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New Frontier: Dynamic Care Plan & SMART on FHIR ApplicationsSession # 141, August 11, 2021

Founder and CEO, EMI Advisors LLC

Evelyn Gallego, MBA, MPH, CPHIMS

DISCLAIMER: The views and opinions expressed in this presentation are solely those of the author/presenter and do not necessarily represent any policy or position of HIMSS.

Associate Director, National Kidney and Urologic Science Translation Program, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Jenna Norton, MPH, PhD

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Welcome

Program Director, NIDDK

Jenna NortonCEO, EMI Advisors LLC

Evelyn Gallego

#HIMSS21

Conflict of Interest

Evelyn Gallego, MBA, MPH, CPHIMS

Jenna Norton, PhD, MPH

Have no real or apparent conflicts of interest to report.

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#HIMSS21

Agenda

• Value Proposition for standards based and person-centered electronic Care Plans (the WHY)

• eCare Plan Development Scope (the WHAT)

• eCare Plan SMART on FHIR Implementation (the HOW)

• How to engage! (the WHERE)

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Learning Objectives

• Illustrate how a standardized dynamic eCare Plan may address the challenges of managing person-centered care across multiple systems

• Describe the clinical and social needs data element identification process and the transition to FHIR profiles and an Implementation Guide

• Explain key aspects of a SMART on FHIR integration with a large integrated delivery system

• Describe how social risk factors can be incorporated into the care planning process

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Value Proposition

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“…and, with the proper medication, they lived happily ever after.”Source: Funny Times

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Multiple Chronic Conditions, Multi-Morbidity or Burden of Illness?

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Others use the term multi-morbidity to include additional factors that contribute to the burden of illness

Multi-morbidity,a term often used synonymously with Multiple Chronic Conditions (MCC), includes those with more than one chronic physical condition, more than one mental health diagnosis, or both.

Disease Severity

Social Factors such as Food Insecurity, Poverty, Homelessness

Functional Impairments and Disabilities

Syndromes such as Frailty

Chronic conditions refer to those “that last a year or more and require ongoing medical attention and/or limit activities of daily living”.

Warshaw G. Introduction: advances and challenges in care of older people with chronic illness. Generation 2006;30(3):5–10.

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The Challenge of Multiple Chronic Conditions (MCC)

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People from low-income backgrounds & under-represented race/ethnic groups developMCC at higher rates & earlierages. Women are more likelyto have MCC than men acrossall age groups.

There is a mismatch betweenthe way care is delivered & research is conducted (disease-specific) and needs (patient-centered) resulting in care that is fragmented and of sub-optimal quality, leading to poor outcomes and increased costs.

People with MCC account for:

NEARLY

1IN 3American

Adults

&Medicare

Beneficiaries

4 IN 5ARE LIVING WITH MCC, THEMOST COMMON CHRONIC

CONDITION

64%

83%OF ALL

Prescriptions

OF ALLClinician

Visits

93%OF ALL

MedicareSpending

70%

71%OF ALL

HealthcareSpending

OF ALLIn-Patient

Stays

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Co-morbidity Among Chronic Conditions for Medicare-for-Service Beneficiaries: 2017

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Distribution of Medicare Fee-for-Service Beneficiaries and Medicare Spending by Number of Chronic Conditions 2017

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17%

21%

29%

32%

53%

24%

17%

6%Percent of Beneficiaries Percent of Total Medicare Spending

0 to 1 condition

2 to 3 conditions

4 to 5 conditions

6+ conditions

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Distribution of Medicare Fee-for-Service Beneficiaries and 30-Day Hospital Readmissions by Number of Chronic Conditions: 2017

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17%

21%

29%

32%

0 to 1 condition

2 to 3 conditions

4 to 5 conditions

6+ conditions

81%

13%

5% 1%Percent of 30-Day Medicare

Hospital Re-admissionPercent of Beneficiaries

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Treatment Plan vs Plan of Care vs Care Plan

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Adapted from Dykes, at al. JAMIA 2014:21(6): 1082-90.

Treatment planEx. Physical therapy treatment plan

Plan of care (POC)Ex. Acute care POC, Home care POC

Care plan

Focu

sM

embe

rs

Focuses on a specific health concern.

Discipline-specific set of related problems or health concerns. Different plans of care require reconciliation into a single care plan.

Typically managed by one clinician.

Typically managed by discipline specific caregivers.

Overarching, longitudinal blueprint of prioritized concerns, goals, and interventions.

Includes all sites and all team members (patients & unpaid caregivers).

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Comprehensive Shared Care Plan Definition:US Department of Health and Human Services 2015 stakeholder panel

1. Gives the person direct access to health data

2. Puts the person’s goals at the center of decision-making

3. Is holistic, including clinical and nonclinical data (e.g., home- and community-based, social determinants needs and services)

4. Follows the person through both high-need episodes (e.g., acute illness) and periods of health improvement and maintenance

5. Allows care team coordination. Clinicians able to 1) view information relevant to their role, 2) identify which clinician is doing what, and 3) update other members of an interdisciplinary team

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Baker, et al. Making the Comprehensive Shared Care Plan a Reality. NEJM Catalyst. 2016: https://catalyst.nejm.org/making-the-comprehensive-shared-care-plan-a-reality/

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Comprehensive Standards Based eCare Plan

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Investigator

eCare PlanStatus Quo

Clinician 1

Clinician 2

Clinician 3

PatientPatient Data

Investigator Clinician 1

Clinician 2

Clinician 3

Patient

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Scope

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NIDDK/AHRQ e-Care Plan for Multiple Chronic Conditions ProjectBuild capacity for pragmatic, patient-centered outcomes research (PCOR) by developing an interoperable electronic care plan to facilitate aggregation and sharing of critical patient-centered data across home-, community-, clinic- and research- based settings for people with multiple chronic conditions (MCC)

https://ecareplan.ahrq.gov/collaborate/

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AHRQ-NIDDK Project Deliverables

1. Data elements, value sets, clinical information models, and FHIR mappings to enable standardized transfer of data across health & research settings for kidney disease, diabetes, cardiovascular disease, chronic pain & long-term COVID

2. Pilot tested patient-, clinician- and caregiver-facing e-care plan applications that integrate with the EHR to pull, share & display key patient data

3. HL7® Fast Health Interoperability Resource (FHIR®) Implementation Guide based on defined use cases and standardized MCC data elements, balloted for trial use

*All deliverables will be open-source & freely available

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#HIMSS21

May 21–Oct 21 Nov 21–Apr 22 May 22–Oct 22 Nov 22–Apr 23 May 23–Oct 23 Nov 23–Apr 24May 19–Oct 19 Nov 19–Apr 20 May 20–Oct 20 Nov 20–Apr 21

Patient App

Clinician App

Caregiver App

COVID 19 Standards

FHIR IG Update

Pilot testing & Evaluation

Connect-a-thon Testing

Facilitate Pilots

Establish Collaborative

Expand the DESS

Develop eCare Plan FHIR IG and APP

Disseminate Project Deliverables

Identify Pilot Sites

Establish TEPsEstablish HL7 Patient Care Plan WGEstablish AHRQ NIH Confluence

Project Kick-Off 20190923

Develop CIM, e-care plan app & IG for CKD

Disseminate deliverable through open-source channels

Expand to COVID, Caregiver

Expand e-care plan app & IG to include CVD, T2D, Pain and Pilot feedback

Implement, test & evaluate e-care plan APP

Coordination with pilot sites

Expand e-care plan data elements & standards: CVD, T2D, Pain

Identify/develop data elements, value sets & FHIR Profiles

Revise MCC version of the app

Revise MCC version of the app

Revise MCC version of the app

Expand to COVID

Expand to COVID

Develop for MCC, Expand to COVID

Revision & Finalization

Revision & Finalization

Revision & Finalization

Revision & Finalization

Round 1 Testing (CKD) Round 2 Testing (MCC & COVID 19)

RevisionBalloting(Sep 2023)

MCC eCare Plan Roadmap (2019 – 2024)

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NIDDK AHRQ

M A N A G E M E N T T E A M

D E V E L O P M E N T R E A L - W O R L D T E S T I N G

Federal Partner Committee Project Monitoring Board

HL7 Patient Care Work Group

Governance Model

Technical Expert Panels Cognitive Medical

OHSUEMI Advisors

RTI

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Coordination with other FHIR Projects

Functional and Cognitive Status Assessments; Advance Directives (CMS based)

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Demonstrate the use of FHIR across the continuum of health care and social services data exchange initiatives and demonstrate alignment across federally funded initiatives.

Person-Centered Social Services Planning (Medicaid 1915c)

Social Determinants of Health

Bidirectional Services eReferral (BSeR)Closed Loop Clinical and Non-Clinical Referrals

DaVinciPayer to Provider Data Exchange

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Technical Expert Panels (TEPs) 100+

PARTICIPANTS

TEP Objective & Approach

Expand Data Elements & Value Sets

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Step 1: Data Element identification

Build from the initial Chronic Kidney Disease data elements and value sets to layer on considerations for cardiovascular disease, type 2 diabetes, and chronic pain, as well as cross-cutting considerations

• TEPs met monthly from October 2019 to September 2020

• Iterative discussions informed selection of a final set of data elements

Final Data Elements available here: https://drive.google.com/file/d/1BFPyw_hSMc1tw6fF0-AukUgras-9pFU4/view?usp=sharing

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Step 2: Data standards identification (ongoing)• TEPs continue to meet monthly to provided feedback on proposed value sets

(Sep 2020 – present)

• Identification of existing value sets from the Value Set Authority Center (VSAC)

• Assessment of existing value sets for appropriate scope/fit for purpose

• Where appropriate value sets do not exist, identification of common clinical terminology codes (ICD-10, SNOMED, LOINC, RxNorm, CPT) to support development of novel value sets

• Building novel value sets in VSAC

• Identification, modification and development of FHIR profiles to support exchange of data elements

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Results to Date• 1100+ data elements, across person/plan details, health concerns, social concerns,

goals, interventions & health status evaluation: https://drive.google.com/file/d/1BFPyw_hSMc1tw6fF0-AukUgras-9pFU4/view?usp=sharing

- Use case conditions: CKD, hypertension, congestive heart failure, ischemic heart disease, type 2 diabetes, chronic pain (symptoms & common pain-related conditions)

- Cross cutting considerations: social determinants of health, cognitive & functional status, mental health, substance use disorders, metabolic & nutrition conditions, hormonal conditions, sleep disorders, health behaviors

• Data standards approaches outlined for person/plan details, health concerns & social concerns: https://docs.google.com/spreadsheets/d/1Wiigfwi8mfwPQylMqWFCTCrp0U00ElPVGSKuzkWifyI/edit?usp=sharing

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Expand e-care plan data elements & standards: …building from CKD

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CKD

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Expand e-care plan data elements & standards: …IHD, CHF, HTN, Pain, Opioids, Type 2 Diabetes, Long COVID

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Long COVID

IHD, CHF, HTNChronic Pain

& Opioids

Type 2 Diabetes

CKD

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Expand e-care plan data elements & standards: …collaborating with complementary efforts

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Long COVID PACIO

IHD, CHF, HTNChronic Pain

& Opioids

eLTSSProject

Type 2 Diabetes

SDOH Data (Gravity)

CKD

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Expand e-care plan data elements & standards: …beyond the work we are doing at NIDDK/AHRQ

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Other CVDs Long COVID PACIO Cancer

BladderHealth

IHD, CHF, HTNChronic Pain

& Opioids

eLTSSProject

Type 2 Diabetes

SDOH Data (Gravity)

Alzheimer’s& Dementia

CKD

#HIMSS21

Expand e-care plan data elements & standards: …beyond the work we are doing at NIDDK/AHRQ

FHIR for Research Other CVDs Long COVID PACIO Cancer

BladderHealth

IHD, CHF, HTNChronic Pain

& OpioidsStandardsAdoption

Health Information Exchanges

eLTSSProject

Type 2 Diabetes

SDOH Data (Gravity)

Alzheimer’s& Dementia

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CKD

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eCare Plan FHIR Implementation Guide & SMART on FHIR Apps

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HL7® and FHIR® Basics• Health Level Seven (HL7): a not-for-profit ANSI-accredited standards developing

organization (SDO) dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information that supports clinical practice and the management, delivery, and evaluation of health services.

• Fast Health Interoperability Resources (FHIR): one of the three leading HL7 standards (FHIR, V2, CDA) intended to facilitate the exchange of health care information between providers, patients, caregivers, payers, researchers, and anyone else involved in the health care ecosystem. Consists of 2 main parts:

- Content Model in the form of “resources”- Specification for the exchange of these resources in the form of real-time RESTful Interfaces

https://www.hl7.org/index.cfmhttps://www.hl7.org/implement/standards/product_brief.cfm?product_id=491

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Public Collaboration: HL7 Patient Care Workgroup

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https://confluence.hl7.org/display/PC/Multiple+Chronic+Conditions+%28MCC%29+eCare+Plan

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MCC eCare Plan FHIR IG Components• Patient Story• Use Cases• Implementation and

Conformance Guidance• Picture and Diagrams

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https://trifolia-fhir.lantanagroup.com/igs/lantana_hapi_r4/MCC-IG/toc.html

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Patient Story Care Team Personas & Story Components• Patricia Noelle (patient)• Rose Noelle (caregiver)• John Carlson (Primary Care Physician [PCP])• Julie Smith (Care Coordinator)• Ben Garcia (Walgreens Pharmacist) • Debbie Reed (Registered Dietitian Nutritionist

[RDN] and Certified Diabetes Educator [CDE])• Philip Thompson (Physical Therapist)• Vince Jones (Nephrologist)• Barbara Wojcicki (Pain Specialist)

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Settings• Patricia’s home, PCP office,

Specialist Office

Activities• Screening• eReferral• Care Planning

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Patient Persona: Patricia Noelle

Age: 65+ years old

Health Concerns: CKD, frailty, mobility, clinical depression, and COVID-19 positive

Social Needs: Transportation and food security

Social Services:• Non-medical transportation• Food education

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Challenges: • Coordination across multi-

disciplinary provider groups

• How to manage progressing CKD

• Sharing multiple assessments across settings

• Not able to see big picture ‘care plan’

• At risk for COVID-19

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eCare Plan Use Cases1. Generate/ update comprehensive eCare Plan in clinical setting

2. Expose (share) eCare Plan to clinical care team and patient/caregiver

3. Identify Care Team Members

4. Subscribe to eCare Plan Updates

5. Consent to share eCare Plan information for research

6. Consent to share eCare Plan sensitive information with specific team members

7. Expose (share) eCare Plan to community-based (non-clinical provider)

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Bold: Primary Use Cases in IG

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resource-pertainsToGoal:

Instantiated FHIR Supported Dynamic Care Planning and Coordination

plannedActivityReference(activity.reference) (intents)***

Administer Oxygen

performedActivity(Activity.outcome.Reference) (events)

Oxygen Administered

Resource Context: Care Plan

2020-09-18 @ 0800

Intervention

2020-09-18 @ 0800

Intervention

resource-pertainsToGoal:

GOAL

Keep PulseOx Between 92 to 96

Goal

Procedure.reason.ref

XXX.Request.reason

Goal

Goal.addresses

Goal.addresses

Goal.addresses

Goal.outcomeRef

Condition*

Observation

Condition*

Observation**

RDS

PulseOx=88

RDS

PulseOx=95

Goal Referenced Resource

2020-09-18 @ 0800

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2020-09-18 @ 1000

Health Concern

Outcome

Health Concern

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Scenarios for Testing

• Scenario 1: Retrieve patient’s chronic kidney disease (CKD) care plan from an EHR • Scenario 2: Retrieve COVID-19 diagnosis• Scenario 3: Retrieve patient CKD relevant labs from EHR• Scenario 4: Retrieve MedicationStatement of medication • Scenario 5: Retrieve QuestionnaireResponse for pain perception from EHR• Scenario 6: Retrieve patient’s chronic pain condition from EHR• Scenario 7: Retrieve patient’s weight observation from EHR• Scenario 8: Retrieve patient’s weight goal from EHR• Scenario 9: Retrieve patient’s dietitian referral (BSeR)

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Example:SMART on FHIR Provider App with COVID-19 DiagnosisSource: HL7 FHIR January 2021 Care Coordination Track Highlight

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Example:SMART on FHIR Patient App with COVID-19 Diagnosis

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Source: HL7 FHIR January 2021 Care Coordination Track Highlight

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eCare Plan SMART on FHIR Implementation

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Site Recruitment• OHSU Internal Medicine (Primary Care)

• OHSU Hillsboro Medical Center (Primary Care)

• OHSU Family Medicine South Waterfront (Primary Care)

• OHSU Nephrology and Hypertension Clinic (Specialty Care)

• Holladay Park Plaza (LTC Facility)

• Mirabella (LTC Facility)

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Training, Roll-out, PilotSite engagement approach

• Virtual kickoff• Newsletter• Biweekly meetings• 1:1 site training

Pre-launch preparation (in progress)• Overview, workflow, technical readiness• Site training

Provider Testing/Chaperoned Patient Testing• Usability/User Acceptance Testing (UAT)• Issue resolution: technical, workflow, communication• Issue resolution• Review evaluation data

Training ResourcesTraining Hub

• One-page informational flyers

• Tip sheets• Training manual• FAQs (provider and

patient apps)• On demand videos

Issue and Error Tracking

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#HIMSS21

User Acceptance Testing ApproachPhase I: Provider testing of both apps

• Now through end of August 2021• Use both test environment and hand-built test patient AND• Explore production data on selected patients• Actual providers + surrogate patient/technical testing liaison• Internal Medicine then LTC/SNF then Dialysis• Prepare for Chaperoned patient and provider testing by adjusting expectations and

protocols to support Phase II

Phase II: Chaperoned patient and provider testing of both apps• Extend the model above with real patient and provider dyads• Ensure the protocol supports the interaction and that providers feel they can lead

their selected patients through the testing

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e-Care Plan Scenario Workflow

Patient

A patient with chronic kidney disease has a visit with their PCP.

During the visit, it is noted the patient has low urine output that warrants evaluation for dialysis care (updates entered in the e-care plan).

Nephrologist reviews the e-care plan and recommends the patient start dialysis.

Interventional radiologist reviews patient history in the e-care plan and assesses complication risk, medications, and past procedures.

Dialysis center receives order for dialysis and draws labs mentioned in the e-care plan and sends updates to clinicians.

Patient can review updates to the e-care plan as changes are made.

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PCP Nephrologist

Dialysis Interventional Radiology

PCP checks the e-care plan to review the nephrologist’s updates/recommendations.

Provider eCare Plan

App

Institutional EHR

Simplified System Diagram

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Contributing Clinical Systems

Outside Clinical Systems

Reconciliation Process (Limited)

FHIR R4 Endpoint

Read Access

FHIR App Middleware

Patient eCare Plan

AppSMART

Authentication via Patient Portal

credentials

SMART Authentication via

EHR credentials

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Challenges and Lessons Learned

1. The importance of pilot testing in standards-based development (for both apps and technical specs like IGs).

2. The need for an agile implementation approach that includes feedback loops and tailoring to the local context.

3. Provide a lens into the current EHR-based functionalities so that we can build on these lessons as we look to scale (add more content and functions) and spread (have more people/systems use it).

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Challenges and Lessons Learned

1. Sandbox development environment differs from the real-world production environment

2. API calls for data elements (as specified in the IG) were not being fulfilled as the apps expected them to be.

3. Hosting and deploying a third party FHIR app requires a relatively high level of technical capabilities.

4. Original training plans were designed around having a completed, deployable app.

5. Significant sections of the app’s visual real estate for data aren’t presently populated, leaving a “moth-eaten” feel.

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Join Us!

#HIMSS21

Join our Community!

• Join the Project Listserv https://ecareplan.ahrq.gov/collaborate/display/EC/Join+the+Project+Listserv

• Participate in weekly HL7 Patient Care Workgroup Care Plan Meetings: Wednesdays 5 to 6 pm EThttps://confluence.hl7.org/display/PC/MCC+Meeting+Minutes

• Review and help us test the MCC eCare Plan FHIR IG https://confluence.hl7.org/display/PC/MCC+eCare+Plan+FHIR+IG

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#HIMSS21

Thank you!

Evelyn Gallegoevelyn.gallego@emiadvisors.net

@egallegolinkedin.com/in/egallego

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Jenna Norton jenna.norton@nih.gov