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1a. Project Name

PACIO Project Functional Status

1b. Project ID


1c. Is Your Project an Investigative Project (aka PSS-Lite)?


1d. Is your Project Artifact being Reaffirmed or proceeding to Normative directly after being either Informative or STU?


1e. Today's Date

1f. Name of standard being reaffirmed

1g. Project Artifact Information

1h. ISO/IEC Standard to Adopt

1i. Does the standard include excerpted text from one or more ISO, IEC or ISO/IEC standards, but is not an identical or modified adoption?

1j. Unit of Measure

2a. Primary/Sponsor WG

Patient Empowerment

2b. Co-Sponsor WG


2c. Co-Sponsor Level of Involvement

Request formal content review prior to ballotRequest periodic project updates; specify period in text box below (e.g. 'Monthly', 'At WGMs', etc.)

2c. Co-Sponsor Update Periods


2d. Project Facilitator

Dave Hill

2e. Other Interested Parties (and roles)

Patient Administration Work Group, PACIO Project

2f. Modeling Facilitator

Chris Pugliese

2g. Publishing Facilitator

2h. Vocabulary Facilitator

Matt Elrod

2i. Domain Expert Representative

Matt Elrod

2j. Business Requirements Analyst

Raj Mahajan

2k. Conformance Facilitator

Chris Pugliese

2l. Other Facilitators

2m. Implementers

MITRE, MatrixCare

3a. Project Scope

Poor quality discharge information is a major barrier to safe and effective transitions. With 45% of Medicare beneficiaries requiring post-acute care (PAC) services after hospitalization, the need for a seamless exchange of health information is great.

In 2014, the Social Security Act was amended to include the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which required the standardization and interoperability of patient assessment in specific categories for post-acute care (PAC) settings, including long-term care hospitals (LTCHs), home health agencies (HHAs), skilled nursing facilities (SNFs), and inpatient rehabilitation facilities (IRFs). It focuses on standardizing data elements in specified quality measure domains and patient assessment domains for cross setting comparison and clinical information exchange, respectively. The Act requires:

• Reporting of standardized patient assessment data through commonly used PAC assessment instruments for LTCHs, SNFs, HHAs, and IRFs
o Minimum Data Set (MDS)for SNFs
o Inpatient Rehabilitation Facility – Patient Assessment Information (IRF – PAI) for IRFs
o LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) for LTCHs
o Outcome and Assessment Information Set (OASIS) for HHAs
• Implementation of data elements specified in each assessment domain using standardized data elements to be nested within the assessment instruments currently required for submission by LTCH, IRF, SNF, and HHA providers
• Data to be standardized and interoperable to allow exchange of data between PAC providers, among others, using common standards and definitions to provide access to longitudinal information and facilitate coordinated care.

Required assessment content includes standardized questions and response options (aka “data elements”) for assessing a patient’s functional status.

This project seeks to:
(1) determine the data model required to comprehensively exchange functional status information between health care settings,
(2) develop FHIR Implementation Guides, Profiles, and necessary Extensions to specify how to syntactically and semantically exchange that data between care settings, (3) develop client and server reference implementations to validate the Implementation Guide, Profiles, and Extensions work in a software system, (4) develop automated test suites to validate operation, and (5) build real world pilots that successfully demonstrate the new capabilities in production.


3b. Project Need

Interoperability challenges persist in post-acute care; providers are not receiving complete and accurate information in a timely manner, leading to patient harm, adverse outcomes, and additional expense. 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. Health IT can significantly alleviate this administrative burden by exchanging post-acute care assessments and associated clinical information between care settings to ensure that the receiving care setting has all of the relevant information they need to best treat the incoming patient, improving patient outcomes, reducing provider burden, improving cost efficiencies, and improving workflows. Moreover, it would allow for advanced computability, standardization, usability, and real-time analytics for PAC facilities, enabling broader use by health IT developers, researchers, providers, and payers.

3c. Security Risk


3d. External Drivers

The IMPACT Act requires data to be standardized and interoperable to allow exchange of data between PAC providers, among others, using common standards and definitions to provide access to longitudinal information and facilitate coordinated care.

3e. Objectives/Deliverables and Target Dates

Project Scope Statement Due: 2019 Oct 4
FHIR IG Proposals Due: 2020 Feb 16
Notice of Intent to Ballot: 2020 Mar 1
FHIR Ballot Core Substantive Freeze: 2020 Mar 13
Initial Content Deadline: 2020 Mar 15
Reconciliation Deadline and Ballot Preview Period: 2020 Mar 22
Final Content Deadline: 2020 April 5
Ballot Readiness Sign Off: 2020 Apr 10-11
Ballot Open for Voting: 2020 Apr 10 – 2020 May 11

3f. Common Names / Keywords / Aliases:

PAC Assessments 1) Resident Assessment Instrument (RAI) Minimum Data Set (MDS) used by Skilled Nursing Facilities (SNFs) 2) Inpatient Rehabilitation Facility – Patient Assessment Information (IRF-PAI) used by IRFs 3) LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) used by Long-Term Care Hospital (LTCHs) 4) Outcome and Assessment Information Set used by Home Health Agencies (HHAs)

3g. Lineage


3h. Project Dependencies

To be determined

3i. HL7-Managed Project Document Repository URL:

To be determined

3j. Backwards Compatibility


3k. Additional Backwards Compatibility Information (if applicable)

3l. Using Current V3 Data Types?


3l. Reason for not using current V3 data types?

3m. External Vocabularies


3n. List of Vocabularies

To be determined

3o. Earliest prior release and/or version to which the compatibility applies


4a. Products

FHIR Implementation Guide, FHIR Profiles, FHIR Resources, Guidance (e.g. Companion Guide, Cookbook, etc)

4b. For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to?

FHIR version R4

4c. FHIR Profiles Version

FHIR version R4

4d. Please define your New Product Definition

4d. Please define your New Product Family

5a. Project Intent

Create new standard

5a. White Paper Type

5a. Is the project adopting/endorsing an externally developed IG?

5a. Externally developed IG is to be (select one)

5a. Specify external organization

5a. Revising Current Standard Info

5b. Project Ballot Type

STU to Normative

5c. Additional Ballot Info

5d. Joint Copyright


5e. I understand I must submit a Joint Copyright Letter of Agreement to the TSC in order for the PSS to receive TSC approval.


6a. External Project Collaboration

Center for Medicare and Medicaid Services (CMS), Office of the National Coordinator (ONC), Department of Veteran Affairs (VA)

6b. Content Already Developed


6c. Content externally developed?


6d. List Developers of Externally Developed Content

6e. Is this a hosted (externally funded) project?


6f. Stakeholders

Clinical and Public Health Laboratories, Quality Reporting Agencies, Regulatory Agency, Standards Development Organizations (SDOs)

6f. Other Stakeholders

6g. Vendors

Pharmaceutical, EHR, PHR, Health Care IT

6g. Other Vendors

6h. Providers

Emergency Services, Healthcare Institutions (hospitals, long term care, home care, mental health)

6h. Other Providers

6i. Realm

U.S. Realm Specific

7d. US Realm Approval Date

7a. Management Group(s) to Review PSS


7b. Sponsoring WG Approval Date

7c. Co-Sponsor Approval Date

7c. Co-Sponsor 2 Approval Date

7c. Co-Sponsor 3 Approval Date

7c. Co-Sponsor 4 Approval Date

7c. Co-Sponsor 5 Approval Date

7c. Co-Sponsor 6 Approval Date

7c. Co-Sponsor 7 Approval Date

7c. Co-Sponsor 8 Approval Date

7c. Co-Sponsor 9 Approval Date

7c. Co-Sponsor 10 Approval Date

7e. CDA MG Approval Date

7f. FMG Approval Date

7g. V2 MG Approval Date

7h. Architecture Review Board Approval Date

7i. Steering Division Approval Date

7j. TSC Approval Date