1. Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS) May 15, 2013 1

2. 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

3. 3 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

4. Agenda Introductions Goals Schedule Discussion of Cara Plaan’s patient story as a baseline for representing and prioritizing Risks and Health Concerns –Ongoing comments can be submitted and viewed on wiki: http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG Call scheduled with HL7 Patient Care Work Group to discuss Risks and Health Concerns –Wednesday, May 15 at 5pm ET Next Steps 4

5. Schedule – May 2013 SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY 1 234 11 AM ET: Overview of HL7 LCC Domain Analysis Model 567891011 11 AM ET Discussion: Risks, Health Concerns, Barriers 12131415161718 11 AM ET Discussion: Risks, Health Concerns, Barriers 5 PM ET Touch Point with PCWG 19202122232425 11 AM ET: Discussion: Preferences and Prioritizations 262728293031 11 AM ET: Map out how to assign Care Team Members to prioritizations

6. Work Group Schedules LCC WG SWG MeetingLCC LeadsDate/ TimeProjects LTPAC SWGLarry Garber Terry O'Malley Weekly Mondays, 11-12pm EST C-CDA: Transfer Summary, Consult Note, Referral Note LCC HL7 Tiger Team Russ LeftwichWeekly Wednesdays, 11- 12pm EST LCC WG comments for HL7 Care Plan DAM LCP SWGBill Russell Sue Mitchell Jennie Harvell Weekly Thursdays 11- 12pm EST C-CDA: Care Plan, HomeHealth Plan of Care HL7 WG SWG MeetingHL7 LeadParticipating LCC Members Date/ TimeProjects HL7 Patient Care WGRuss Leftwich Elaine Ayers Stephen Chu Michael Tan Kevin Coonan Susan Campbell Laura H Langford Lindsey Hoggle Bi-weekly Weds, 5 - 6pm EST Care Plan DAM Care Coordination Services (CSS) HL7 Structured Documents WG Bob Dolin Brett Marquard Sue Mitchell Jennie Harvell Weekly Thursdays, 10-12pm EST CDA (various) HL7 SOA WG CCS ProjectJon Farmer Enrique Meneses (facilitators) Stephen Chu Susan CampbellWeekly Tuesdays 5 - 6pm EST Care Coordination Services (CSS) HL7 Patient Generated Document Leslie Kelly HallWeekly Fridays, 12- 1pm EST Patient-authored Clinical Documents

7. 7 Use the following patient story as baseline for a more tangible discussion about Risk, Health Concerns, Barriers and Preferences with the PCWG How best to designate and represent these considerations in the patient story, either implied or manually entered How and to what extent are each of these considerations listed out, where implied or manually entered How to prioritize each consideration Discussion Overview

8. 8 High Level Health Concerns

9. 9 Patient Preferences DirectiveDescription 8.4State of Patient preferences for other medically-indicated treatments 8.4.1Antibiotics 8.4.1.1Use oral, IM or IV 8.4.1.2Use oral only 8.4.1.3Use oral only for symptom relief or comfort 8.4.2Medications 8.4.2.1Give any medication that is clinically updated 8.4.2.2Give medications only for relief of symptoms or comfort 8.4.2.3Do not administer medications except for pain relief 8.4.3Transfusions/Any blood product 8.4.4Hospital Transfer 8.4.4.1Transfer for any situation requiring hospital-level care Continued on next slide

10. 10 Patient Preferences, cont’d… DirectiveDescription 8.4.4.2Transfer to hospital for severe pain or severe symptoms that cannot be controlled otherwise 8.4.4.3Do not transfer to hospital but treat with options available outside hospital 8.4.5Medical Workup 8.4.5.1Perform any medical tests indicated to diagnose and/or treat a medical condition 8.4.5.2Perform limited medical tests necessary for symptomatic treatment or comfort 8.4.6Dialysis 8.4.6.1Give chronic dialysis for end-stage kidney disease if medically indicated 8.4.7Artificially Administered Fluids and Nutrition 8.4.7.1Artificially administer fluids and nutrition if medically indicated 8.4.8Other Orders

11. 11 Cara Plaan is a 48 year old woman who recently had a blood clot in her left leg after a cross country auto trip. She has been placed on Warfarin, custom fitted stockings, and advised to not sit for long periods. She declined an alternative anticoagulant therapy, which was described to her as effective and safer, but much more expensive. She is a lactovegetarian. She is a smoker. There is a history of breast cancer in three female maternal relatives. She has only recently become employed after a period of unemployment and does not currently have health insurance. Cara Plaan: A Patient Story

12. 12 48 year old woman who recently had a blood clot in her left leg after a cross country auto trip. At increased risk above general population (special population) Risk of recurrence of clot as well as embolism—is this represented as prior history or future risk? Intervention: education, instruction Cara Plaan: Risk 1

13. 13 Placed on Warfarin, custom fitted stockings and advised not to sit for long periods of time. “Extrinsic” risk as defined by current DAM—risk of bleeding comes from intervention Extrinsic vs. intrinsic might not be relative here. Person’s immobilization reason (airplane vs. bed rest) should not change classification of risk. Cara Plaan: Risk 2

14. 14 She declined an alternative anticoagulant therapy, which was described to her as effective and safer, but much more expensive. Barrier or treatment preference? Decision modifiers (factors that weight the logic and choices) A barrier or treatment preference that rises to the level of intervention becomes a health concern Cara Plaan: Risk 3

15. 15 She is lactovegetarian. Implications for medication therapy—is this a health concern? Requires a plan, monitoring, special diet, documentation…appears to be health concern based on action requirement Actions in model include interventions, monitoring, watchful waiting and therapeutic nihilism Preservation of wellness must be planned, so it becomes a health concern Cara Plaan: Risk 4

16. 16 She is a smoker. Cara Plaan: Risk 5

17. 17 There is a history of breast cancer in three female maternal relatives. Cara Plaan: Risk 6

18. 18 She has only recently become employed after a period of unemployment and does not have health insurance. Cara Plaan: Risk 7

19. 19 Discussion on Preferences and Prioritizations Map out how to designate preferences and prioritizations Determine how to best represent/model preferences and prioritizations For Next Week

20. Proposed Next Steps Schedule next Touch Point meeting with PCWG Update discussion schedule Finalize LCC’s Comments by August 4, 2013 for submittal as part of September Ballot

21. 21 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 evelyn.gallego@siframework.orgevelyn.gallego@siframework.org Sub Work Group Lead Russ Leftwich cmiotn@gmail.comcmiotn@gmail.com Program Management Lynette Elliott lynette.elliott@esacinc.comlynette.elliott@esacinc.com Becky Angeles becky.angeles@esacinc.combecky.angeles@esacinc.com

22. 22 Background Slides

23. 23 3.4Observation, Condition, Diagnosis, Concern NOTE: The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. The examples provided here are greatly simplified so as to illustrate certain aspects of SNOMED CT implementation. Observations, Conditions, Diagnoses, and Concerns are often confused, but in fact have distinct definitions and patterns. "Observation" and "Condition": An HL7 observation is something noted and recorded as an isolated event, whereas an HL7 condition is an ongoing event. Symptoms and findings (also know as signs) are observations. The distinction between "seizure" and "epilepsy" or between "allergic reaction" and "allergy" is that the former is an observation, and the latter is a condition. SNOMED CT distinguishes between "Clinical Findings" and "Diseases", where a SNOMED CT disease is a kind of SNOMED CT clinical finding that is necessarily abnormal: [ 404684003 | Clinical finding ] [ 64572001 | Disease ] SNOMED IG Definitions Continued on next slide

24. 24 The SNOMED CT finding/disease distinction is orthogonal to the HL7 observation/condition distinction, thus a SNOMED CT finding or disease can be an HL7 observation or condition. "Diagnosis": The term "diagnosis" has many clinical and administrative meanings in healthcare A diagnosis is the result of a cognitive process whereby signs, symptoms, test results, and other relevant data are evaluated to determine the condition afflicting a patient. A diagnosis often directs administrative and clinical workflow, where for instance the assertion of an admission diagnosis establishes care paths, order sets, etc. A diagnosis is often something that is billed for in a clinical encounter. In such a scenario, an application typically has a defined context where the billable object gets entered. "Concern": A concern is something that a clinician is particularly interested in and wants to track. It has important patient management use cases (e.g. health records often present the problem list or list of concerns as a way of summarizing a patient's medical history). SNOMED IG Definitions, cont’d… Continued on next slide

25. 25 Differentiation of Observation, Condition, Diagnosis, and Concern in common patterns: "Observation" and "Condition": The distinction between an HL7 Observation and HL7 Condition is made by setting the Act.classCode to "OBS" or "COND", respectively. The distinction between a SNOMED finding and SNOMED disease is based on the location of the concept in the SNOMED CT hierarchy. There is no flag in a clinical statement instance for distinguishing between a SNOMED CT finding vs. disease. "Diagnosis": Result of a cognitive process: Could potentially be Indicated by post-coordinating a SNOMED CT finding method attribute with a procedure such as "cognitive process". Directs administrative and clinical workflow: These use cases typically rely more on the context in which the diagnoses are entered (e.g. where an order set has a field designated for the admission diagnosis). In such a case, the distinction of a (particular kind of) diagnosis is that it occurs within a particular organizer (e.g. a condition within an Admission Diagnosis section is an admission diagnosis from an administrative perspective). Something that is billed for: The fact that something was billed for would be expressed in another HL7 message. There is nothing in the pattern for a diagnosis that says whether or not it was or can be billed for. SNOMED IG Definitions, cont’d… Continued on next slide

26. 26 "Concern": The HL7 Patient Care Technical Committee is developing a formal model for condition tracking. In that model, a problem (which may be an Observation, a Procedure, or some other type of Act) is wrapped in an Act with a new Act.classCode “CONCERN”. The focus in this guide is on the use of SNOMED CT, whereas the Patient Care condition tracking model is the definitive source for the overall structure of a problem list. It should be noted that the administrative representation of a diagnosis and the representation of a concern break the rules from section 3.1.1 Observations vs. Organizers, in that these designations are based on context, whereas the designation of something as an Observation vs. Condition is inherent in the clinical statement itself. SNOMED IG Definitions, cont’d…

27. 27 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 Risks

28. 28 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 Barriers

29. 29 Preference Definition How are preferences represented? Positive vs. negative preferences Overview as it relates to care plan exchange and workflow Preferences