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What’s the purpose of hosting this connectathon track? What do you hope to achieve?

Poor quality discharge information is a major barrier to safe and effective transitions. With 45%1 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, respectively2. The Act requires:

• Reporting of standardized patient assessment data through commonly used PAC assessment instruments for LTCHs, SNFs, HHAs, and IRFs

PAC Setting Assessment Instrument

Skilled Nursing Facility (SNF) Minimum Data Set (MDS)

Inpatient Rehabilitation Facility (IRF) Inpatient Rehabilitation Facility – Patient Assessment Information (IRF – PAI)

Long-Term Care Hospital (LTCH) LTCH Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS)

Home Health Agency (HHA) Outcome and Assessment Information Set (OASIS)

• 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.

The CMS Data Element Library (DEL) supports IMPACT Act requirements by serving as the centralized repository for CMS PAC assessment data elements and their associated health information technology (IT) standards to promote interoperability of patient data. Required assessment content includes standardized questions and response options (aka “data elements”) for assessing a patient’s functional status, cognitive function/mental status, special services/treatments/interventions, medical conditions/co-morbidities and impairments. The mission of the Data Element Library (DEL) is to create a comprehensive, electronic, distributable, and centralized resource of CMS assessment instrument content. In support of the IMPACT Act, the goals of the DEL are to:

· Serve as a centralized resource for CMS assessment data elements (questions and response options)

· Promote the sharing of electronic CMS assessment data sets and health information technology standards; and

· Influence and support industry efforts to promote Electronic Health Record (EHR) and other health IT interoperability3 PAC providers are required to submit data for all patients at admission and discharge , using PAC assessments, to the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. This data is used for quality measurement, payment, survey and certification, public reporting, and other CMS and provider activities. Furthermore, because providers are required to submit this data to CMS for all patients at both admission and discharge, it can be reused and exchanged during care transitions to inform patient care. Despite the development of the DEL, interoperability challenges persist; providers are not receiving complete and accurate information in a timely manner, leading to patient harm. 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 incorporating PAC assessments and DEL content into electronic health records (EHRs) to facilitate health data exchange and therefore improved patient outcomes, reduced provider burden, improved cost efficiencies, and improved workflows. Moreover, it would allow for advanced computability, standardization, usability, and real-time analytics of the DEL via FHIR interfaces for PAC facilities, enabling broader use by health IT developers, researchers, providers, and payers. As the PAC assessments are updated on a regular basis, a DEL FHIR API could ensure EHRs had access to the most current data sets. Starting in FY 2018, MITRE developed prototype source definitions for a set of FHIR profiles that describe how to use FHIR to convey the DEL patient assessment information defined by the IMPACT Act. The proof-of-concept prototype demonstrated that the DEL patient assessment information could be fully described by a generated FHIR Implementation Guide (IG), through FHIR profiles and extensions, which will allow Health IT implementers easy access to the

information to the DEL. Further work is underway to provide a complete IG and reference implementation for DEL resources and data. The success of the reference implementation could inform future efforts defining FHIR IGs for all PAC data that would also harmonize with other interoperability initiatives across the healthcare spectrum, including acute and ambulatory care.

This Connectathon track will allow us to confirm the quality of the 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)

Much of the input will be defined in part with help from clinicians within the Post-Acute Care Interoperability (PACIO) Project4, led by CMS and MITRE. Validation with a wider clinician audience, such as Connectathon participants and our MITRE colleagues, would be beneficial.

Related tracks

Patient Track

Care Planning and Coordination Track

Proposed Track Lead

Dave Hill,


Dave Hill (MITRE), Track Lead, Sean Mahoney (MITRE), Hibah Qudsi (MITRE), Chris Klesges (MITRE), Tim Shaffer (MITRE), Jake O’Donnell (MITRE), others TBD

Track Orientation

A webinar will be hosted on August 13, 2019 at 2 PM EDT to share further participation information about this track.

System Roles

Data Element Library (DEL) – will provide standardized assessment values via FHIR API

EHR – client to pull data from DEL, streamlining PAC assessment completion process

Role 1 Name


Scenario Step 1: Patient discharge from PAC facility

Precondition: PAC facility required to complete PAC assessment per CMS requirements

Success Criteria: Completion of PAC assessment; available standardized assessment values are derived from the DEL for all questions and potential response values

Bonus point: Integration into clinical workflow; automated completion and submission of specific PAC assessment forms through EHR

Scenario Step 2: PAC Facility submits PAC assessment using standardized/ computable/ interoperable values to CMS

Precondition: Completed PAC assessment form

Success Criteria: Successful reception by CMS

Bonus point: FHIR interface for iQIES


Testing will be done through ONC Inferno. Test scripts will be available on GitHub.

Test cases include:

· Verify assessment contains the required and conditionally recommended questions

· Verify discharge hook is defined

Security and Privacy Considerations

This Track will not use any PII/PHI, only synthetic data

The Data Element Library contains no PII/PHI