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Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013 1
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Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

Mar 27, 2015

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Page 1: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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

May 8, 2013

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Page 2: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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

Page 3: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

Agenda

• Introductions

• Goals

• Schedule

• Discussion of Risks, Health Concerns, Barriers and Preferences as they relate to LCC’s vision of care plan exchange and workflow

– Ongoing comments can be submitted and viewed on wiki:

• http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG

• Next Steps

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Page 4: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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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

Page 5: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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

Discussion: Risks, Health Concerns,

Barriers

12 13 14 15 16 17 1811 AM ET

Discussion: Risks, Health Concerns,

Barriers

5 PM ET Tentative Touch Point with

PCWG

19 20 21 22 23 24 25

11 AM ET: Map out how to

designate/model Prioritizations

26 27 28 29 30 3111 AM ET: Map out how to assign Care Team Members to

prioritizations

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• Health Concern• Definition• Overview as it relates to care plan exchange and

workflow

Overview: Health Concern

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• Health concerns reflect the issues, current status and “likely course” identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member.

• “Problems” and “diagnoses” will capture medical/surgical diagnosis but are insufficient to capture the full array of issues that are important to individuals. Health concerns include:• Medical/surgical diagnoses and severity• Nursing/Allied Health/Behavioral Health issues• Patient reported health concerns• Behavioral/Cognition/Mood issues• Functional status, including ADL issues• Environmental factors (e.g. housing and transportation)• Social factors including availability of support and relationships• Financial issues (e.g. insurance, eligibility for disability)

Care Plan Glossary Definition of Health Concerns

Page 8: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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High Level Health Concerns

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• Risk• Definition

• Intrinsic: family history, genetic predisposition to condition/disease

• Extrinsic: comes with an intervention (such as risks caused by drugs the patient is taking)

• Some risks are not necessarily health concerns—can be decision by patient themselves or something care team member identifies as risk

• Should well accepted risks be identified as health concerns or is the presence of that risk sufficient to identify that risk for the sake of decision support? (e.g. bleeding risk with anti-coagulant medications)

• Inbound vs. outbound risks (HL7 concept)• Overview as it relates to care plan exchange and workflow

Overview: Risk

Page 10: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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• Barrier• Definition

• If a barrier is identified is it automatically considered a health concern?

• Are barriers associated with goals or interventions? (suggest interventions)

• Does a coded value set for barriers exist?• Overview as it relates to care plan exchange and

workflow

Overview: Barrier

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• Preference• Definition

• How are preferences represented?• Positive vs. negative preferences

• Overview as it relates to care plan exchange and workflow

Overview: Preference

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• Define how Risks, Barriers and Preferences relate to Health Concerns, map out how to categorize them

• Represented as Health Concerns

• Perhaps represented as negative preferences in model

• Is the opposite of a Risk a “mitigating factor” (in relation to decision support)?

• Discuss how Risks, Barriers and Preferences relate to Goals and Interventions, map out how to categorize them

Points for Discussion

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Care Plan Workflow

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Care Plan Relationships

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

• Map out how to mitigate irrational choices

For Next Week

Page 16: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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

Page 17: Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 8, 2013.

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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 [email protected]

• Sub Work Group Lead• Russ Leftwich [email protected]

• Program Management• Lynette Elliott [email protected]• Becky Angeles [email protected]