In order for the interoperable exchange of assessment content to occur in the manner illustrated in Diagram 1 and Diagram 2 above, a technical approach and tools would have to be developed consistent with HITECH requirements and industry standards. This study, in consultation and collaboration with several technical experts (see Study Methods for names of experts), examined and identified both content and exchange format standards for the MDS and OASIS instruments and content for patient assessment summary documents that could be an entrance point for interoperable HIE on behalf of LTPAC providers. The standards are explained in the next subsections.
To leverage the MDS or OASIS assessment instrument, LTPAC providers need a technical infrastructure and tools that are consistent with HITECH requirements and existing industry standards.
Content Standards for MDS and OASIS Assessment Instruments
For the MDS or OASIS content to be interoperable (machine-readable), the assessment instruments must be linked to existing content standards and vocabularies. Interoperable content facilitates the efficient re-use of assessment data in different EHR systems and across different applications in a single EHR product. Experts reviewed the MDS and OASIS and identified the following content standards applicable data elements in the instruments:
Logical Observation Identifiers Names and Code (Clinical LOINC®), used for common laboratory tests and clinical observations.
Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT), a comprehensive clinical terminology.
International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM); for future implementation, ICD-10 relates to the 10th edition.
HL7 administrative code sets for gender and marital status.
The content standards mapped (linked) to the individual MDS and OASIS items were compiled in a Rosetta Stone spreadsheet for each instrument (Appendix D: MDS Rosetta Stone Spreadsheet, and Appendix E: OASIS Rosetta Stone Spreadsheet). The Rosetta Stones used the CMS data dictionary for the assessment items and provides a reference by MDS and OASIS item to the applicable LOINC name and code, SNOMED concept and code, ICD-9-CM code and/or ICD-10-CM code. The process and mapping rules for developing the Rosetta Stones are discussed in detail in Appendix C: Rosetta Stone Mapping Guidelines and Heuristics.
Clinical experts used the MDS and OASIS Rosetta Stones to identify a clinically relevant subset of items for the Patient Assessment Summary Documents. Stakeholders were solicited to identify an initial set of items which were validated through a consensus process. The process for identifying and validating the subset of items in the assessment summary is discussed in Appendix J: Patient Assessment Summary for Health Information Exchange. Based on the input from clinical stakeholders and experts, Rosetta Stones were also created for the MDS and OASIS Patient Assessment Summary Documents (Appendix K: MDS Assessment Summary Rosetta Stone, and Appendix L: OASIS Assessment Summary Rosetta Stone).
Exchange Architecture for the MDS and OASIS
The ability to exchange patient assessment information will require LTPAC providers to use the standardized exchange formats that are widely accepted by the industry. Lantana Consulting Group was engaged to recommended and develop technical tools to support the exchange of interoperable MDS and OASIS assessment content. There are two primary exchange formats recommended for the MDS and OASIS:
Health Level 7 Clinical Document Architecture (HL7 CDA) is a standard that allows clinical documents and its content to be exchanged.
Health Level 7 Continuity of Care Document (HL7 CCD) is a form of the CDA standard that is focused on the most relevant administrative, demographic, and clinical information about a patient. It is based on the American Society for Testing and Materials E2369-05 Standard Specification for Continuity of Care Record and provides a means for one health care provider to summarize patient data and forward it to another provider to support continuity of care.
To enable the interoperable exchange of assessment instruments, Lantana Consulting Group facilitated the development and balloting of a new HL7 CDA standard for assessment instruments (HL7 Implementation Guide for CDA Release 2: CDA Framework for Questionnaire Assessments, Release 1 standard29). This implementation guide highlights the application of this standard to the MDS 3.0 as an example.
To ensure providers and vendors are able to properly convert and validate non-interoperable MDS 3.0 to an interoperable format consistent with the HL7 CDA implementation guide for Patient Assessments, Lantana developed technical tools focusing on the MDS 3.0.
Lantana Consulting Group provided guidance on using the CCD exchange format for summary records. Although technical tools were not developed under this study, the work is being advanced by the Keystone Beacon Community and under the S&I Framework Longitudinal Coordination of Care Patient Assessment Summary Document Sub-Workgroup (see Advancing the Technical Infrastructure through the S&I Framework for more information on the initiative).
Summary of Technical Tools and Resources Developed
This study developed several tools, highlighted in Table 3, to facilitate the application, widespread use, and dissemination of content standards related to the MDS or OASIS assessment information.
|TABLE 3. Resources to Support Application of Content and Exchange Standards to MDS and OASIS
| Implementation Resource
|Rosetta Stone Mapping Guidelines and Heuristics
||This resource offers the guidelines and rules that were used to map recognized HIT vocabularies -- specifically, LOINC® and SNOMED CT -- to the MDS and OASIS assessments, and the use of coded vocabularies in an HL7 messaging standard (the CDA Patient Assessment Questionnaire Implementation Guide) to enable the interoperable transmission of these assessments. The exchange standard enables assessments to be represented as intended by assessment developer (using a "model of use" format) and enables the re-use of assessment content (i.e., using the model of meaning format).
||C: Rosetta Stone Mapping Guidelines and Heuristics
|MDS 3.0 Rosetta Stone
||This resource maps each MDS 3.0 question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for nursing home EHR vendors and HIE organizations.
||D: MDS 3.0 Rosetta Stone
|The MDS value set of diagnosis concepts file provides a set of SNOMED concepts to illustrate how the MDS problem/diagnosis section could be semi-populated from the EHR.
||D: MDS Value Set of Diagnosis Concepts
|OASIS Rosetta Stone
||This resource maps each OASIS question and answer to applicable terminologies and code sets including LOINC®, SNOMED, ICD-9-CM and ICD-10. This is expected to be a useful reference for home health EHR vendors and HIE organizations.
||E: OASIS Rosetta Stone
|Rosetta Stone for MDS Assessment Summary
||A technical resource in Excel which identifies the MDS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.
||K: MDS Assessment Summary Rosetta Stone
|Rosetta Stone for OASIS Assessment Summary
||A technical resource in Excel which identifies the OASIS item selected for the summary, the related SNOMED concept, LOINC code, CCD Section, and analyzed compatibility with HITSP C32 requirements.
||L: OASIS Assessment Summary Rosetta Stone
|Exchange Format Standardization
|Current Standards Landscape
||A discussion about the current standards and their application to assessment content and enabling re-use of health information. This resource could be used by LTPAC providers and vendors to facilitate their awareness and understanding.
||F: Current Standards Landscape
||This appendix document provides a summary of the technical tools available in the toolkit.
||G: Interoperability Toolkit
|HL7 CDA Implementation Guide
||This guide describes how to represent questions and answers in PAIs as an HL7 CDA document. The implementation guide represents the MDS 3.0 as an example of a CDA patient assessment document.
||G: Interoperability Toolkit CDA Implementation Guide for Assessment Instruments
|MDS Conversion/ Validation Utilities
||Various tools for transforming the MDS from a CDA format to the CMS transmission format and tools to validate the conversion.
||G: MDS Transform Tool and Validator
|CCD Guidance and Considerations
||This document provides general information on how to design a valid CCD document using patient assessment content from the MDS.
||G: MDS CCD Design Document
|Standards Development and Adoption Recommendations
||Provides recommendations for advancing and accelerating the use of HIT and EHRs in the LTPAC industry based on existing standards and known gaps. Discusses the relationship of existing and potential national policy strategies in relating to the standards recommendations.
||H: Standards Development and Adoption Recommendations
Advancing the Technical Infrastructure through the S&I Framework
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:
Patient Assessment Summary Document Sub-Workgroup30
- 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).
- 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).
- 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.
- 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.
- Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.
Longitudinal Care Plan Sub-Workgroup31
- Validate and refine, as needed, the content that is to be included on the home care POC (formerly 485-form).
- 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).
- Re-use, as feasible, standardized OASIS assessment content provided by this ASPE study (see Appendix E: OASIS Rosetta Stone).
- 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).
- 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).
- Ensure that work undertaken by this Sub-Workgroup is coordinated with HL7.
LTPAC Care Transition Sub-Workgroup32
- Develop a priority list of acute/post-acute transitions based on volume, clinical instability and acuity of the required information.
- Develop standard clinical content defined by the receiving clinicians for all high-priority transitions.
- Develop resources to support interoperability of all clinical content across all sites of care.
- 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.
Issues Requiring Further Consideration
Individuals served by LTPAC providers often have chronic illnesses and disabilities resulting in physical and cognitive functional limitations. They interact routinely with multiple providers. The ability to communicate functional status between providers and caregivers is crucial to ongoing care planning and treatment. This study calls out an important gap that could be addressed by the industry.
Currently there is not a uniform definition, assessment method or scale for functional status to be communicated consistently across care settings. This creates challenges for representing functional status in a standardized vocabulary to support continuity of care, information exchange and re-use. Functional status information is important to assessing an individual's level of functioning and providing appropriate and needed health and supportive services. Functional status impacts the individual's quality of life, wellness, and ability to care for self, and is often a factor in public and private payment methodologies as well as in quality management and clinical outcome measurement.
Work is needed to enable the inclusion of functional status content to support the meaningful use of EHRs across the health care continuum. Specification of the HIT content and messaging standards related to functional status will enable the exchange of critical information to support quality and continuity of care.
Appendix I: Recommendations for Functional Status provides more specific suggestions for addressing the standards related to functional status.