January 2021 Connectathon Planning PACIO MEETING 1222020 Agenda

January 2021 Connectathon Planning PACIO MEETING - 12/2/2020

Agenda • Timeline • Possibilities • Role Assignment © 2020 The MITRE Corporation. All rights reserved.

Connectathon Preparation - Timeline November 13 December 11 Connectathon 26 January 13 -15, 2021 • Planning kickoff! • Possibilities and roles • Sample data complete • Virtual © 2020 The MITRE Corporation. All rights reserved. • Use case determined • Track proposal due • Functionality Complete November 19 January 6, 2021

Possibilities Feature What Systems Quality Measure Integration Pull PACIO data and calculate e. CQMs Quality Measure System (Client) Health Data Manager (Server) HIE Integration Pull/post(? ) health info from HIE Health Data Manager (Client) HIE (Server) PAC Assessment Reporting to CMS PAC facilities report assessments to CMS Pseudo-EHR (Client) Pseudo-i. QIES# (Server) Real EHR Replace pseudo-EHR HHA/HCBS EHR Identity Management Patient matching, basis for consent Health Data Manager (Client) Identity Provider (Server) Advance Directives Exchange basic AD information* Client Server * Yet to be defined © 2020 The MITRE Corporation. All rights reserved. # i. QIES = internet Quality Improvement and Evaluation System

HL 7 September 2020 Connectathon Use Case https: //confluence. hl 7. org/ display/FHIR/202009+PACIO-e. LTSS+Post. Acute+Care+Transition+Su mmary? preview=/8697343 8/91987398/PACIOe. LTSS%20 Transitions%20 C are%20 Care%20 Summary% 20 Track%20 Use%20 Case_2 020 -9 -8. pdf © 2020 The MITRE Corporation. All rights reserved.

Proposed January 2021 Connectathon Architecture Advance Directives Client © 2020 The MITRE Corporation. All rights reserved.

Quality Measures • Working with Clinical Quality Information • May 2020 Connectathon • Successfully calculated CMS 149 (Dementia: Cognitive Assessment) • September 2020 Connectathon • Added CMS 104 (Anti-Thrombotic Therapy) • Plans for January 2021 Connectathon • Data for quality measures in May and September were manually utilized • Goal for January is more direct integration with PACIO servers • Directly retrieve PACIO assessments and calculate measures © 2020 The MITRE Corporation. All rights reserved.

HIE Integration • Meeting with Michigan Health Information Network (Mi. HIN) this Friday • Will determine the scope and level of integration © 2020 The MITRE Corporation. All rights reserved.

Early Vision – Integrating i. QIES Patient / Provider Care Setting Data Element Library © 2020 The MITRE Corporation. All rights reserved. Assessments - i. QIES

Real EHR • Matrix. Care EHR to replace Pseudo-EHR at the HHA • Transition of Care (retrieving and displaying e. LTSS and PACIO data) • PAC Assessment App • Write data to Health Data Manager (SDC Questionnaire. Response, PACIO data) © 2020 The MITRE Corporation. All rights reserved.

Identity Management • Integration between Patient Centric Solutions and ID. me • Session at Connectathon on Identity Management and Patient Consent technologies © 2020 The MITRE Corporation. All rights reserved.

Advance Directive Interoperability (ADI) FHIR IG Use Case Overview Content Use Cases Use Case 4: Verify current version of [Content] © 2020 The MITRE Corporation. All rights reserved. Portable Medical Order for Life-Sustaining Treatments Use Case 3: Request and access [Content] Episodic Patient Instruction Use Case 2: Update and share [Content] Advance Directive Information Use Case 1: Create and share [Content]

Advance Directive Interoperability (ADI) FHIR IG Use Case Overview (continued) Use Case 1: Create and share [Content] Use Case 1 a: Create and share advance directive information CDA Use Case 1 b: Create and share episodic patient instruction Use Case 1 c: Create and share advance Portable Medical Order for Life-Sustaining Treatments Use Case 2: Update and share [Content] Use Case 2 a: Update and share advance directive information Use Case 2 b: Update and share episodic patient instruction Use Case 2 c: Update and share advance Portable Medical Order for Life-Sustaining Treatments Use Case 3: Request and access [Content] Use Case 3 a: Request and access advance directive information Use Case 3 b: Request and access episodic patient instruction Use Case 3 c: Request and access advance Portable Medical Order for Life-Sustaining Treatments Use Case 4: Verify current version of [Content] Use Case 4 a: Verify current version of advance directive information Use Case 4 b: Verify current version of episodic patient instruction Use Case 4 c: Verify current version of advance Portable Medical Order for Life-Sustaining Treatments © 2020 The MITRE Corporation. All rights reserved. CDA Data Blob thru FHIR Break the Glass (Emergency)

Possibilities / Roles Feature What Quality Measure Integration Pull PACIO data and Quality Measure System (Client) calculate e. CQMs Health Data Manager (Server) Follow up with Rob Patient Centric Solutions HIE Integration Pull/post(? ) health info from HIE Patient Centric Solutions Follow up with Mi. HIN PAC Assessment Reporting to CMS PAC facilities report Pseudo-EHR (Client) assessments to CMS Pseudo-i. QIES# (Server) MITRE Real EHR Replace pseudo. EHR HHA/HCBS EHR Matrix. Care Identity Management Patient matching, basis for consent Health Data Manager (Client) Identity Provider (Server) Patient Centric Solutions ID. me (final confirmation) Advance Directives Exchange basic AD information* Client Server * Yet to be defined © 2020 The MITRE Corporation. All rights reserved. Systems Health Data Manager (Client) HIE (Server) Who Max. MD, My. Directives Patient Centric Solutions? Ad. Vault? # i. QIES = internet Quality Improvement and Evaluation System

CMS Data Element Library FHIR API Prototype • Implementation Guide: https: //paciowg. github. io/del/ • Hosted Reference Implementations • Server: https: //api. logicahealth. org/PACIO/ • Client: https: //deldemo. herokuapp. com • Reference Implementation Code (Apache 2. 0 license) • Server: https: //github. com/paciowg/del • Client: https: //github. com/paciowg/del. Demo • Test Scripts: https: //github. com/paciowg/inferno © 2020 The MITRE Corporation. All rights reserved.

CMS internet Quality Improvement and Evaluation System (i. QIES) FHIR API Prototype • Implementation Guide: Under development • Reference Implementation Code (Apache 2. 0 license): Under development • Test Scripts: To be developed © 2020 The MITRE Corporation. All rights reserved.

PACIO Functional Status • Implementation Guide: https: //build. fhir. org/ig/HL 7/fhir-pacio-functional-status/ • Hosted Reference Implementations • Server: http: //hapi. fhir. org/base. R 4 • Client: https: //snf-transfer-summary. herokuapp. com/ • Reference Implementation Code (Apache 2. 0 license) • Server: https: //github. com/jamesagnew/hapi-fhir • Client: https: //github. com/paciowg/transfer-summary-ri-client • Test Scripts: https: //github. com/paciowg/inferno © 2020 The MITRE Corporation. All rights reserved.

PACIO Cognitive Status • Implementation Guide: https: //build. fhir. org/ig/HL 7/fhir-pacio-cognitive-status/ • Hosted Reference Implementations • Server: http: //hapi. fhir. org/base. R 4 • Client: https: //snf-transfer-summary. herokuapp. com/ • Reference Implementation Code (Apache 2. 0 license) • Server: https: //github. com/jamesagnew/hapi-fhir • Client: https: //github. com/paciowg/transfer-summary-ri-client • Test Scripts: https: //github. com/paciowg/inferno © 2020 The MITRE Corporation. All rights reserved.

PACIO Advance Directives • Implementation Guide: Under development • Reference Implementation Code (Apache 2. 0 license): Under development • Test Scripts: To be developed © 2020 The MITRE Corporation. All rights reserved.

The PACIO Project is a collaborative effort to advance interoperable health data exchange between post-acute care (PAC) and other providers, patients, and key stakeholders across health care and to promote health data exchange in collaboration with policy makers, standards organizations, and industry through a consensus-based approach. Learn and share more about the PACIO Project at www. PACIOproject. org

FHIR Resources Anticipated for Advance Directives Health Concerns Goals Interventions Health Status & Outcomes Condition (Health Concern) Goal Procedure, Medication Administration, others Observation Care. Plans Health Agent Appointments am e e. T r Ca DNR Orders Medical/Physician Orders for Life Sustaining Treatment Goals at End of Life, Care Experience Preferences Intervention Preferences, Instructions Obligations, Prohibitions Health Statuses that are a Precondition for certain choices Care Plan at a point in time Consent Composition Portable Medical/Physician Orders for Life Sustaining Treatment Contracts Medical Orders **No New FHIR Resources are needed © 2020 The MITRE Corporation. All rights reserved. 21