Longitudinal Coordination of Care (LCC) Workgroup (WG)HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS)

May 1, 2013

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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 o Hold = Elevator Music = frustrated speakers and

participants• This meeting is being recorded

o 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.o 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

Agenda

• Introductions

• Goals

• Schedule

• Debrief on submitted HL7 SOA CCS Ballot comments

• Overview of HL7 Patient Care Workgroup Care Plan Domain Analysis Model

• Begin discussion to elicit comments for submittal as part of September ballot

• Next Steps

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• For this initiative:• Interoperable and shared patient assessments across

multiple disciplines

• Shared patient and team goals and desired outcomes

• Care plans which align, support and inform care delivery regardless of setting or service provider

• For this Tiger Team:• Alignment of HL7 artifacts with LCC artifacts to

support care plan exchange

• HL7 CCS provides Service Oriented Architecture

• Care Plan DAM provides informational structure

• LCC Implementation Guides provide functional requirements

Goals

Schedule – May 2013SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

1 2 3 4

11 AM ET: Overview of HL7

LCC Domain Analysis Model

5 6 7 8 9 10 1111 AM ET: Map

process for defining/categoriz

ing Health Concerns

12 13 14 15 16 17 1811 AM ET

Discussion: Define Risks vs. Health Concerns

19 20 21 22 23 24 25

11 AM ET Touch Point with PCWG

26 27 28 29 30 31

11 AM ET: LCC Map out how to

designate/model prioritization

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• Care Coordination Service Comments ballot• Comments aggregated from last 3 weeks TT calls• Submitted to HL7 for ballot close April 29• Aggregated comments will be posted on wiki for

review• Comments to be reviewed by CCS in coming weeks• HL7 CCS project has offered to review with LCC • Target to have normative ballot for functional model

Sept 2013• CCS will have dependency on Care Plan DAM• CCS ballots functional model, not Care Coordination

Service

HL7 Ballot Comments Debrief

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• The Domain Analysis Model (DAM) was created by the HL7 Patient Care WG (PCWG).

• The goal of LCC is to review the DAM and provide input from a provider perspective and to harmonize elements that overlap with LCC efforts around care plan exchange and workflow.• Ideally comments will be rolled into the DAM before it

goes to ballot in September.• The DAM is illustrated in the following two slides.

PCWG Domain Analysis Model Overview

Plan Structure OverviewTop Level Model Structure ** Attributes, some classes and associations hidden for this illustration (Assumes that Instructions are Actions. Master All-care Plan (MAP) that shows the interrelationships is missing)

General Definition: A “list of steps with timing and resources, used to achieve an objective. See also strategy. It is commonly understood as a temporal set of intended actions through which one expects to achieve a goal. “ Wikipedia

Plan Types:Care Plans, Plans of Care, Treatment Plans** The abstract plan is a modeling technique to represent shared components.

The Model Captures:•Who - Patient, Care Team, Family, other Support Individuals...•Why – Concerns, Risks and Goals•What – Proposed and Implemented Actions, Interventions, Instructions, Outcomes Observations, various types of Reviews•When - Effective times, completion times, update times•Where –Steward organization, place of service for interventions

04/20/23 HL7 Patient Care - Care Plan Initiative 8

Domain Analysis Model Plan Structure Overview

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Domain Analysis Model

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• The care plan workflow illustrated in the following four slides is the LCC’s vision of the relationships among care plan components.

• Goal is to identify overlap and harmonization opportunities between the DAM and the LCC’s care plan workflow.• This workflow diagram was developed as a

collaborative effort by individuals in the LCC Work Group:

Care Plan Workflow Overview

Larry Garber, MDTerry O’Malley, MDBill Russell, MDJoanne Lynn, MDLaura Heerman Langford, PhD, RN

Russ Leftwich, MDSusan Campbell, PhD, RNJennie HarvellSue Mitchell, RHIA

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Care Plan Workflow

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Care Plan Relationships

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Care Team Member Responsibilities

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Registries and Clinical Support in Patient Centered Medical Home

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• Define differences between Risks and Health Concerns, map out how to categorize them

• Define Barriers, map out how to categorize them

• Define Goals, Concerns and Interventions, map out how to designate prioritization of each

• Map out how to mitigate irrational choices (this could fall under Risk discussion, as well)

• Map out how to assign Care Team Members to prioritized Goals, Concerns and Interventions

• Patient priorities vs. Care Team Member priorities

• Align terminologies, definitions and Use Cases between PCWG and LCC

Points for Discussion

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• Map out the process for defining Health Concerns

• How to determine what is a Risk vs. Health Concern vs. Barrier

• For next week: Discussion of Risks (Intrinsic vs. Extrinsic), Health Concerns, Barriers as they relate to LCC’s vision of care plan exchange and workflow

For Today’s Discussion

Proposed Next Steps

• Schedule Touch Point meeting(s) with PCWG• Update discussion schedule• Finalize LCC’s Comments by August 4, 2013 for

submittal as part of September Ballot

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Contact Information

We’re here to help. Please contact us if you have questions, comments, or would like to join other projects.

• S&I Initiative Coordinator• Evelyn Gallego evelyn.gallego@siframework.org

• Sub Work Group Lead• Russ Leftwich cmiotn@gmail.com

• Program Management• Lynette Elliott lynette.elliott@esacinc.com• Becky Angeles becky.angeles@esacinc.com