Patient Care Coordination Dynamic Care Planning Profile (DCP) Presented by: Emma Jones, Jeff Danford

Dynamic Care Planning - DCP (HL7 FHIR)

The Problem Patients are suffering from an increasing number of complex or chronic health conditions which require frequent episodes of care involving multiple providers. With this complexity, it is difficult to plan care for patients There need to be a means of defining how care planning ‘interventions’ can be derived from clinically relevant order sets, protocols, clinical practice guidelines, etc as part of the clinical workflow. FHIR may provide a solution to the problem. However, currently there is not enough guidance provided by HL7 FHIR resources on the use of FHIR planDefinition resource to create carePlan activities.

DCP Actors and Transactions In Summary DCTM enables effective care planning and collaboration between applicable care team members and the patient.

PlanDefinition for Care Planning Provides support for HL7 CCS ‘Plan Template capability’ A plan template consists of predefined “standardized” plan elements which are commonly included when addressing a combination of patient health concerns, health risks and health goals. The plan templates could be based on research, clinical evidence or best practices. For example, there could be a plan template to treat patients with diabetes mellitus and cardiovascular disease; these templates could be used by a provider as a starting basis to customize and personalize the care for an individual. HL7 Service Functional Model; Coordination of Care Service (CCS) – http://www.hl7.org/implement/standards/product_brief.cfm?product_id=452

Dynamic Care Planning (DCP) The Dynamic Care Planning (DCP) Profile provides the structures and transactions for care planning, creating, updating and sharing Care Plan Definitions (e.g. order sets, protocols, practice guidelines, etc.) and Care Plans by: Discovering Care Plan Definitions Creating/updating Care Plan Definitions Listing Care Plan Definitions Discovering Care Plans Creating/updating Care Plans Listing Care Plans

DCP High Level Details Provides the structures and transactions for care plan definition and care plan creation, updates, management and sharing care planning information that meet the needs of many, such as providers, patients and payers. Depicts how information about multiple care plans and care plan definitions can be shared and used to provide care. Care plans and care plan definitions can be dynamically updated as the patient interacts with the healthcare system. A patient may be associated with multiple types of care plans at any given time. A provider is able to access, create/update care plan definitions as needed. Standards HL7 FHIR CarePlan, PlanDefintion/ActivityDefinition and Subscription resources HL7 Coordination of Care Services (CCS) Functional Model

Example: Diabetes Type II ‘Protocol or Order set’ (E.g. Medications) First Line Monotherapy (ADA 2017) MetFORMIN HCl - 500 MG Oral Tablet; TAKE one TABLET Twice daily with meals; Qty: 60; Tablet; Days Supply: 30; Refill: 2 MetFORMIN HCl - 850 MG Oral Tablet; TAKE one DAILY WITH MEALS; Qty: 30; Tablet; Days Supply: 30; Refill: 2 MetFORMIN HCl ER (OSM) 500 MG Oral Tablet Extended Release 24 Hour; TAKE one TABLET Daily with evening meal; Qty: 30; Tablet Extended Release 24 Hour; Days Supply: 30; Refill: 2 Alternative Monotherapy Glimepiride 1 MG Oral Tablet; TAKE one TABLET DAILY WITH BREAKFAST.; Qty: 30; Tablet; Days Supply: 30; Refill: 2 GlipiZIDE XL 5 MG Oral Tablet Extended Release 24 Hour; Take one daily 30 minutes before breakfast.; Qty: 30; Tablet Extended Release 24 Hour; Days Supply: 30; Refill: 2 GlyBURIDE 5 MG Oral Tablet; Take one daily with main meal; Qty: 30; Tablet; Days Supply: 30; Refill: 2 Jardiance 10 MG Oral Tablet; TAKE one TABLET Daily; Qty: 30; 30 Ta Bottle; Days Supply: 30; Refill: 2 Pioglitazone HCl - 15 MG Oral Tablet; TAKE one TABLET Daily; Qty: 30; Tablet; Days Supply: 30; Refill: 2 Repaglinide 0.5 MG Oral Tablet; TAKE one TABLET Before each meal; Qty: 120; Days Supply: 30; Refill: 2

Diabetes Type II ‘Protocol or Order set’ (e. g Diabetes Type II ‘Protocol or Order set’ (e.g. supplies, labs, screening, etc) Diabetic Supplies Blood Glucose Monitor System w/Device Kit; USE AS DIRECTED.; Qty: 1 Fingerstix Lancets Miscellaneous; USE AS DIRECTED.; Qty: 1; 200 EA 200 EA Box; Refill: 2 Ketostix In Vitro Strip; USE AS DIRECTED.; Qty: 1; 100 EA 100 EA Box; Refill: 2 Initial Labs Basic Metabolic Panel Blood Glucose - Fasting Blood Glucose - Fingerstick Blood Glucose - Random Comprehensive Metabolic Panel Hb A1c Hepatic Function Panel Lipid Panel Serum Thyroid Stimulating Hormone (TSH) Urinalysis Routine Urinalysis with Microscopy Hypoglycemia Rescue Therapy Blood Glucose Test In Vitro Strip; USE AS DIRECTED.; Qty: 1; 100 St Box; Refill: 2 Glucagon Emergency 1 MG Injection Kit; INJECT 1 MG Once PRN as needed for hypoglycemia; Qty: 1 Screening for Complications Diabetic Foot Examination Examination of Retina Macular Exam Monofilament Foot Sensation Test Pedal Pulse Taking Screening for Comorbities Adult Depression Screening (age >= 18 yrs) Sleep Study Suicide Risk Assessment

Diabetes Type II ‘Protocol or Order set’ (e. g Diabetes Type II ‘Protocol or Order set’ (e.g. vaccine, reminders, diet, referrals, etc) Dietary Recommendations Diabetes diet, specified calories; Follow a diabetic diet with 1500 calories. Diet, DASH; We want to put you on the DASH diet for {count1} calories. Diet, high fiber; Start eating more fiber. Diet, low sodium; Restrict the salt in your diet by avoiding highly salted foods. Diet, low sodium, specified; Restrict your sodium (salt) intake to 2 grams per day. Diet, Mediterranean; We recommend that you follow the "Mediterranean diet." Diet, TLC; We want you to follow the Therapeutic Lifestyle Changes (TLC) diet. Referrals Diabetes Educator Referral Dietician Referral Endocrinology Referral Mental Health Counselor Referral Nephrology Referral Ophthalmology Referral Optometry Referral Podiatry Referral Immunizations Hepatitis B; INJECT one ML Intramuscular Influenza (Split PF); INJECT 0.5 ML Intramuscular Pneumovax 23 25 MCG/0.5ML Injection Injectable; INJECT 0.5 ML Intramuscular Prevnar 13 Intramuscular Suspension; INJECT 0.5 ML Intramuscular Reminders Basic Metabolic Panel; Every 1 years Basic Metabolic Panel; Every 3 months Comprehensive Metabolic Panel; Every 1 years Diabetic Foot Examination; Every 1 years Hb A1c ; Every 6 months Hb A1c ; Every 3 months Hepatic Function Panel; Every 1 years Lipid Panel; Every 6 weeks, end after 1 occurrences Lipid Panel; Every 1 years Monofilament Foot Sensation Test; Every 1 years Pedal Pulse Taking; Every 1 years Urine Microalbumin/Creatinine Ratio; Every 1 years Urine Protein/Creatinine Ratio; Every 1 years Follow Ups Follow Up in 1 Month Follow Up in 2 Months Follow Up in 3 Months

ActivityDefinition Resource Each item is an activityDefintion What is an ActivityDefinition Resource? A shareable, consumable description of some activity to be performed. May be used to specify actions to be taken as part of a workflow, order set, or protocol, or it may be used independently as part of a catalog of activities such as orderables. Provides a ‘template’ of an action to be performed ActivityDefinition

PlanDefinition Resource Pre-defined group of actions to be taken in particular circumstances Process of applying a PlanDefinition to a particular context typically produces request resources representing the actions that should be performed Metformin 500 mg tab … Glimepiride 1 MG Oral Tablet ... Jardiance 10 MG Oral Tablet … Blood Glucose Monitor System w/Device Kit … Endocrinology Referral … …etc ActivityDefinition Protocol/Template/orderSets PlanDefinition DM Type II definition

Care Planning The process of applying a PlanDefinition produces request resources (representing the actions that should be performed) within a CarePlan ActivityDefinition ActivityDefinition library Protocol/Template/orderSets PlanDefinition e.g. DM Type II definition Patient specific basedOn Care Plan

Care Planning (Cont.) The process of executing the pre-defined care plan activities depending on business logic of the receiving system. ActivityDefinition ActivityDefinition library Protocol/Template/orderSets PlanDefinition e.g. DM Type II definition Patient specific basedOn Care Plan Activity Request e.g. MedicationRequest Activity Event – uses action resources e.g. MedicationDispense initiates

Activity Event – uses action resources e.g. MedicationDispense ActivityDefinition PlanDefinition actionDefintion (group) First Line Monotherapy Metformin HCL 500 mg ….. description: Metformin HCl 500 MG Oral Tablet; TAKE one TABLET Twice daily with meals; 60 tablet; 2 refills purpose: Defines a guideline supported prescription for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ActivityDefinition library Protocol/Template/orderSets PlanDefinition e.g. DM Type II definition Patient specific basedOn Care Plan HealthConcern Diet Recommendation – follow a 1500 calories diabetic diet ….. description: Diabetes diet, specified calories; Follow a diabetic diet with 1500 calories. purpose: Defines a guideline supported patient instructions for the treatment of DM Type II usage: This activity definition is used as part of Diabetes Mellitus, Type 2, Adult +MU care guides approvalDate: 04/28/2017 lastReviewDate: 05/04/2017 effectivePeriod: 05/04/2017 --> 05/04/2018 ….. identifies Activity Request e.g. MedicationRequest addresses HealthGoal fulfils initiates Activity Event – uses action resources e.g. MedicationDispense

Existing Use Case

Use of Care Plan Definition Service eRx Lab Care Plan Contributor Care Plan Definition Service EHR etc Select Patient Add Diagnosis Pass Diagnosis Associate Diagnosis PlanDefinitions Select PlanDefinition PlanDefinitions ID Provide Applicable ActivityDefinitions All ActivityDefinitions Interventions: Medications Referrals Lab orders Procedures Etc. Select Interventions Save CarePlan (Draft) Send Request Resources Update Return Response Update CarePlan with Various resource statuses Update CarePlan with dateTime Stamp

Use of Care Plan Service eRx Care Plan Contributor Lab Care Plan Service Care Plan Definition Service EHR Select Patient etc Retrieve Care Plan Provide Care Plan Add/Update Diagnosis Pass Diagnosis Associate Diagnosis PlanDefinitions Select PlanDefinition PlanDefinitions ID Provide Applicable ActivityDefinitions All ActivityDefinitions Interventions: Medications Referrals Lab orders Procedures Etc. Select Interventions Save CarePlan (Draft) Send Request Resources Update Return Response Update CarePlan with Various resource statuses Update CarePlan with dateTime Stamp

Update Care Plan Definition Service eRx Lab Care Plan Contributor Care Plan Service Care Plan Definition Service etc EHR Select Patient Retrieve Care Plan Provide Care Plan Add/Update Diagnosis Pass Diagnosis Associate Diagnosis PlanDefinitions Select PlanDefinition PlanDefinitions ID Provide Applicable ActivityDefinitions All ActivityDefinitions Update PlanDefinitions Select Interventions Save CarePlan (Draft) Send Request Resources Interventions: Medications Referrals Lab orders Procedures Etc. Update Return Response Update CarePlan with Various resource statuses Update CarePlan with dateTime Stamp

FHIR Implementation Guide See Profile Overview https://wiki.ihe.net/index.php/Dynamic_Care_Planni ng

Future Use Cases

Creating/Updating CareTeam (PCC 2019) eRx EHR Care Planning Guidance Service Provider Directory EHR Lab etc Select Patient Add Diagnosis Pass Diagnosis Associate Diagnosis PlanDefinitions Select PlanDefinition PlanDefinitions ID Applicable ActivityDefinitions All ActivityDefinitions Interventions: Referrals CareTeam Participants Organization Select ReferralRequest, CareTeam components Save CarePlan (Draft) Nutritionists, Hospitals (by Zip code, etc) Providers, organizations available Response Update CarePlan And save CarePlan (Draft) Send Request Resources Update Return Response Update CarePlan with Various resource statuses Update CarePlan with dateTime Stamp

Use of CDs Hooks EHR Pass Diagnosis PlanDefinitions PlanDefinitions ID eRx EHR Care Planning Guidance Service EHR CDS etc Lab Select Patient Add Diagnosis Pass Diagnosis Associate Diagnosis PlanDefinitions Select PlanDefinition PlanDefinitions ID Applicable ActivityDefinitions All ActivityDefinitions Interventions: Medications Referrals Lab orders Procedures Etc. Select Interventions Save CarePlan (Draft) CDS Hooks Guidance (Alerts & Warnings) Update CarePlan And save CarePlan (Draft) Send Request Resources Update Return Response Update CarePlan with Various resource statuses Update CarePlan with dateTime Stamp

Questions?