Chronic Care Coordination/Community Referral Workflow Brief Profile Proposal for presented to the PCC Planning Committee Jon Hilton, Health Informatics Society of Australia 10 th September, 2009

PCC Planning Committee The Problem To provide efficient support for planned care and follow-up in Chronic Disease Management (CDM)To provide efficient support for planned care and follow-up in Chronic Disease Management (CDM) Care Management Profile (CM) links guidelines for care with clinical data sourcesCare Management Profile (CM) links guidelines for care with clinical data sources –In CDM, guidelines are typically embodied in a simple care plan that specifies referrals to a care team. Tracking of referral with reporting by exception on clinical issues is an efficient way to support care management. –Existing care planning and management systems are already implementing this functionality and would benefit from a standardised approach This is foundational work required to support business processes and decision making in planned care for CDMThis is foundational work required to support business processes and decision making in planned care for CDM

PCC Planning Committee Use Case Doctor creates and lodges a copy of the care plan in a shared repository, and creates electronic referrals to the care team. Doctor asks patient to arrange appointments.Doctor creates and lodges a copy of the care plan in a shared repository, and creates electronic referrals to the care team. Doctor asks patient to arrange appointments. Each member of the care team acknowledges receipt of the referral. As appointments are made and attended, each member lodges a referral record and record of encounter (optionally flagged for non urgent attention) in a shared repository. Urgent clinical needs are addressed by providers as usual.Each member of the care team acknowledges receipt of the referral. As appointments are made and attended, each member lodges a referral record and record of encounter (optionally flagged for non urgent attention) in a shared repository. Urgent clinical needs are addressed by providers as usual. Doctor is able to access the shared repository and can identify non attendances and flagged records of encounter for further attention.Doctor is able to access the shared repository and can identify non attendances and flagged records of encounter for further attention.

PCC Planning Committee Proposed Standards & Systems IHE XDS, XDS-MS, IHE PCC Content ProfilesIHE XDS, XDS-MS, IHE PCC Content Profiles HL7 REFHL7 REF Alternatives exist in the PCC Content Profiles (see discussion on CM above for rationale for new proposal)Alternatives exist in the PCC Content Profiles (see discussion on CM above for rationale for new proposal)

PCC Planning Committee Discussion The intention is to start with a well chosen foundation that can be built over time. Such an approach would allow maximum flexibility while minimising cost of entry and time to develop profile.The intention is to start with a well chosen foundation that can be built over time. Such an approach would allow maximum flexibility while minimising cost of entry and time to develop profile. Profile Editor: Jon Hilton Health Informatics Society of Australia (HISA)Profile Editor: Jon Hilton Health Informatics Society of Australia The aim here is to take advantage of existing standard messages and profiles where possible. Given the potentially very broad user base, the intention is to design the profile to support a low effort and cost entry point for providers with often unsophisticated systemsThe aim here is to take advantage of existing standard messages and profiles where possible. Given the potentially very broad user base, the intention is to design the profile to support a low effort and cost entry point for providers with often unsophisticated systems