Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) April 24,

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Agenda Introductions Goals Schedule Presentation and discussion of HL7 Service Oriented Architecture Care Coordination Service (CCS) ballot comments Next Steps 3

4 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 – April 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY AM ET: HL7 Care Coordination Services Overview to LCC AM ET: LCC Tiger Team Meeting for CCS Ballot Preliminary CCS Ballot Comments Due AM ET: Final LCC CCS Ballot Review Meeting Final CCS Ballot Comments Due LCC CCS Ballot Comments Due to HL7

Plan Capability set Prioritization of the parts of Care Coordination Service Who owns what? Mark Plan items for Action Capability Set What this entails How to identify the care team member’s role with respect to the individual being cared for Invite Collaboration Participants Plausibility of inviting a care team Plausibility of the Care Coordination Service to identify resources that might be needed Care Team Conversation Capability Set How this becomes part of Care Coordination Service Other Comments for Consensus Discussion Points

Plan Capability Set

8 Change Plan: more complex process that includes several intermediate steps such as "prioritization" of problems and interventions, harmonization of proposed interventions, which require sharing of the proposed changes, review, comment and reconciliation. The model does not seem to represent the iterative process required at all steps in building, implementing, revising a care plan (e.g. listing health concerns, prioritizing these concerns, prioritizing the interventions, reprioritizing health concerns and interventions based on the initial formulation, measuring success of interventions and the availability of resources which triggers a continuous review of what is working, what is possible and what is acceptable to the patient (and providers). Continued on next slide… Plan Capability Set Comments

9 Who “owns” the reconciled version of the plan? While the patient is mentioned as participating, it is unclear as to what role and at what intersections in the plan the patient (and or proxy/care provider) agrees with the plan. While it is a “living object”, it seems that there should be a designation of when it “settles” and is actionable. If there are “discussions”, when and who makes a decision? Plans of care are discipline specific or single provider specific. They are reconciled internally and not across disciplines or other providers. They may have only one participant (and if there are no other Plans of care it becomes both the Care Plan and a Plan of Care) Plan Capability Set Comments, cont’d

10 Prioritization must be captured and must be part of Care Coordination Service model Everyone who contributes to care plan must have prioritizations Model must account for things like priority, goal and barrier concept, etc. Document includes prioritization language but prioritization is not dealt with in the functional capabilities Care Plan, Plan of Care and Treatment Plan are nested concepts Ownership of any given step in iterative process needs to be clearly defined Plan Capability Set Discussion

Mark Plan Items for Action Capability Set In the world of “paper” care plans, one can take a red pen and make “markings” to identity items of interest for planning discussion. As an example, these markings may indicate to follow up on, to correct, to consolidate or reconcile various plan items. CCS defines a set of common markings which may be applied to electronic care plan items but also allows users to use their own marking names. The “Mark Plan Items for Action” capabilities support the ability of users to make these markings in the electronic equivalent of the care plan, plan of care or treatment plan. Markings with the same name form groupings, made explicit by CCS as a way to form working sets to support collaborative care team discussions and actions Mark Plan Items Comments

12 Do these components become part of the legal medical record? “Care team members can mark conflicting goals that need to be discussed.” This seems to be a “discussion” component of the record, which occurs in a different context in health care: recommendations to the provider and/or patient. I didn’t see any audit functions associated with these Services. Doesn’t Auditing and review of the auditing need to be part of the Service Offering? I would assume we would need a whole new set of functions relative to the audit. Many of these functions will be usable only by authorized User. Precondition of “individuals registered in some directory” is unclear. How is patient or care provider identified? Mark Plan Items Comments

13 What does this entail? How can the care team member’s role be identified with respect to the individual being cared for? How can the care team member be related to or associated with a goal or intervention? Mark Plan Items Discussion

Invite Collaboration Participants An invitation is a request from one individual to another to participate as a collaborator in coordination of care activities for one patient. Participants join the Care Team via an invitation based process which results in organically growing the patient's care team. Instead of making a phone call or sending faxes a licensed independent practitioner, a nurse or a physician, would send an invitation to collaborate. This invitation is the first step to initiate interactions with new care team members for referrals, transitions of care, consultations, etc Invite Collaboration Participants

Invite Collaboration Participants Table

16 In general, the service functions that are proposed are not described in enough detail, and the input, outputs, etc. are not close to being complete. I don’t know if it is typical for an HL7 Service to have a diagram with all of the service functions and who does what to whom, but it sure seems like something like that will help the implementer and certainly a reviewer. I didn’t go back and ask if there were missing service functions. I do know that in some cases the paired sets didn’t perform parallel functions. The model by which the Care Plan, Plan Of Care, Treatment Plan is based is new and there is no validation being done back to existing models on LCC. Continued on next slide… Invite Collaboration Participants Comments

17 The intention is that the use of the model is to provide a Service Based set of s/w, and NOT create any type of parallel CDA for interoperability use. Is it really fair to assume that everyone will have access to the s/w and that no one will still need to rely on the use of documents? The business case for “patient inviting” providers to participate is not clear. If consults are made or facility regulations require that the provider intervene, this is a clinical responsibility. Is this the same as a referral? Precondition includes a “care giver” yet earlier reference to “steward” was used. Is this the same? Do invitations to Plan of Care and Treatment Plan apply? This seems to be restrictive in terms of “information allowed” which is counter intuitive to the general health care provider. What is the output? How is this confirmed? Invite Collaboration Participants Comments, cont’d

18 Plausibility of inviting a care team Plausibility of the Care Coordination Service to identify resources that might be needed Any services missing from model (throughout the document, not necessarily specific to this particular Capability Set) Invite Collaboration Participants Discussion

Care Team Conversation Thread Capability Set The CCS conversation model works as follows: Captures the free form text, natural language, content of business interactions May capture structured observations resulting from question/answer electronic form interactions. Discussions may links to the semantic structured context pertaining to the conversation (structured “clinical statements”) A conversation may simply consist of free text such as a question from a patient to his or her provider. A conversation may also pertain to some aspect of the care plan such as: a communication about a specific health goal, health concern, health risk, intervention outcome, associated plan and goal reviews or some diagnostic observation about the patient. The semantic links put the conversation in context. Conversations will naturally form threads containing multiple communications about some topic. Care team communications may also have optional multimedia support (attached photograph of video clip) Care Team Conversation Thread

20 The use of “conversation” is confusing in the context of patient care; it not included in vocabularies, standards nor reimbursement methods. While the conversation “is private” it still is traceable. Question if providers are comfortable with this process and/or if it is efficient in the determination of the care plan. When is the patient involved in the decision process? Discussions of care planning, particularly with the patient, are often captured in the patient record. How are these portions of the record going to be incorporated into that conversation? Care Team Conversation Capability Set Comments

21 Need to further define how this becomes part of Care Coordination Service Is this a social media platform for care planning? Care Team Conversation Capability Set Discussion

Care Plan Capability Set This seems to be implemented without full analysis on the patient’s ability and barriers to care plan items. In terms of the “Clinical Appropriateness Capability”, it seems best to identify this as a CDS, which is what most in the industry are comfortable with. CDS is to present best practices, but in many very complex patients, there is no clear directive on “appropriateness” but rather a clinical decision on what will be the best treatment scenario for the patient. Care Plan Action Capability Set doesn't seem to be complete. There are not concepts such as harmonization, prioritization, modification and review. There are no iterative loops. "Abandon" and "Completed" are two different loops. Continued on next slide… Other Comments for Consensus

Care Plan Capability Set, cont’d Find Available Resources: there needs to be a feedback process into the prioritization, modification, harmonization loop so that proposed interventions can be reconfigured to match available resources. This is not the end of a process, it starts a new loop. Does this include data collected from patient on whether they want to accept the resource? Data – Special vs. Simple Associations The examples are not the highest priority links among health concerns, interventions, team members, goals/outcomes. We should substitute our hierarchy: Health Concerns to Interventions and Interventions to Goals(prioritization), Interventions to Team Members (implementation) and Team Members to Outcomes (responsibility for implementation) Other Comments for Consensus, cont’d

Proposed Next Steps Generate any final Ballot Comments and send to Russ or Lynette by Noon ET on Thursday, April 24 for inclusion Finalize LCC’s Ballot Comments by Friday April 26th Submit Ballot Comments to HL7 by Monday, April 29th

25 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 Sub Work Group Lead Russ Leftwich Program Management Lynette Elliott Becky Angeles