way? you build a template. and the template, as jennie mentioned, canbe a discharge summary or a transition of care summary or a care summary. it doesn't matter because, again, the templatesare just a way to hold the legos and then exchange them. so the templates are modular as well.

you can have a bunch of different templatesin a particular document, or you can have the same templates in another document. they can be exchanged. that's the whole beauty of standardized interoperabledata. think of the data elements as legos. think of the consolidated cda documents. it doesn't have to be more complex than this,it's just a way to organize legos so you can pass them in a way that is recognizable tosomebody else. then you can mix them all up again.

that's the essence of standardized informationexchange. so what the data element library is goingto be doing is taking these data elements and, sort of, starting down at the bottomof the page on the left, with loinc. loinc is logical observation identifiers namesand codes. okay. does that help? loinc. this is just a vocabulary that we can linkparticular observations to. so if you observe, you know, a green goldfish,there's probably a loinc code for green goldfish.

and you can send that code and somebody elsewill know that you're referring to a green goldfish. the loinc is very, very specific. snomed is sort of a response code, it's moreclinically based. what did i see? so these two standardized vocabularies arewhat underlies the legos and how specific they can be. go to the right side of the page, then youhave the consolidated cda documents. these are the transfer standards.

this is how we wrap the legos up to send themsomewhere. the other side is how we make the legos inthe first place. so once you get those two pieces, that's whatwe mean by standardized information, it's vocabulary and exchange. then you can like what impact is doing, andthat's taking the federally mandated assessment instruments, and converting their contentinto these standardized pieces. and they will all live in the data elementlibrary. and out of these pieces, this is where itgets back to clinical care, we can build documents. and so this is a set of documents, unfortunately,the animation didn't come through.

but the biggest, the purple document is apermanent transfer of care document. it contains hundreds of data elements. and out of those hundreds of data elementsyou can actually use them to create other smaller documents such as the one on top,a test procedure report. that's if you send someone for a test, andthey want to report what it is, they can send you back, this is what we did, this is whatwe found, this is what you have to do. if you want to go to the yellow box that'srequesting that test, you'll say this, is why i want the test. these are the reasons that i'm sending themto you.

here are their allergies. here's how to contact me if there's a complication. it contains more information than the testreport. similarly, the green box is a report of aconsultation. i'm sending someone to you, you're going totell me what you've found, what needs to be done and how i'm supposed to follow up. the blue box is my request for that consultation. it might be sending you to the emergency room,in which i'll tell them what your current problem is, what we did, what the medicinesare, what the allergies are, what your code

status is. i'll tell them all of that. they don't have to tell that back to me, theyhave to tell me what they did and what i have to do. so these are all data elements that are actuallycaptured in that final big purple data set. you can build a whole bunch of different documenttypes on the same data. and that's, again, the power of standardizedand interoperable data. so this gets us back again to how can we usethese new tools, the standardized data, to connect and to build the new systems we'regoing to have to build under the new payment

models? and it really starts from the most simpleto the most complex. so, here are the lists, these are seven high-valueexchanges. the first, the adt document, very simple,doesn't contain a lot of information, very easy to build, easy to exchange. this is how we're going to glue ourselvestogether probably first as you saw in some of the teft grants that are testing whetheror not they're going to be able to connect using adt feeds. you're going to see people making connections.

i'm going the tell you when there's a changein status. i'm going to tell you when someone goes tothe emergency room. it would be nice if the home health agencyknew if someone went to the emergency room. if the emergency room told them, by the wayms. jones is in the ed. you don't have to see her today because she'snot going to be there. that's the sort of information that againmakes the system work better. then there are some gaps however in our standards,our exchange and our vocabulary, the biggest gap right now i think is around the individual'sperception or what matters most to them. what are their goals, their priorities, theirpreferences?

it's been worked upon, but it's very, verycomplicated. but imagine the value that would come if wecould exchange among ourselves our current understanding of what the individual valuesmost. that's the way person-centered care is goingto be, value will be propagated across whatever system. we also need to get a consent. do i want my information exchanged acrossthe continuum of care? and it varies by state. there's no national standard around this.

it's a state standard. there are opt-in states that say in orderfor me to be able to send your information electronically you have to give me signedpermission that says you may send my information. if you don't send that, i can't. then there are the opt-out states, which say,i'm going to send your information unless you tell me not to. two different approaches. they end up with a very different mix. we also are just starting to figure out whatwe name the people that are on the team.

because we're going to need, if we've gotthis big system of care, we're going to try to coordinate care, we need to know who we'recoordinating. who's doing what? where are they? what services are they providing? what outcomes are they measuring? who's responsible for what? this is how we're going to build the longitudinalcare plan, to be built on these simple modules that get pulled together.

and then the other documents we're workingon, and they're actually standards in place for them, they're difficult to build. they take a lot of data. but again, these are modular. they're built from small pieces, reassembled. you can end up building very, very complexdocuments on the basis of a bunch of very standard data elements. and that's where this is all heading. and when we move this information, we're goingto actually affect so many parts of our system,

it's going to be difficult to measure theimpact. but it's going to have a lot to do with quality,with safety, with patient satisfaction. and, you know, it's going to ripple out intotraining. how do we train people to provide the sameinformation to do it in a consistent way? it's going to affect throughput. who comes in? who goes out? how quickly they move? because the information instead of being abarrier becomes a facilitator for movement.

and finally, i think it's going to make usa lot more efficient. so that's, sort of, where the standards getus, where the gaps in the standards are now. but understand that there's a lot out therethat we can already begin to use. and we're going to build the system incrementally. so my advice is start using what's out there,and use it for reasons that make sense to you. there will be more and more material to useas time goes on. i'm going to pass it back to jenny for thefinal wrap up. â»â» so the last two slides, these are thelast two slides.

they are just basically a summary of whatdr. o'malley and i have talked about. we've talked about a series of cms activitiesrelated to standardizing the assessment data elements, and the activities related to makingthe post-acute care assessment data elements interoperable, mapping them to national healthit standards, including the vocabulary standards as well as mapping them to document exchangestandards. and then publishing that information to thepublic so that you all will be able to use that information, your vendors can leveragethat information. the activities that states are now beginningto pursue as a result of the state medicaid directors letter, making available the enhancedfunding.

and also actually, i guess you did speak aboutsome of the cmmi demonstration programs that are supporting the alternative payment models. and also, the quality measure activity underthe impact act are very important system delivery modifications. and so in addition, i referenced the pilotprogram under the medicaid teft demonstration program, the onc activities related to thehealth it strategic plan, the nationwide interoperability roadmap. there are activities in terms of setting nationalstandards for vocabulary and document exchange as well as security and other standards.

and also, there are now, a relatively newapproach for health it modular certification. and their there are pilot programs relatedto health information exchange which include a focus on long-term post-acute care. we talked a lot about the benefits of interoperablehealth information exchange supporting communication across the entire care continuum from emergencymedical providers, to acute-care hospitals, physicians, long-term post-acute care, behavioralhealth, and making available information when and where needed. the benefits of supporting exchange, reducingcostly and unnecessary services such as hospital readmissions that are preventable and alsothe duplication of services that are unnecessary

because information hadn't previously caughtup with the individuals during the course of their service delivery. and so, dr. o'malley mentioned payment reformas being a key driver for the adoption of interoperable health information exchange. and i just want to underscore whether it'sthe implementation of alternative payment models, or the increasing focus on qualitymeasurement as a way to assess quality in, for example, post-acute care settings, bothof those will be drivers for service delivery transformation and associated health informationexchange. so again, a lot of what's underlying all ofthese activities is the need to improve quality

in post-acute care but also across the carecontinuum and reduce the unnecessary costs, and escalating cost associated with our currentpayment system that is largely fee for service driven, and not connected to quality. so i think that about summarizes the presentationfrom dr. o'malley and me. and so we'll take time for questions. thank you. if there are any questions. hi. my name is jen schriber. i represent acuity healthcare, which is a group of ltch hospitals across four states. i find this work very exciting, the overarchinggoals.

it's amazing. it's where we need to be. one thing you guys didn't mention at all andi haven't really heard mention of other than in the abstract, is the concept of validation. the legos you're talking about are very discretedata elements, but those discrete data elements are abstracted from medical records by humanbeings, from documentation that's done by human beings. and it seem to me to be putting the cart beforethe horse to talk about how we're going to use the data before anyone has said, you know,that the data is actually correct.

so can you speak a little bit to what theplans are to validate that data? you know, specifically when we're talking,obviously both about patient care, which is why we're all here, but also about the paymentreforms that are coming, which i think we can all agree that payment reforms are appropriate. but that's a powerful incentive to make surethat data looks -- can be a powerful incentive to make sure that data looks a certain way. â»â» i don't know if we need to keep jumpingup. i don't know if you can hear us if we're notstanding up. so good question.

really great question, actually. and part of the validation effort is happeningat cms now, in terms of testing the data elements that are being advanced for the differentquality measures. and so, cms spends a lot of time, and i don'tknow if you've had a chance to participate in the technical expert panels that cms convenesfor different quality measures. but before data elements are being advanced,they do go through a series of tests to look at the reliability and validity of those dataelements for use in the quality measures that they're being considered for. so there is some testing that is happeningalready with respect to those data elements.

and then similarly for many years, a boatloadof testing that goes along with using data elements in different payment algorithms. in terms of testing for information exchangepurposes, and is this data element on eating or whatever the data element is going to becommunicating the information that the sender of that piece of information is intendingfor the receiver to receive? i think that's a really good question. and i don't know of any testing but perhapsoutside of your massachusetts program if you all were looking at that. so i think it's a really good comment.

and i think as interoperable health informationexchange moves forward, i think it's something that needs to be looked at. one of the things, i think it was dr. o'malley'scomment, is that the extent to which electronic health information exchange is happening atthis point is happening largely between or by physicians and acute care hospitals, becauseof the ehr incentive programs. and the office of the national coordinatorhas looked at the extent to which acute care hospitals and physicians are actually engagedin interoperable health information exchange in addition to just simply using sort of certifiedidhr technology. and one of their reports in 2014, i thinkit was, looked at the extent to which these

providers are exchanging interoperable informationwith providers outside their network. and for physicians, their exchange of informationoutside, with physicians outside of their network, it was relatively low. i think around about 10% of physicians weredoing that. in terms of information exchange by the eligibles,eligible providers with long-term post-acute care providers for example, it was less than1%. so there's not, at this point, much interoperableexchange happening with long-term post-acute care providers. but i think going to your point, as it increases,i think we do need to be looking at whether

or not the information being sent is whatwas intended to be received by the receiver. â»â» yeah. thanks, jen. actually it's worse than what you said. it's not only -- not only are the data elementsas collected now by different people reflecting the same observations, they're being collectedin the same way, doesn't mean the same thing. but if you take it down a level, are the observationsthat are being made, have they been tied adequately to the correct loinc code, for example?

or did they use the right code? is it an ambiguous code? so difficulties of exchanging electronic informationstarts really at the base. is it linked to the proper vocabulary to beginwith? then you go up the level that you are addressing,which is, is it being collected in the same and this is where there is a lot of testinggoing on. and the data elements in all of the federallymandated assessment instruments have a long history of being worked onto be unambiguous. and there's a tremendous amount of the trainingthat gets put out there to make sure that

people collect in the same way. as you all know, you've been at the wrongend of the training, i'm sure. the other piece of this, i think, and again,harkening back to jennie's original slide that says, "caveats" nothing that i say isnecessarily cms policy. in fact it is definitely not cms policy. but in my opinion, i think the gg codes thatyou're now struggling with, that's really a testing bed. because we have gg across the post-acute carecontinuum. and that's where these new common elementsare going to come out.

so essentially the testing is ongoing. think of the gg as the playground. they don't count for anything right now, butthey're going to count for a lot soon. because a lot of those gg codes are goingto become the common data sets that will be used across post acute. it's not the entire data set because you'llstill be doing things that are ltch specific or snf specific, but you'll be collectinga common set that have been developed and recognized to mean the same thing at eachsite. so your point is an excellent point.

and to jenny's point, we're growing. we're building this set of legos. we're going to start one lego at a time. we'll get 10, then 100 and a million. â»â» to terry's point, forgetting the elephantin the room. standardized data elements, right, exactlyright correct. so this effort, the impact act requirementto standardize, make sure these data elements say the same words, have the same meaning,have the same definitions across the post-acute care settings, in the post-acute care assessmentinstruments, that's one step.

and i think terry is right. it is a testbed. and cms does intend to evolve data elementsover time. so i think that's one thing. and then to your other point about do we havethe right hit code? there is work underway now as part of thedata element library to look at previously assigned hit codes, loinc codes or snomedcodes and were the correct codes assigned? and in some instances, there were some issueswith the codes that had been assigned. and so we're now working with the standarddevelopment organizations to clarify or refine

the assigned codes. and so, when the library information is published,that information -- i mean, those codes, just as a footnote -- will be published by thestandard development organizations. the keeper of loinc is a organization calledregenstrief, the keeper of snomed is a organization called ihtsdo. the benefit of the library is, as i said before,it's one-stop shopping. so you'll get the assessment data elementsand the loinc codes as well as the smomed codes in a single field, if you will. so we're working with those standard developmentorganizations to both correct past coding

errors, but also to secure additional codesfor data elements. â»â» emily morgan with kindred healthcare. i have a question about cybersecurity. (laughter) i know a couple of systems thathave have spent millions of dollars to try to make sure they're own internal systems,because they're on acos and networks within themselves, just to make sure they don't getpart of the cyberattack. and when you listen to the people who comein to test drive the system, they say oh, despite all you've spent, it's not good enough. what is the federal it strategy for this interms of the cybersecurity?

i know i sound like i'm a panic person. but if we're going to start exchanging allthis information out there, how secure do we think it really is going to be? i think it's a good idea to share it. don't get me wrong. but i just don't necessarily want somebodyto know that i'm on psych meds or that i have a std, or something like that. not that i have any of those. (laughter) just as examples.

â»â» but if i did, i wouldn't. (laughter) but again, another great question. this is a huge area and of great concern,not just to health information exchange, but think of any segment of the economy. you know, think of banking. how about that? think of technology, think of anyone you canthink of. they're all concerned. and i think it's safe to say that the peoplewho want to hack into your system are working

harder at that than you are at protectingit. there is john hilanca who's a well-known itdoc, did a study of harvard professors. it was a phishing study. he sent out something in very poor englishsaying, you know, please give me your password and your social security number. i need to verify your email log-on, whichyou should include as well. and guess what? a third of these 2000 physicians sent in theinformation. so cybersecurity really starts with-- it startsand probably ends with the workforce, and

sort of what are the policies and proceduresabout maintaining security? so hippa is a great umbrella. at least we're under-- at least we're underhippa, which plugs a bunch of holes in how we leak paper around. we don't do a great job on that. once it gets electronic, then you have multipliedthe potential impact. there are the national security committee,the fbi, the cia, department of defense. they are all working very hard on cybersecurity. and what they learn will be passed down tohealthcare ultimately.

i'm just going to -- it's just -- there'smultiple levels to it. i share your concern. i think healthcare data is among -- if youhad to rank it in the 0-100 scale of where security is would probably give it a 30. it's certainly not up where the cia is. but it's up there. information is an important complex problem,a big concern. it's going to be solved incrementally. i don't think there's a magic bullet to it.

it going to start with local policies on howto handle information and then go from there and from there is also making your systemsecure as you reference it. does that address your -- sure. i feel much better now, right. â»â» hi. i just have a quick question regarding -- sothis is -- i'm from a columbus ltch in new jersey. i have a question about meaningful use. does the ltch qualify for meaningful use ornot, and why?

i mean, i would qualify for meaningful uselike the long-term acute care? would i qualify for meaningful use? i'm just asking about the qualifications,like for meaningful use? yes, i mean our ltch? â»â» yeah, which is long-term acute care facility. â»â» sure, you know, right. it's hard. (laughter). part of the problem was that meaningful usewas tied to certified electronic health systems.

certified is the applicable piece. so it turns out the only people who reallyput in certified ehrs were hospitals and physician groups who were getting the incentive payment. ltchs by in large, with some exemptions, butby in large, they do not have certified ehr technology. so that's, sort of, one of the key things. so you may be doing the same thing in theltch that you do in a hospital. you may be seeing the same patients that youin see in the ltch as you do in the hospital. in the hospital you would be eligible formeaningful use incentives.

in the ltch, doing the same thing, you wouldn'tbe. so it's still a patchwork. meaningful use hasn't been extended acrosspost-acute care care. the dilemma is even greater for physiciansin skilled nursing facilities who have none of those systems, and again still the samepatients. and it actually may count against them. â»â» okay, all right. â»â» high-tech legislation that authorizedthe ehr incentive program and the meaningful use incentives for the eligible providersidentify the provider types in law who would

be eligible for the ehr incentives. and those identified providers included acutecare hospitals, and eligible professionals, including physicians and other specified providerswho could qualify for incentive payments if they demonstrated meaningful use using thecertified ehr technology. and so, long-term post-acute care providersfor example, ltchs, or irfs, or snfs, or home health agencies were not among the providertypes that were listed in the statute that could qualify for incentives regardless ofwhatever technology they were using. they were just not named. and therefore, cms could not make availablethe incentive payment to those ineligible

again, whether they were using technologyor not, if they were using certified technology or not, didn't matter. cms could not make available incentive programsto those ineligible provider types. â»â» i just had a question as to whether ornot the vendors work should be apart of this with the -- competitive bidding within theequipment -- (low audio)? â»â» so cms pays for services delivered byproviders. and so the vendors are servicing the provider. and so the provider is in some instances notin all instances, right, but in some instances, the provider will work with a vendor to supportthe provider services whether that's through

an ehr or some other hit application, or orderingsystem, or supplies. that's kind of the course of doing businessby the provider to support their service delivery. in terms of sharing information with vendorsabout the impact act and data element standardization and interoperability and that sort of thing,there have been presentations to different -- in different venues where there are bothprovider and vendors that participate in those conversations. so i think there's been a pretty good efforton getting the word out to vendors about these impact act requirements and opportunitiesfor vendors to be aware of and then leverage these national health it standards in termsof their assessment instruments for example,

that the assessment instruments that theysupport the provider's use of. so i'm not sure if that gets at your questionor not. or your comment. â»â» how does this interface with va hospitals-- and those kind of federal -- (low audio). â»â» so that's an interesting question. it's been awhile since i've looked at theva. but it used to be that the va used the minimumdata set. so the va could be yet another user of thelibrary and come to the library and see the link health it standards for the mds and integratethose health it standards into the vista product,

i think is the emr product used within theva system. but again there's no requirement for anyoneat this point to use these health it standards in terms of making assessment informationinteroperable. there's no requirement on the medicare/medicaidproviders. there's no requirement on vendors. it is an is opportunity for providers to improvetheir service delivery, improve the continuity and coordination of care and to reduce theircost in the event they become apart of an alternative payment model. increasingly in those models, acute care hospitalswill be looking for more more responsible,

higher-quality trading partners. and the use of technology is one way of achievingthat. â»â» hello, alex from columbus hospital, newjersey. and i'm chief financial officer, and the questionabout could talk more about this like payment approach. i mean, based on quality. like instead of what we have right now, imean from the current approach, we are supposed to provide more procedures, to treat moresick patients. right now i feel like it's going to changedrastically, right.

so what's the message that you're sending? we have to take patients who we can help,who are going to get better, for example. what are we going to do with patients whoare not getting better? what do we have to do with this kind of patient? how are we going to treat them? â»â» just out of curiosity, what type of providerorganization are you? â»â» long-term care. â»â» a long-term care, acute care hospitalor skilled nursing facility? â»â» no, this is a ltch.

â»â» okay, got it. well, so one comment and then i'll defer toterry. but there are no alternative payment modelsor value-based payment models pending as far as i'm aware for ltchs. there are quality measures that are beingadvanced for ltchs, and quality reporting programs for ltchs as well. so they're post-acute care providers. and so, i want to reassure you, i guess aboutthat. so i think looking at your ability to performwell on the quality measures that are being

advanced as a result of the impact act, andmeasured in your quality reporting program, i think will -- is an important focus foryou, because, you know, kind of par for the course with quality reporting programs, consumersthen look at performance according to those metrics. so that's patient level, is that what you'resaying? â»â» for example, one patient-- the patientis not getting better. you're not going to pay? â»â». no. it is not that.

â»â» none of these programs are going to restrictnecessary care. someone's not getting better, then they needsomething, either something different than what you're providing, or something differentthan you're providing. so again, it is sort of case by case. but you're going to be -- the reimbursementmodels are very different depending on where you are and who you are. and i think what you'll see is not a failureto pay for services that are provided, you'll probably see a move to lower cost sites ofcare when it's appropriate. so instead of sending someone to ltch yousend them to snf.

instead of sending them to snf you send themhome. so i think that's going to be a shift yousee long before you see very acute complex patients being cared for anywhere other thanltchs. and the market will support that care, tojenny's point, as long as you meet the quality requirements. so you're going to be looking at dischargingto the communities, to avoidable readmission reduction are sort of two big ones. those are coming forward. but i'd focus on those, just taking good careof the people you've got.

your market will come to you if you're providingreally good care. â»â» kyle from craig hospital in colorado. so my question would be, so with the populationhealth, that's assuming that your patients are staying within your community and yourrealm of care, half of our patients leave the state after we care for them. so any sense of how that's going to look like? because when they go back to massachusetts,say, our ability to impact their health is a little bit more limited, because we're notable to physically care for them. â»â» it really gets to the issue of sort ofattribution of patients.

how do you figure out who's really responsiblefor the care? there are lots of algorithms out there thatare being tested, and they're being used for that. my guess would be that you would probablynot be their primary caretaker if they're going back to massachusetts. so they may not be attributed to you undera alternative payment model. all right. you'll might be providing services to them. you might be providing services to them onthe behalf of another alternative payment

model, perhaps the one in massachusetts thatsays the best rehab care they can get is at craig hospital. we're going to send them there because it'sworth the trip. but i don't think they're going to be attributedto you. i don't think anyone in post-acute care isgoing to have an adverse impact on their payment based on who gets sent to them, or who theycare for. i think that's going to hit the hospital andthe acos, and the medicare advantage plans that have really the population.