Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Advancing the Technical Infrastructure through the S&I Framework

12/01/2011

The content and exchange standards that have been applied to PAIs and the resources summarized in Table 3 are being used in the ONC S&I Initiative. The LCCWG has been created as a community-led initiative to support HIE on behalf of LTPAC stakeholders and address potential gaps in the S&I Transitions of Care work products to support engagement of LTPAC providers in HIE activities. The LCCWG has established three sub-workgroups. Each of these three sub-workgroups has expressed their intent to re-use standardized MDS and/or OASIS assessment data to support their use. The following describes the workgroup charges:

  1. Patient Assessment Summary Document Sub-Workgroup30

    1. Validate and refine, as needed, a subset of MDS 3.0 and OASIS content that could be clinically useful to exchange with hospitals, physicians, other LTPAC providers, and/or family members. The subset that of MDS 3.0 and OASIS content that will be targeted is that which was identified through this ASPE study (see Appendix K: MDS Summary Rosetta Stone; and Appendix L: OASIS Summary Rosetta Stone).
    2. Re-use the standardized MDS 3.0 and OASIS assessment content provided by this ASPE study (see Appendix D: MDS 3.0 Rosetta Stone; and Appendix E: OASIS Rosetta Stone).
    3. Provide input and guidance on the transformation tool being developed by the Geisinger Keystone Beacon Community to transform the non-interoperable MDS 3.0 and OASIS into an interoperable clinical document that can be made available for HIE.
    4. Develop a CDA implementation guide and schema leveraging work under way by the Geisinger Keystone Beacon Community to enable the interoperable exchange of Patient Assessment Summary Documents.
    5. Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.

     

  2. Longitudinal Care Plan Sub-Workgroup31

    1. Validate and refine, as needed, the content that is to be included on the home care POC (formerly 485-form).
    2. Identify content and format standards needed to represent content of the home care POC (formerly 485-form). The Sub-Workgroup will take into account and re-use previous standards identified through the ToC Initiative for the home care POC (formerly 485-form).
    3. Re-use, as feasible, standardized OASIS assessment content provided by this ASPE study (see Appendix E: OASIS Rosetta Stone).
    4. Keep aware of and provide feedback on the standards being identified and piloted by the VNSNY, home care electronic medical record vendors, home care agencies, and hospitals/physicians exchanging an interoperable home care POC (formerly 485-form).
    5. Develop a CDA implementation guide and schema leveraging work under way by the VNSNY home care POC pilot to enable the interoperable exchange of home care POC (formerly 485-form).
    6. Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.

     

  3. LTPAC Care Transition Sub-Workgroup32

    1. Develop a priority list of acute/post-acute transitions based on volume, clinical instability and acuity of the required information.
    2. Develop standard clinical content defined by the receiving clinicians for all high-priority transitions.
    3. Develop resources to support interoperability of all clinical content across all sites of care.
    4. Re-use of selected data elements from OASIS and MDS to populate the transitions data sets from home health agencies and skilled nursing facilities/extended care facilities.

The three sub-workgroups of the Longitudinal Coordination of Care initiative are expected to use standardized content from assessment instruments to support LTPAC's inclusion in HIE and improve shared care and transitions. Standardizing the MDS and OASIS creates the foundation for LTPAC providers and vendors to build more sophisticated, interoperable HIT systems.

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