Component 22, Component Guide - files.healthit.govfiles.healthit.gov/Component_22/Comp22_Component_G… · Web viewCare coordination is the deliberate organization of patient care

Component 22:

Care Coordination and Interoperable Health IT

Systems

Component Guide

Health IT Workforce CurriculumVersion 4.0/Spring 2016

This material (Comp 22) was developed by Columbia University and The University of Texas Health

Science Center at Houston, funded by the Department of Health and Human Services, Office of the

National Coordinator for Health Information Technology under Award Number 90WT0004. This work is

licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

To view a copy of this license, visit

http://creativecommons.org/licenses/by-nc-sa/4.0/

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Component Number: 22

Component Title: Care Coordination and Interoperable Health IT Systems

Component Description:Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. Interoperable health IT that is patient-centered makes the right data available to the right people at the right time across products and organizations, and in a way that can be relied upon and meaningfully used by recipients. The ability to seamlessly share health information is essential to building a patient-centered interoperable health IT ecosystem in the United States to facilitate coordination of care.

Component Objectives:At the completion of this component, the student will be able to:

1. Define patient-centered care coordination, discuss best practice tools and emerging models for care coordination, distinguish care coordination roles and responsibilities, and identify stakeholders.

2. Describe key elements for transforming to team-based care, identify types of team-based interventions, and implement multi-disciplinary care planning.

3. Compare and contrast the barriers and challenges to achieving and examine the government’s vision for interoperable health IT.

4. Explore the technical principles of health interoperability by distinguishing its various levels and dimensions, differentiating intra- and inter-organizational interoperability, and identifying its key tools.

5. Explain the rationale for interoperability standards, identify various health interoperability standards in use, and list and describe key health interoperability standards.

6. Recognize the special requirements for implementing health care interoperability projects and describe the steps required to implement and support interoperability projects.

7. Identify key health interoperability topics addressed in health IT related legislation and discuss how the Meaningful Use program aims to facilitate care coordination.

8. Articulate the issues that health information exchange (HIE) is intended to address, identify the challenges to successful HIE implementation, examine the strategies

Health IT Workforce Curriculum Care Coordination and 2Version 4.0 Interoperable Health IT Systems

(organizational, technological, and policy-related) utilized to advance HIE, and discuss the future of HIE.

9. Define mHealth and telehealth, list examples of its use, and describe its application to care coordination and patient access to care.

10.Summarize federal policy to protect health information for care coordination, discuss challenges related to policy implementation, and provide examples of tools and techniques for evaluation of compliance.

11.Relate the importance and describe the concept of patient-driven care coordination and list ways that technology can be used to drive care decisions.

12.Explain the value and use of a data-driven care coordination strategy and discuss challenges in its implementation.

Component Files

Each unit within the component includes the following files:

Lectures (voiceover PowerPoint in .mp4 format); PowerPoint slides (Microsoft PowerPoint format), lecture transcripts (Microsoft Word format); and audio files (.mp3 format) for each lecture.

Application activities (discussion questions, assignments, or projects) with answer keys.

Self-assessment questions with answer keys based on identified learning objectives.

Some units may also include additional materials as noted in this document.


Component Units with Objectives and Topics

Unit 1: Overview of Care Coordination

Description:

This unit provides insight into what is known and tested about patient-centered care coordination. Evidence-based care coordination allows for seamless transitions across the health care continuum in a deliberate effort to improve outcomes and reduce errors and redundancies. This overview is designed to offer best-practice tools and a roadmap for new and emerging care coordination models. Learn about care coordination implementation in a variety of care settings and programs, from what is being tried, tested, and applied by those on the care coordination journey. Case examples representing a range of programs demonstrate care coordination successes.

Objectives:

1. Define care coordination effectiveness.2. Explain the purposes for care coordination.3. Discuss various models of care coordination.4. Compare care coordination roles and responsibilities in the post-Affordable Care

Act models of care across the care continuum.5. Discuss specialty care coordination.6. Discuss long-term care/post-acute care.7. Identify stakeholders in care coordination.

Lectures:

a. What is Care Coordination? (MM:SS)

1. Purpose and definition of care coordination

b. Care Coordination Models (MM:SS)

1. Patient Centered Medical Home (PCMH)2. Other models of care coordination

c. Long-Term Care Coordination (MM:SS)

1. Specialty care coordination2. Long-term care/post-acute care3. Stakeholders in care coordination

Unit 2: Team-Based Approach to Patient Care

Description:


This unit will examine methods for transforming traditional care delivery systems to innovative, empowered, patient-centered, team-based care delivery systems. Clinical and non-clinical guideline resources, including tools for multi-disciplinary, team-driven care planning will be explored.

Objectives:

1. Identify best-practice types of team-based interventions.2. Discuss key elements for transforming to team-based care.3. Plan for transformation to team-based care.4. Identify evidence-based clinical practice guidelines resources.

Lectures:

a. Multidisciplinary Care Planning (MM:SS)

1. Types of team-based interventions2. Developing a team-based intervention/roll-out strategy

b. Transformation Planning (MM:SS)

1. Utilization of clinical care pathways or evidence-based clinical practice guidelines2. Evidence-based clinical practice3. Prioritization of clinical conditions

c. Evidence-based Clinical Practice (MM:SS)

Unit 3: Overview of Interoperable Health IT

Description:

Increasing emphasis is being placed on the need for robust coordination of patient care across various types of providers and settings to ensure the best outcomes. Key to the fidelity of such coordination is the targeted sharing of information between health care professionals and the system tools they use to record and generate it. Optimal sharing involves not only the transmission of data from one application to another, but also the proper assignment of context and meaning so that information is rapidly interpretable and actionable by the recipient. Interoperable health IT ensures such value-added information sharing. This unit introduces the topic of interoperable health IT by defining it, summarizing its benefits, reviewing the barriers and challenges to achievement, and examining the government’s vision of interoperable health IT.

Objectives:

1. Define health care interoperability.2. Summarize the vision and benefits of interoperable health IT.


3. Identify and examine several barriers and challenges to obtaining interoperable health IT.

4. Discuss the U.S. strategy for health interoperability.

Lectures:

a. Benefits of Health Care Interoperability (MM:SS)

1. Definitions of health care interoperability2. Interoperability within an organization and between organizations3. ONC’s national strategy4. Vision of interoperable health IT5. ONC’s definition of a learning health system6. Benefits of interoperability

b. Barriers to Interoperable Health IT (MM:SS)

1. List from U.S. Government Accountability Office2. List from ONC Health IT Policy Committee3. List from JASON Report4. Interoperability as a continuum5. Challenges

c. National Strategy for Health Interoperability (MM:SS)

1. ONC’s national strategy2. Federal Health IT Strategic Plan3. ONC’s Shared Nationwide Interoperability Roadmap

Unit 4: Principles and Technology of Interoperable Health IT Systems

Description:

This unit explains health interoperability from a technical perspective. We examine health interoperability’s various dimensions and levels, compare and contrast intra- versus inter-organizational interoperability, and survey the tools and technologies that enable it.

Objectives:

1. Name and define types of interoperability.2. Explain the complexities of semantic harmonization and the benefits of using

standards.3. Describe and contrast intra- and inter-organizational interoperability.4. Identify and discuss common types of tools and technologies used to solve

health interoperability problems.


Lectures:

a. Technical Definitions of Interoperability (MM:SS)

1. Foundational interoperability2. Structural interoperability3. Semantic interoperability4. Semantic harmonization5. Steps to achieving interoperability

b. Intra-Organizational and Inter-Organizational Interoperability (MM:SS)

1. Intra-organizational interoperability2. Data ownership3. Inter-organizational interoperability4. Patient matching5. Terminologies6. Governance and trust7. Data flows8. Interoperability needs

c. Tools and Technologies for Interoperability Part 1 (MM:SS)

1. Interface engine2. Enterprise master patient index3. Terminology management4. Health information exchange (HIE) software

d. Tools and Technologies for Interoperability Part 2 (MM:SS)

Unit 5: Standards for Interoperable Health IT

Description:

Key to the success of IT interoperability in any field is the development, adoption, and use of standards. This is especially critical in health care where the information shared between participants is conceptually complex. This unit explains how health IT standards evolved and why they are important and provides an overview of those used to facilitate health interoperability.

Objectives:

1. Explain why standards are required, how they are developed, and how adoption is encouraged.

2. Name and describe the types of interoperability standards available.3. Summarize the functionality of HL7 V2®, CDA®/CCDA, and FHIR®.


4. Recognize HL7 V2® messages, CDA® documents, and FHIR® resources.

Lectures:

a. Overview of Standards (MM:SS)1. Importance of standards2. Development of standards3. Adoption of standards

b. Survey of Standards (MM:SS)

1. Lower-level standards2. Health care content standards3. Terminology standards4. Implementation guides/profiles

c. Introduction to HL7 V2® (MM:SS)

1. Message types2. Uses3. Structure of message4. Segment definition5. Encoding6. Limitations

d. Introduction to HL7 CDA® (MM:SS)

1. HL7 version 32. Structure3. eXtended Markup Language (XML)4. Header5. Narrative block6. Continuity of care document (CCD)

e. Introduction to HL7 FHIR® (MM:SS)

1. Characteristics2. Resources3. RESTful application programming interface (API)

Unit 6: Implementing Health Interoperability

Description:

The adherence to solid project management principles and practices is important to successful IT implementations. This is especially true regarding interoperability projects. This unit examines the special requirements, tasks, and challenges involved


with implementing and maintaining interoperability efforts throughout the entire project lifecycle.

Objectives:

1. Identify the major tasks required to implement interoperability. 2. Explain why interoperability implementation projects are needed.3. Define and discuss each phase of the interoperability implementation lifecycle.4. Describe how to apply each phase of the interoperability implementation lifecycle

to simple interoperability implementation problems.5. List types of production issues with interoperability and identify and describe

support strategies.

Lectures:

a. Implementation: “Organize” Phase (MM:SS)1. Interoperability capabilities2. Implementation project3. Implementation lifecycle4. Special considerations for interoperability projects5. Project planning tips

b. Implementation: “Analyze” Phase (MM:SS)

1. Requirements gathering2. Gap analysis3. Mapping work4. Data incompatibilities5. Workflow issues6. Desirable interoperability qualities of vendors and vendor systems7. Results of analysis

c. Implementation: “Design” Phase (MM:SS)

1. Architecting a solution2. Identifying the relevant incompatibilities3. Designing interfaces4. Designing for workflow efficiency5. Results of design phase

d. Implementation: “Build” and “Test” Phases (MM:SS)

1. Build phase2. Build phase considerations3. Build completion


4. Test phase5. Preparations6. Test plan

e. Implementation: “Go-Live” Phase (MM:SS)

1. Go-live plan2. Go-live support

f. Implementation: “Go-Live” Phase and Production Support (MM:SS)

1. Challenges of interoperability2. Types of issues3. Incident management4. Production issues

Unit 7: Policy and Interoperable Health IT

Description:

Various components that are enabling health interoperability have been under development for years and many have made their way into systems and products used by providers. Adoption, implementation, and use of such components have been accelerating recently due to a significant focus in government policies on the need for patient care coordination across providers and settings of care. This unit summarizes major US policy that has played a role in facilitating interoperable health IT.

Objectives:

1. List the impact of key heath interoperability-related topics in health care legislation.

2. Identify and discuss how the Meaningful Use program and the ONC certification programs have impacted interoperable health IT.

3. Assess and leverage Meaningful Use, ONC certification, and other health IT policy activities to facilitate interoperability.

Lectures:

a. Overview of Policy and Interoperable Health IT (MM:SS)1. Regulated health IT2. Quick review of U.S. government3. Health IT-related congressional acts4. Health IT-related regulations5. Key reports6. Government-related efforts for interoperability7. “Stimulus bill”


8. Meaningful Use Program9. Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

b. Meaningful Use, ONC Certification, and Interoperability (Part 1) (MM:SS)1. Meaningful Use Stage 12. 2011 ONC regulations standards3. Stage 2 objectives4. 2014 ONC regulations standards5. Stage 2 challenges / efforts for providers and hospitals6. Interoperability accomplishments

c. Meaningful Use, ONC Certification, and Interoperability (Part 2) (MM:SS)1. Stage 3 regulations2. Modified Stage 23. Stage 3 and interoperability4. 2015 ONC certified features5. Meaningful Use and interoperability6. Merit-based Incentive Payment System (MIPS)

d. Assessing and Leveraging Meaningful Use and ONC Certification Progress for Interoperability (MM:SS)1. Ask probing questions2. Additional certified features3. Helpful Meaningful Use information for interoperability strategy and decisions4. Leverage active projects and future plans

Unit 8: Exchange of Health Information

Description:

This unit covers the reasons that the exchange of health information is an important component of a modern health care system, the challenges that exist to realizing the exchange of health information at the national level, some of the strategies that have been taken to advance the exchange of health information – for example, health information exchange organizations, Direct, and Meaningful Use – and future directions for the exchange of health information.

Objectives:

1. List the quality problems in health care that the exchange of health information is intended to remediate.

2. Describe the nature of health information technology assets that the exchange of health information is designed to interconnect.


3. Explain the motivations, capabilities, and challenges of health information exchange organizations (HIEOs).

4. Explain the motivations, capabilities, and challenges of using Meaningful Use and Direct to advance the exchange of health information.

5. Describe the future directions for the exchange of health information.

Lectures:

a. Introduction (MM:SS)1. Reasons for health information exchange2. Scenarios for health information exchange3. Quality of care4. Health care spending5. Strategy for building national health information infrastructure6. Mid-2000s: U.S. health care landscape7. National Health Information Network (NHIN)8. Mid-2000s: approaches to achieve interconnected infrastructure

b. Health Information Exchange Organizations (MM:SS)1. Challenges to interconnecting hospitals/large organizations2. Health information exchange organizations3. Examples: SHIN-NY (State Health Information Network-New York) and Healthix4. Issues5. Status6. Impact7. Hurdles for scaling8. Concerns

c. Advancing Health Information Exchange through Meaningful Use and Direct (MM:SS)1. Meaningful Use program2. Adoption of EHRs3. Meaningful Use and interoperability objectives4. Challenges5. Criticisms/ramifications6. Status7. Directed exchange

d. Future Directions for Health Information Exchange (MM:SS)1. General status of health information exchange2. Commonwell Health Alliance3. The Sequoia Project


4. The Argonaut Project5. Interoperability measures6. ONC 10-year interoperability roadmap

Unit 9: Expanding Access with Technology

Description:

The use of mobile health (mHealth) technologies has expanded patient access to health care and provider access to patients. This unit will describe the types of mobile health technologies that impact care coordination and the ways in which the data from such technologies can be used in clinical care. This unit also explores the value of expanding care delivery using best-practice telehealth tools and services. It will also describe the growing use of telemonitoring systems as a bi-directional and electronically-mediated delivery of health care over short or great distances; how social determinants are related to access to care needs and telehealth solutions; consideration of appropriate telehealth technologies in the context of physiological, psychiatric, and psychological assessments and remote monitoring; and collaborative self-management support and patient self-care feedback loops under the supervision of trained health care providers.

Objectives:

1. Name and describe three mobile health (mHealth) technologies.2. Describe a real world scenario in which a mHealth technology is used to achieve

better coordination of care.3. Explain ways in which mHealth data can be used by clinicians.4. Identify access to telehealth solutions in a variety of settings.5. Compare models of telehealth systems.6. Evaluate populations served with telehealth tools and services.

Lectures:

a. Introduction to Mobile Health Technologies (MM:SS)1. Mobile health applications in care coordination

b. mHealth Data (MM:SS)

1. Mobile-based e-health applications linking to electronic health records

c. Introduction to Telehealth (MM:SS)

1. Telehealth tools and services

Unit 10: Ensuring the Security and Privacy of Information Shared

Description:


This unit reviews the applicable federal laws and regulations related to protected health information used for care coordination. Methods and tools for assessment and evaluation to ensure compliance will be included. The need for and specifications for establishing data provenance are covered. In addition, sensitive information use during care coordination will be examined.

Objectives:

1. Identify the applicable federal and state laws and regulations related to protected health information shared during care coordination.

2. Assess the processes and systems to ensure compliance with applicable privacy and security regulations during care coordination.

3. Explain the challenges of establishing, preserving, and restoring trust from multiple stakeholder perspectives.

4. Review interoperable systems for weaknesses in structure or processes, which may result in a loss of trust.

5. Discuss the need for data provenance.6. Analyze the system specifications and functionality to establish data provenance.7. Categorize the privacy concerns appropriately.8. Modify privacy and security policies and procedures for sensitive protected health

information and other special considerations.9. Employ the appropriate tools and methods to ensure privacy and security during

care coordination processes.

Lectures:

a. Legal Aspects of Care Coordination (MM:SS)1. Overview of privacy and security

b. Ensuring Compliance (MM:SS)

1. HIPAA and other privacy and security regulations related to information shared during care coordination

c. Data Provenance (MM:SS)

1. Establishing, preserving, and restoring trust in an interoperable health ecosystem2. Establishing and preserving data provenance

d. Data Privacy and Meaningful Consent (MM:SS)

1. Special privacy concerns and methodsa. Specific patient types/casesb. Emergent situationsc. Data for researchd. Interstate


2. Methodsa. Consent rules and managementb. Secure encrypted exchangec. Integrity and availability methods

3. Data segmentation

Unit 11: Supporting Patient-Driven Care Coordination

Description:

The use of health IT tools is to place the patient at the center of all care activities. This unit will explore the use of technology to support and enable patient-driven coordinated care.

Objectives:

1. Explain the importance of patient-driven care coordination.2. List ways a patient can use technology to drive care decisions.3. Describe the concept of patient-initiated information exchange.

Lectures:

a. Patient-Initiated Information Exchange (MM:SS)1. Information exchange2. Technology3. Blue Button4. iBlue Button5. Personal health record6. Patient portal7. Barriers

b. Patient Preferences for Information Sharing (MM:SS)

1. Need for information sharing2. Tools3. Organizations4. Current state5. Patient-provider partnership6. Demographic considerations7. Challenges

c. Information-Driven Patient Education (MM:SS)

1. Definition of patient education2. What patients want


3. Vision4. Technology: television, Video/DVD, Internet, email, apps and games, EHR-

driven, patient portals5. Barriers: health literacy, language, culture, technology

d. Health IT-Supported Communication between Primary Care Provider and Specialist (MM:SS)

1. Introduction2. Background3. Patient-driven care coordination4. Information needs5. Technology tools6. Barriers7. Solutions

Unit 12: Data Driven Care Coordination Strategy

Description:

This unit provides data-driven coordination strategy as characterized by improving the use of technology and analytics in the successful transfer of patient care information. Learn the value proposition for establishing delineated measurement in aspects of shared patient information, care delivery, and communication across the care continuum. Evaluate the need and challenges for demonstrated data-driven improved health outcomes, provider and patient satisfaction, and decreased total costs of care for defined populations.

Objectives:

1. Identify the care coordination data sources.2. Demonstrate care coordination effectiveness using analytics.3. Evaluate interoperability opportunities and challenges.

Lectures:

a. Care Coordination Data Evaluation (MM:SS)1. Care coordination identifiers2. Analytics in care coordination

b. Interoperability and Care Coordination (MM:SS)1. Opportunities and challenges to care coordination


Component AuthorsComponent Developed by:

Assigned Institution:Columbia University (CU); The University of Texas Health Science Center at Houston (UTH)

Team Lead(s): Bruce Forman, MD, Columbia University

Virginia Lorenzi, MS, CPHIMS, FHL7, Columbia University

Primary Contributing Authors:

Susan Fenton, PhD, RHIA, FAHIMA, Principal Investigator, The University of Texas Health Science Center at Houston

Virginia Lorenzi, MS, CPHIMS, FHL7, Columbia University

Lecture Narration

Voiceover Talent

Ned Boyle, Renee Dutton O-Hara

Susan Fenton, The University of Texas Health Science Center at Houston

Sound Engineer

Ned Boyle, Renee Dutton O-Hara

Team Members:

Areebah Ajani, Instructional Designer, The University of Texas Health Science Center at Houston

Tiffany Champagne-Langabeer, PhD, MBA, RD, LD, The University of Texas Health Science Center at Houston

Raven David, MPH, CHTS-PW, Project Manager, Columbia University

Jettie Eddleman, BSN, RN, Texas A&M University

Susan Fenton, PhD, RHIA, FAHIMA, Principal Investigator, The University of Texas Health Science Center at Houston

Rita Kukafka, DrPH, MA, FACMI, Principal Investigator, Columbia University


Brenda Kulhanek, PhD, MSN, MS, RN-BC, American Nursing Informatics Association

Gil Kuperman, MD, PhD, Columbia University

Jennifer Ringler, MHA, Columbia University

Megan Robertson, Project Manager, The University of Texas Health Science Center at Houston

Robert S. Steele, MD, FAAFP, Texas A&M University

Victoria Tiase, MSN, RN, Columbia University


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Component 22, Component Guide - files.healthit.govfiles.healthit.gov/Component_22/Comp22_Component_G… · Web viewCare coordination is the deliberate organization of patient care