Longitudinal Coordination of Care (LCC) Workgroup (WG)

1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) April 10, 2013

2. Meeting Etiquette • Remember: If you are not speaking, please keep your phone on mute • Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = frustrated speakers and participants • This meeting is being recorded • Another reason to keep your phone on mute when not speaking • Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know. • Send comments to All Participants so they can be addressed publically in the chat, or discussed in the meeting (as appropriate). From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  All Participants

3. Agenda • Introductions • Proposed Next Steps / Schedule • Presentation from Care Coordination Services

4. Proposed Next Steps • Presentation from Care Coordination Services • Review Ballot Artifacts • Generate Ballot Comments in the next 2 weeks • Finalize LCC’s Ballot Comments by Friday April 26th • Submit Ballot Comments to HL7 by Monday, April 29th

5. Schedule – April 2013

6. HL7 Care Coordination ServiceCCS April 10th, 2013 Jon Farmer, Enrique Meneses

7. Business Context A patient moving through the continuum of care • With a Care Plan • Pursuing specific health goals • With progress being measured over time Care Team Participants • Patient, family, providers, managers, specialists, school nurse, etc. • Want active but controlled participation from a CDS agent, too Coordination at care transitions is very cumbersome! • The challenge lies in changediscussions (e.g. goal adjustments) • The care team composition is constantly in flux HL7 Care Coordination Service (CCS)

8. Objective Enable easy flexible, controlled collaboration around a Shared Master Care Plan • Provide a virtually consolidated Care Plan (CP) • The CP can be updated (with change logs) from multiple participants • For those connected , the patient progress, goals, etc. are current at all times • Spec will include pub/sub binding(s) for storages to get async updates • Easy Flexible Collaboration • Care team is an association of people … It is inherently social. If foundational sharing agreements are made (not part of spec), then interactions can then grow “organically” by invitations across care settings • This realization is the foundation of the “Care Coordination Service” • Controlled • The context of care plan change discussions must be clear • Advanced conformance profile would require prior-version views of the plan HL7 Care Coordination Service (CCS)

9. Master CP: Current, Lean, but also Federated Multidisciplinary Master Care Plan plan or plan fragment EHR MCP MCP MCP • A guide to the target health state • CP owner manages the retention of items of lasting significance • The master plan may contain sub-plans (comorbid & specialty) • Its elements (goals, planned interventions, etc.) evolve continuously • A “living object” built for purposeful collaboration • Participants (clients) stay in-sync “on the same page” at all points in time • Outlives all episodes, managed as a digest, not an accumulator • It is “just the plan”, but holds references to summaries, outcomes EHR accumulates the carehistory. The Master Plan does not HL7 Care Coordination Service (CCS)

10. Business Context HL7 CCS – Care Coordination Service

11. How complete, how detailed • We defined detailed operations (with parameters) for most services • Did not have time to detail what specific services will be included in each functional profile (or to specify which ones are required) • We hope and expect to get lots of feedback on the functional profiles esp. from implementers HL7 CCS – Care Coordination Service

12. Privacy and Security Policy • We don’t make any assumptions on access control policy, no matter how reasonable it seems, since to make assumptions is to cripple the uptake. However, we sought to support whatever policy applies in anybody’s environment: • The CP DAM is fine-grained; • The operations are well factored and they operate on specified plan items; So all input parameters for policy evaluators are there. • We intentionally kept the “roles” of users as generic as possible HL7 CCS – Care Coordination Service

13. Business Scenarios • Collaborative Contribution to an Integrated Care Plan • Care Team Members work together to devise and maintain the plan and its parts • Sequential transitions of care • Plan content gets lost on intake and discharge • Iterative Plan Reviews and Revisions • Constant iteration by any or all players • Starting and Monitoring of Actions • Not workflow, but some basic controls • Deployment of Plan “Templates” • Good practices can be promoted for wider use • CDS Agent as a Discussion Participant • RoboDoc is here! HL7 CCS – Care Coordination Service

14. Functional ProfilesEnvisioned “Packages” for implementation • Plan Reading • Plan Template Authoring • Care Planning • Execution Support • Progress Tracking • Plan Reconciliation • Clinical Decision Support Integration HL7 CCS – Care Coordination Service

15. Plan Reading • Read a care plan and its related plans of care and treatment plans • Link & include remote plans in other CCS servers • Support both push and pull update models • Conventional on-demand reads • publish-subscribe (push) modes - can subscribe to piecemeal updates to some or all parts of the plan HL7 CCS – Care Coordination Service

16. Plan Template Authoring • Initialize and maintain a plan but be able to instantiate various items from templates • Save a plan or portions of it as a named reusable template • Maintain templates collaboratively as with plans • Support online discussions of specified topics; allow for participants to propose, accept, reject changes • Use codes, but also collect narratives to guide usage) Note: Functionally this profile relates to the HL7 Order Sets DSTU HL7 CCS – Care Coordination Service

17. Care Planning • Instantiate plan from scratch or from template • Individualize it for the current patient • Collaboratively review & adjust items over time HL7 CCS – Care Coordination Service

18. Execution Support • Basic start/suspend/resume/stop, etc. for any plan item • Planned actions may hold starting criteria, but no “auto-start” • Needed next actions may be entered as appropriate by duly authorized team members. • Decisions may be prompted; a plan item may offer alternatives • Order entry: • Order attributes are limited to those included in CP DAM • The CSS can accept a start command; implementation can trigger interaction • Resource scheduling • query for availability (resource type, time slots request) • Choose a candidate and issue the ‘assign” operation. • Out of scope: ability to refine search providers based on credentialing HL7 CCS – Care Coordination Service

19. Progress Tracking • Supports reviews of the plan’s effectiveness (or of particular interventions) relative to criteria • Query for progress data • Subscribe to alerts upon unmet incremental milestones/goals, planned but overdue actions • As a principle, we support detection and recording of events by humans or by machine. The API will support but not require the automatic detection of events by the server HL7 CCS – Care Coordination Service

20. Plan Reconciliation • Produce a list to support gap/overlap analysis; but do not automatically decide what to delete • Automatically organize plans of care under care plans; combine plans of care for the same specialty • The implementation may generated “proposed” suggestions (plan items) - not automatically accepted. • In addition to on-demand invocations, an agent process could suggest gaps or overlaps asynchronously HL7 CCS – Care Coordination Service

21. Business Service Capabilities • Normative content of HL7 CCS service functional model (SFM) • Express business functions • Not a technical specification • Independent of business process, rules or policies • Detailed enough to provide requirements for development of technical specification (OMG phase) Working draft at: http://wiki.hl7.org/index.php?title=Care_Coordination_Capabilities HL7 CCS – Care Coordination Service

22. Capability Listing 1 • Associate Supportive Content • Dissociate Supportive Content • Mark Plan Item • Retrieve Marking Group Planning Mark Plan Items for Action Manage Supportive Plan Content • Find Plan • Find Plan Template • Create Plan • Associate Plans • Change Plan • Close Plan • Read Plan • Share Plan • Synchronize Plan • Publish Plan Template HL7 CCS – Care Coordination Service

23. Capability Listing 2 • Maintain Conversation Threads • Invite Conversation Participants • Indicate Availability • Find Availability Care Team Membership Participant Availability Care Team Conversation • Find Person • Invite Collaborator • Respond to Invitation • Add Member • Remove Member • Find Collaborator Relationships HL7 CCS – Care Coordination Service

24. Capability Listing 3 • Propose • Check Clinical Appropriateness • Start, Suspend, Resume, Cancel, Complete activities • Find Available Resource • Check Resource Availability • Allocate Resource Patient Observations Care Plan Action • Capture Patient Observations • Associate Observations • Edit Observations • Retrieve Observations • Identify Health Assessment Scales HL7 CCS – Care Coordination Service

25. Capability Listing 4 • Consolidate Plans • Get Reconciliation Work List Care Review Consolidation/Reconciliation • Acceptance Review • Activity Outcome Review • Goal Review • Plan Review HL7 CCS – Care Coordination Service

26. Resources & Questions HL7 CCS Project Leads • Enrique Meneses – Enrique.Meneses@careflow.com • Jon Farmer - Jon.Farmer@dncx.com HL7 Wiki http://wiki.hl7.org/index.php?title=Care_Coordination_Service HL7 CCS – Care Coordination Service