Work Group Discussions

Assumptions

Assumption 1:

The Continuity of Care Document (CCD) standard from HL7 is the emerging general purpose document standard for supporting communication of person-centered health records (full/summary/extracts). CCD incorporates ASTM’s Continuity of Care Record (CCR) semantic content, and many systems will be able to transform CCR and CCD instances as required. CCD represents an implementation of HL7’s Clinical Document Architecture (Release 2) (CDA R2) standard and can serve either as a standard or as a pattern for communication of health information.

Assumption 2:

A priority focus of our work will focus on establishing a pattern(s) for incorporating functioning, health, and wellness information into the functional status section of the CCD. We will implement that pattern for a “privileged” (select set of instruments prioritized by our task group).

Assumption 3:

A corollary focus will be to show how some broader based assessments (including minimum data sets such as InterRAI, MDS, and OASIS) may also be represented as CCD’s in and of themselves. In this case, the data set would be parsed out among the various sections of the CCD. This will raise interesting questions regarding when assessments should be represented as CCD’s or as observations within the function status section of the CCD. In addition we will discuss whether a CCD representation of a minimum data set may be incorporated within a general CCD by reference. In other words, when may a single entry in a CCD functional status section be another CCD.

Assumption 4:

The CHI/NCVHS recommendations for functioning and disability including specifications for use of Clinical LOINC to encode instrument questions and answers, ICF for Content, and standard terminologies including Clinical LOINC, ICF and SNOMED CT for exact and usefully related matches will substantially inform early versions of our work. We will have to evaluate additional work occurring as part of AMIA Terminfo projects that represents strategies for encoding nursing assessments and scales with SNOMED CT

Questions

Question 1:

Do we want to establish minimum recommendations for functional status content to be incorporated into CCD? I would be very concerned about using “SHALL” (required) language for such content. I am ambivalent concerning using “SHOULD” language.

Question 2:

How formal is our catalog? Is it simply a workgroup document? Or should we see it as a contribution to a national registry, for example the one that is being established within NLM to manage assessment instrument mapping?

Question 3:

When we incorporate an instrument/scale into the CCD, are we incorporating only the instrument itself, or also recommendations, conclusions, mapping, etc? I don’t even really know how to ask this question yet?

Post Acute Care - Personal Assessment Instrument (PAC PAI)

Post-Acute Care - Development of a Patient Assessment Instrument

E-Mail for CMS Open Door Forum

Special Open Door Forum:

Post-Acute Care -Development of a Patient Assessment Instrument

Thursday, December 21, 2006 2:00 PM - 3:30 PM EST (1:00 - 2:30 pm CT)

The Centers for Medicare & Medicaid Services (CMS) invite you to attend a Special Open Door Forum to discuss the development of a post-acute care patient assessment instrument to be used in the payment reform demonstration mandated under Section 5008 of the Deficit Reduction Act

(DRA) of 2005. Under this provision, The Secretary is to establish a demonstration program by January 1, 2008 that would:

*use a comprehensive assessment at hospital discharge to help determine appropriate PAC placement based upon patient care needs and patient clinical characteristics;

*use a standardized assessment instrument to measure health status, functional status and other factors during treatment in PAC settings and at discharge from PAC settings

*gather data on care outcomes in various PAC settings

Through this Special Open Door Forum, CMS is seeking input and comments from health industry representatives and other interested stakeholders on the conceptual model being developed for the proposed PAC patient assessment instrument. Since the demonstration will test the use of this PAC assessment instrument starting at hospital discharge, and completed at inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs) and long-term care hospitals (LTCHs), it would be important to receive feedback from affected stakeholders.

Issues to Address from Phase One

Number 1:

From Katherine Berg: Classification vs measurement: It is important for the group to consider the difference between classification and measurement. The ICF is often used as a framework to discuss which instruments to choose to address the constructs of interest. Most clinicians not use the ICF codes or language in their daily practice. Researchers choose reliable valid instruments to measure change and monitor outcomes. Quality indicators also need reliable and valid data to define the indicators.

Number 2:

From Katherine Berg: Monitoring changes over time: Concept mapping to ICF domain areas is possible for many instruments, however it is much more challenging to get the gradations or response categories to match. The ICF modifiers (no impairment, minimal impairment) etc have not been shown to be reliable. It is even more challenging to consider that we would map different instruments to the same concept. ADLs appear to be the easiest to match yet even there we will have differences. The OASIS asks about ability, self report instruments such as SF-36 ask about level of difficulty (which is often difficult for older adults to answer because they have not tried the activity recently), the FIM asks about the most dependent episode in the last 24 hours and the MDS or interRAI instruments ask specifically about performance in the last 3 days. Such differences add complexity to documentation or linkage. SNOMED can provide a yes/no answer but how would we code the differences in observation period. ICF has no time or frequency qualifiers to say that the problem is recent. The ICF does not have any way to code a recent change in performance or participation. These often signal the need for care or service planning. Similarly, interRAI instruments code certain mood or anxiety behaviors relative to frequency in the last 3 days as a measure of severity. ICF only codes B152- emotional functions – no impairment, mild etc….. We have demonstrated the reliability of using the frequency response options.

A 6 Minute walk test is a reliable and responsive measure of mobility. It is documented as distance walked (metres) in 6 minutes. Another commonly used measure is gait speed (metres per second). Both tests have demonstrated reliability, validity and are responsive to change in status ie can detect clinically meaningful changes even if they are of small magnitude. However, both would get linked to the ICF item on walking- with modifiers of no impairment, mild etc. it is not clear how to link various differences in distance or speed to the qualifier codes of the ICF. But is would be difficult to ensure that everyone is using similar reference points and difficult to judge when a true improvement or deterioration has occurred. The iCF article mentions that one possible use of the ICF is in quality indicators. I have not seen this demonstrated in any research articles. Indeed, when constructing quality indicators, it is important to have reliable elements and consistent information on other risk factors. The MDS (interRAI) tools are being used for quality indicators for public reporting in the US, for hospital and other sector reports in Canada and in multiple other countries. ICF codes would not be suitable for constructing quality indicators on patient outcomes.

Number 3:

From Katherine Berg: The other issue that we have not yet discussed is the issue of linking a battery of tests covering specific domains ( which seems to be the approach we have taken as a first step) vs identifying specific areas that should be consistently addressed in a continuity of care document to assure good quality of care. Is such a discussion within the scope of our working group? For example, it is important to document along the continuum that someone has no depressive symptoms so that when they do report a symptom, it can be recognized as a change or a new event