Health Homes Novel Prototype

1. Health Homes Novel Prototype

2. Health Homes are cool solutions for problems that exist today • Patients don’t go to the right doctor • What if a care coordinator could guide a patient • Care transitions fail 70% of the time when the patient is responsible • What if the patient didn’t have to facilitate communication between providers • On average it take 17 years for a best practice to become a common practice

3. Technology standards and systems enable health homes • Standards Exist • Integration Effort • We are going to show you one simple scenario of how existing systems and standards can be the infrastructure that enable your health home policies

4. Health HomesA Novel Prototype Person Centered Care Plan Thank You Next Slide

5. System Stack – Element 1 (eHrs) Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities BH Providers (WITS) FQHCs Hospitals Custom Queries Quality Measures

6. Standards Stack – Element 1 (eHrs) Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities BH Providers (WITS) FQHCs Hospitals CCD The Continuity of Care Document (CCD) Standardizes Medical Records File Formats So that people have portable medical records

7. System Stack – Element 2 (HIE) Secure Record Sharing HIE + A DIRECT HIE is: A Directory of Participating Care Provider Addresses (ex doctor@direct.hie.com) Compatible with EHRs, email, and PHRs

8. Standards Stack – Element 2 (HIE) Secure Record Sharing HIE + CCD An HIE is: A Directory of Participating Care Providers (Internet Address) Secure Transmission of Interoperable Records (Encryption) Assured Record Authenticity (Digital Signing) DIRECT

9. System Stack – Element 3 (C2S) Secure Record Sharing Consent2Share 42 CFR pt2 HIE + • Consent2Share (C2S) is a patient portal that • Enables patients to electronically provide and update their privacy preferences • Elevates administrative burden placed on providers

10. Standards Stack – Element 3 (C2S) Secure Record Sharing Consent2Share 42 CFR pt2 HIE + Sharing Permit + = XACML DIRECT • So that providers only share records when the patient allows: • HIEs can ask C2S patient’s privacy preferences permit sharing of a CCD • C2S can evaluate the CCD content, identity of providers seeking to share, and patient’s consent preferences • Providers only receive Patient Health Information when patient preferences “Permit” CCD

11. System Stack – Element 4 (Pop Health) Transition: txt

12. Standards Stack – Element 4 (POP Health) Quality Reporting Document ArchitectureQRDA

13. System Stack – Element 5 (Query Health) Transition: txt

14. Standards Stack – Element 5 (QUERY Health) Quality Reporting Document ArchitectureQRDA Continuity of Care Document CCD Health Quality Measures Format HQMF

15. Standards Stack – Element 6 (Health Home) Transition: txt

16. So that Care Coordinators can…. Transition: txt

17. Now a Novel Look at a Health Home ProtoType DIRECT CCD XACML Quality Measures Statistics

18. Referrals Plans of Care Care Coordination Billing Secure Record Sharing Consent2Share 42 CFR pt2 Home Health Functions HIE + Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities BH Providers (WITS) FQHCs Hospitals Custom Queries Quality Measures Query Health popHealth +

19. Home Health Functionality Referrals Plans of Care Care Coordination Billing XACML DIRECT Consent2Share 42 CFR pt2 + HIE CCD Providers and EHRs Long-Term Care/ HCBS Developmental Disabilities BH Providers (WITS) FQHCs Hospitals Quality Measures Statistics Quality Measures Custom Queries + Query HealthGold popHealth

20. WITS Providers and EHRs

21. LTSS Providers and EHRs

22. DIRECT Health Information Exchange

23. Consent 2 Share Consent 2 Share