PACIO Project SEPTEMBER 2020 WORK GROUP MEETINGS PACIO

PACIO Project SEPTEMBER 2020 WORK GROUP MEETINGS

PACIO Project - The Patient Story • Poor communication across care providers • Medication discrepancies such as drug omissions during transitions of care and multiple modes of information transmission result in delays in PAC services and can lead to adverse events and preventable readmissions • Redundant information collection creates inefficiencies and burden • Reliance on patient recall during periods of high stress • Recall of information can be unreliable • Patients may be unconscious, incapacitated, or otherwise unresponsive / unable to communicate information • Increased patient / family stress • Increased Cost and Provider Burden • Additional costs related to hospital stays from adverse events, readmissions • Additional administrative costs to locate, reconcile, and coordinate information Source: CMS DCPAC © 2020 The MITRE Corporation. All rights reserved. 2

PACIO Project The PACIO Project is a collaborative effort between industry, government and other stakeholders, with the goal of establishing a framework for the development of a Fast Healthcare Interoperability Resource (FHIR) technical implementation guide(s) and Reference Implementations to facilitate health information exchange. PACIO prioritized Functional Status and Cognitive Status as areas of clinical importance in need of most immediate standardization. http: //pacioproject. org © 2020 The MITRE Corporation. All rights reserved.

Track Summary PURPOSE • Exchange patient level cognitive and functional status data between multiple disparate health IT (HIT) systems, incorporated with electronic Long-Term Services and Support (e. LTSS) care plan and patient goals data, in a consumable format for clinicians, patients, and family members. • Test integration of CMS assessment data elements from the Data Element Library (DEL) into health IT systems using FHIR APIs. CONFLUENCE SITE https: //confluence. hl 7. org/display/FHIR/2020 -09+PACIO-e. LTSS+Post-Acute+Care+Transition+Summary © 2020 The MITRE Corporation. All rights reserved.

PACIO Project Connectathon Use Case • • • PACIO Project engaged approximately 25 -30 members, representing multiple organizations and professions, to construct a use case for exchange of patient data Top portion of the diagram illustrates the different systems involved in the use case and the flow of information The use case is divided into 6 scenes, which show the patient transitioning between multiple healthcare settings https: //github. com/paciowg/sample-data/blob/master/2020 -05%20 HL 7%20 May%20 Connectathon/2020 -05 -12_PACIO-e. LTSS%20 Use%20 Case_FINAL. pdf © 2020 The MITRE Corporation. All rights reserved.

PACIO Project Connectathon System Diagram Scene 5 Scene 1 Scene 6 Scene 3 Scene 2 Scene 3 Scene 4 © 2020 The MITRE Corporation. All rights reserved.

Scene 1 Screen Capture Ms. Betsy Smith Johnson receives home community-based services (HCBS) services at home. A social worker documents e. LTSS data including care plan and goals. e. LTSS data is pushed to the Data Hub. Server © 2020 The MITRE Corporation. All rights reserved. Viewer Push to Data Hub

Scene 2 Screen Capture Betsy experiences a fall at home and is admitted to the hospital for surgery. After the surgical intervention, Betsy is assessed by physical, occupational & speech language pathology therapists (PT/OT/SLP) and is recommended to continue her therapy in a skilled nursing facility (SNF). Cognitive and functional assessments completed and documented in the hospital EHR are pushed to the Data Hub. Selects the EHR Patient for the PAC Assessment Queries the pseudo-DEL for the list of available PAC Assessments Converts the completed PAC Assessment Questionnaire. Response to Structured Data Capture (SDC) Sends the converted SDC Questionnaire. Response to the EHR © 2020 The MITRE Corporation. All rights reserved.

Scene 3 Screen Capture Betsy is admitted to the SNF for PT/OT/SLP services for 14 days. The SNF retrieves the e. LTSS data and assessment data from the Data Manager to inform her care. Functional and cognitive status is assessed on admission and discharge and pushed to the Data Hub. © 2020 The MITRE Corporation. All rights reserved.

Scene 4 Screen Capture The assessment application pulls the standardized assessment data from the CMS DEL and presents forms to the clinician performing the assessments. © 2020 The MITRE Corporation. All rights reserved.

Scene 5 Screen Capture After 14 days, Betsy is ready for discharge back home. The HHA agency coordinator reviews the patient's data from the Data Manager as part of the triage process. © 2020 The MITRE Corporation. All rights reserved.

Scene 6 Screen Capture While at home, Betsy and her authorized family caregiver access the e. LTSS data and assessment data through a patient mobile/web application. © 2020 The MITRE Corporation. All rights reserved.

Participants Track Leads • Siama Rizvi, rizvi@mitre. org • Sean Mahoney, smahoney@mitre. org Organizations • CMS • Altarum • FEI • MITRE • Patient Centric Solutions • Max. MD © 2020 The MITRE Corporation. All rights reserved.

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.

HL 7 September 2020 Connectathon Architecture © 2020 The MITRE Corporation. All rights reserved.

Notable Achievements • Successfully exchanged data between 15+ systems utilizing 4 FHIR Implementation Guides • Exchanged data containing: • e. LTSS Care Plan • e. LTSS Patient Goals • PACIO Functional Status • PACIO Cognitive Status • DEL Questionnaire • Medication Statements • Conditions, Demographics, Devices, Encounters • And more! • Collaborated with Clinical Reasoning Track to calculate e. CQM 104 (stroke) and 149 (cognition) © 2020 The MITRE Corporation. All rights reserved.

Screenshots © 2020 The MITRE Corporation. All rights reserved.

Discovered Issues Communications issues between PAC assessment app, pseudo-EHR, and Data Manager • Data and interface issues • Will continue to work through © 2020 The MITRE Corporation. All rights reserved.

Connectathon 24 - e. CQM Testing • Collaborated with the Clinical Reasoning track to perform review of PACIO sample data using a quality measure use case • CMS-149 (Dementia: Cognitive Assessment) and CMS-104 (Anti-Thrombotic Therapy) • Executed Quality Measure against refined data to obtain a Numerator and Denominator result from PACIO data © 2020 The MITRE Corporation. All rights reserved.

Next Steps • Finalize changes to PACIO IGs to prepare for out-of-cycle balloting • Continue developing PACIO Use Case • Add scenes • Continue to build robust data set • Continue to add IT Implementors, real world systems to replace reference implementations © 2020 The MITRE Corporation. All rights reserved.

Present and Potential Future Use Cases Quality Measures Functional Status Cognitive Status STU 1 Ballot Prep Speech Pathology Advanced Directives Frailty Post COVID In Development http: //pacioproject. org © 2020 The MITRE Corporation. All rights reserved. Real-Time Medication Reconciliation Nutrition Discovery

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.

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.