Patient Care Coordination Tone Southerland Greenway Medical Technologies Co-chair, IHE PCC Marcia Veenstra Senior Health Inc. Co-chair, IHE PCC Nursing Sub-committee

What is PCC? Scope includes: –Integration issues that cross providers, patient problems or time. –General clinical care aspects such as Document exchange Order processing Coordination with other specialty domains –Address workflows and the integration needs of speciality areas without a separate domain within IHE

A content profile is… A sharable information component that can be exchanged.. –Within an HIE (XDS) –Via Media or USB Device (XDM) –Via Reliable Messages (XDR) Human Readable –CDA Level 1 and 2 Machine Processable –CDA Level 3 A Library of Reusable Parts

Library of Templates Documents LAB Problems Vitals Result Problem Obs Severity Referral XPHR Vital SectionsEntriesParts

5 PCC Profiles Medical Summaries Emergency Department Referral Exchanging PHR Content Antepartum Care Summary Emergency Department Encounter Summary Functional Status Assessments IntegrationContent Query for Existing Data Antepartum Record Immunization Registry Content Care Management Request for Clinical Guidance Labor and Delivery Record Patient Plan of Care EMS Transfer of Care

Labor and Delivery Record The LDR Profile provides information to the health care providers about the labor and delivery and the newborn in an in- patient setting Useful for –Transfers of care in the in-patient setting (OR or NICU) –Post-partum outpatient care

Emergency Responder Pre-Hospital Care Report The ER-PCR Profile computerizes crash victim emergency contact information (ECON) and personal health record (PHR) data, thereby helping on-site Emergency Responders improve post-crash emergency healthcare and outcomes for crash victims

Query for Clinical Guidance The QCG Profile provides a way to communicate decision support inputs and outputs between HIT and CDS systems. This provides a way for HIT applications to quickly incorporate CDS capabilities from a variety of sources into different workflows

Detailed Scores/Assessments This white paper provides a generic section for Score Systems and Assessment Scales separating the structure from the score specific details Uses HL7 V3 Patient Care – Care Provision – Assessment Scale Topic DSTU as foundation

Nursing Objectives SubCommittee Objectives: –Recognize currently nurses do not have cross enterprise nor intra-enterprise interoperability documentation as part of their electronic workflow –Describe expectations of care outcomes related to interoperable health records –Provide interoperable documentation for nursing practice in all specialties

Desired Nurse/Patient Outcomes Availability of patient and clinical information prior to admission/transfer Early intervention minimized complications Complete clinical information promotoes safety and improved outcomes Continuity of interdisciplinary plans of care using nursing data promotes safer transfers of care, evidence for outcomes improvements and patient satisfaction

Nursing Roles Treating the human response along the health – illness continuum –Support health maintenance and disease prevention –Perform patient care and treatment –Educate for prevention of illness and promotion of health and wellness –Collaborate with multiple disciplines

Coded Nursing Documentation Health Assessment –Vital signs and measurements, including Pain –Body sounds, including Heart, lung, abdomen –Internal and external patient fluid management –Activities of daily living Plan of Care Educate the patient and family Disease, medication and treatment management Lifestyle changes and disease prevention Safety in health and illness Pain management

For Further Information PCC on the wiki: – PCC Tech Google Group: – PCC Plan Google Group: –