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Submitting WG/Project/Implementer Group

PACIO Project

Track Resources:

Track Webinar:

General CMS Connectathon Participant Information:

Justification and Objectives

The purpose of this track is to exchange patient level Cognitive Status data between two disparate health IT (HIT) systems, in a consumable format for clinicians. High quality and timely health information exchange is essential to promote positive health outcomes, reduce provider burden and deliver cost effective healthcare. Acute care settings have made significant strides towards interoperability recently, but post-acute care (PAC) setting still struggle to keep pace with progress toward interoperability.

Despite being excluded from EHR incentive programs, EHR adoption in PAC settings is relatively high. In 2018, ONC released a data brief reporting that 78% of Home Health Agencies (HHAs) and 66% of Skilled Nursing Facilities (SNFs) had adopted EHRs in 2017. (Comparatively, in the same year, 96% of non-federal acute care hospitals had implemented certified EHRs). However, key indicators of interoperability (electronically find, send, receive, and integrate data) remain low in PAC settings.

Considering that 45% of Medicare beneficiaries require (PAC) services after hospitalization, costing taxpayers over $73 billion dollars annually, the need for a seamless exchange of health information across care settings, and with patients, is significant.

The 2014 Improving Medicare Post-acute care Transformation Act (IMPACT Act) requires the use of standardized Medicare quality measures and assessment data in PAC settings, and also requires that the standardized data be interoperable. The intent of the IMPACT Act is to:

  • Support access to longitudinal information to help inform clinical decision making and promote coordinated patient care
  • Enable data comparison across healthcare settings
  • Improve discharge planning and health information exchange

In response to IMPACT requirements, CMS developed standardized patient assessments in specific categories, including assessments for functional status and cognitive status, which are used across multiple care settings for quality measurement, payment, survey and certification, and public reporting.  In addition, providers can use these standardized data elements, and their mappings to HIT standards (e.g.- LOINC, SNOMED-CT), to support quality improvement efforts, care planning, and for health information exchange when a person transitions between healthcare settings, including hospitals, outpatient services, home and community based services, PAC settings (Hospices, Home Health Agencies (HHA), Inpatient Rehabilitation Facilities (IRF), Long-term care Hospitals (LTCH), Skilled Nursing Facilities), and others. CMS assessment data elements are not limited to PAC settings; other healthcare settings outside of PAC also can use them to improve care.

Interoperability challenges persist across the healthcare ecosystem. Providers are not receiving complete and accurate information in a timely manner, leading to adverse outcomes and additional expenses. Failure to exchange accurate, timely data often leads to inefficient workflows, duplicative data entries, and increased risk of patient harm attributable to missing or inaccurate information. HIT can significantly alleviate administrative burden by supporting health information exchange across care settings to ensure that the relevant information necessary to care for the incoming patient is delivered to the right person, at the right time- therefore improving patient outcomes, reducing provider burden, improving cost efficiencies, and improving workflows. Moreover, enhanced data exchange would allow for advanced computability, standardization, usability, and real-time data analytics, enabling broader data use by health IT developers, researchers, providers, and payers.

To incrementally further the goal of cross-setting interoperable data exchange, CMS prioritized cognitive status as an area of clinical importance in need of standardization. CMS created a set of questions and responses addressing cognitive status with corresponding LOINC/SNOMED codes that is standardized across all PAC settings. Members of the PACIO Project, a collaborative effort to advance interoperable health data exchange between PAC providers, patients, and other key stakeholders, worked with CMS to develop an IG for exchange of cognitive status data elements starting with the short Confusion Assessment Method (CAM). PACIO selected short CAM data elements because exchanging this information quickly and efficiently is essential to ensuring a person’s safe transition from one healthcare setting to another. Additionally, the interoperable exchange of short CAM elements paves the way for semantic interoperability, because those data elements are represented the same way in each PAC assessment.

The Cognitive Status connectathon track will allow us to confirm the quality of the PACIO Cognitive Status IG materials, gain experience with testing, and show us where additional revisions to the IG may be helpful for implementers.

This track will use what version of FHIR.

This track will use version R4 of FHIR.

Clinical input requested (if any)

CMS created standardized cognitive status assessments, which are used across multiple settings, with guidance from multiple sources, including clinical subject matter experts, measure developers, and others. Clinical input is welcome regarding the exchange of cognitive assessment content between HIT systems and integration into clinical workflows. Members of the Post-Acute Care Interoperability (PACIO) Project, including CMS and MITRE, with clinical experience will be present to discuss which key cognitive status data elements they have identified to be exchanged during transitions of care, but validation by a wider clinician audience of connectathon participants would be beneficial.

Related tracks

CMS Data Element Library Track

PACIO Functional Status Track

Proposed Track Lead

Tim Shaffer,

Expected participants

Tim Shaffer (Track Lead, MITRE), Beth Connor (CMS), Lorraine Wickizer (CMS), Liz Palena Hall (ONC), Sean Mahoney (MITRE), Jessica Skopac (MITRE), Siama Rizvi (MITRE), Dave Hill, (MITRE), Mary Anne Schultz (CSUSB), Rob Samples (ESAC), Michelle Dougherty (RTI), Zabrina Gonzaga (Lantana), Nancy Lush (Lush Group)

Track Orientation

A webinar, scheduled on December 17th at 3pm EST, will provide further information about participation in this track.

Access Information

  1. Please call the following number:

          WebEx: 1-877-267-1577

  1. Follow the instructions you hear on the phone.

Your WebEx Meeting Number: 996 198 039


To join from a Cisco VoIP enabled CMS Region or from CMS Central Office

  1. Dial ext. 63100

Enter Meeting Number: Use Meeting WebEx Number provided above.


To join this meeting online

  1. Go to
  2. If requested, enter your name and email address.
  3. If a password is required, enter the meeting password: (This meeting does not require a password.)
  4. Click “Join”.
  5. Follow the instructions that appear on your screen.

System Roles

Healthcare Setting A* – FHIR-based HIT system containing cognitive status data for patient
Healthcare Setting B* -- Client HIT system to receive patient’s cognitive status data from Setting A HIT system, for display to receiving clinician

Consumer – FHIR-based application that is able to receive patients’ cognitive status data from healthcare setting A or B.

*Either the sending or receiving system may be a PAC or other setting, but at least one party in the exchange must be a PAC setting.

Role 1 Name


Precondition: Completed baseline mobility assessment at admission and discharge.

Scenario 1: Healthcare Setting A discharged Ms. Smith and PAC Setting B has admitted her. PAC Setting B is able to retrieve the data for cognitive assessments performed at Healthcare Setting A.

Scenario 2: PAC Setting A discharged Ms. Smith and Healthcare Setting B has admitted her. Healthcare Setting B is able to retrieve the data for cognitive assessments performed at PAC Setting A.

Scenario 3: Either healthcare setting electronically shares Ms. Smith’s cognitive status data through a consumer facing application accessible by Ms. Smith or her designated proxy/caregiver/family member.

Success Criteria: Successfully transfer of mobility assessment data between settings A & B and/or with consumers, in a manner that is consumable by clinicians and consumers.

Bonus 1: Exchange patient cognitive status data with more than two systems.

Bonus 2: Perform bidirectional data exchange between systems.


Testing will be done through ONC Inferno.  Test scripts can be found at

Test cases include:

  • Verify FHIR server correctly responds to RESTful assessment data requests and queries
  • Verify CAMS assessments contain the required and conditionally recommended data in required data sets

Security and Privacy Considerations

Clients and servers shall support SMART on FHIR security protocols, although this track will not use any PII/PHI, only synthetic data.  

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