Longitudinal Coordination of Care (LCC) Workgroup (WG)HL7 Tiger TeamPatient Care WG Care Plan DAM

August 14, 2013

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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

Agenda

• Goals

• Schedule

• Review of recommendations made to PCWG for Care Plan DAM

– Items implemented in time for ballot

– Items not implemented in time for ballot

– Items not included in the DAM

• Next Steps

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• 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 and technical specifications

• Ongoing comments can be submitted and viewed on wiki:

http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG

Goals

Work Group SchedulesLCC WG

SWG Meeting LCC Leads Date/ Time Projects

LTPAC SWG Larry GarberTerry O'Malley

Weekly Mondays, 11-12pm EST

C-CDA: Transfer Summary, Consult Note, Referral Note

LCC HL7 Tiger Team

Russ Leftwich Weekly Wednesdays, 11- 12pm EST

LCC WG comments for HL7 Care Plan DAM

LCP SWG Bill RussellSue MitchellJennie Harvell

Weekly Mondays and Thursdays 5-6pm EST

C-CDA: Care Plan, HomeHealth Plan of Care

HL7 WGSWG Meeting HL7 Lead Participating LCC

MembersDate/ Time Projects

HL7 Patient Care WG Russ LeftwichElaine Ayers Stephen Chu Michael Tan Kevin Coonan

Susan Campbell Laura H Langford Lindsey Hoggle

Bi-weekly Weds, 5 -6pm EST

Care Plan DAMCare Coordination Services (CSS)

HL7 Structured Documents WG

Bob DolinBrett Marquard

Sue MitchellJennie Harvell

Weekly Thursdays, 10-12pm EST

CDA (various)

HL7 SOA WG CCS Project Jon Farmer Enrique Meneses (facilitators) Stephen Chu

Susan Campbell Weekly Tuesdays 5 - 6pm EST

Care Coordination Services (CSS)

HL7 Patient Generated Document

  Leslie Kelly Hall Weekly Fridays, 12-1pm EST

Patient-authored Clinical Documents

Schedule – August 2013SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

1 2 3

4 5 6 7 8 9 1011 AM ET

Meeting Cancelled

11 12 13 14 15 16 1711 AM ET

Review of completed DAM

with implemented recommendations

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25 26 27 28 29 30 31

FINAL TIGER TEAM MEETING

Review of Final Balloted DAM• Recommendations that were implemented in the DAM are in

bold italic in this presentation.

• Recommendations that were not implemented (because they were process or not part of an informational model) are in italic.

• Majority of recommendations made were implemented in ballot documentation.

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Support Care Plan and Plan of Care

• Recommend that DAM should support both the Care Plan and Plan of Care, sequential and multi-threaded workflows; needs to define the buckets of all the information for all of these.• “The Care Plan structure is designed to support the

implementation of different types of plans, including Treatment Plans, Plans of Care and Care Plans as defined by the ONC (LCC) Longitudinal Coordination of Care project. There is a generic “Plan” structure which together with a number of supporting components describe health concerns, health goals, interventions (plan activities), preferences, health risks, acceptance review, outcome review, care team roles, participations and their relationships.” (PCWG Care Plan DAM Specification document, p 47, line 1550)

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Support Care Plan and Plan of Care

Figure 6 Core Components of the Plan

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Goal Acknowledgment / Acceptance

• Recommend adding attribute to Goals that can indicate that the goals have been agreed to by both the Provider and the Patient or that there is not agreement between the two.

• Recommend adding another attribute that supports specific health concern and intervention related goals (who has agreed to these goals).

• Recommend including the ability in the model for a Care Team Member to accept/acknowledge their association

• Recommend allowing for variance analysis with levels of intervention.

• Recommend adding/supporting an ability to harmonize multiple treatments and Plans of Care and to create a Master Care Plan in the care of complex Patients in complex organizations.

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Goal Acknowledgment / Acceptance

Figure 7 Associations Activity, Health Goal, Health Concern, Health Risk and Care Barriers

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Goal Acknowledgment / Acceptance

Figure 9 Types of Reviews

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Goal Acknowledgment / Acceptance

Figure 10 Care Team Conversations

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Goal Acknowledgment / Acceptance

Figure 15 Plan Communications Logical Information Model

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Preferences

• Recommend adding a separate Advance Directives section that contains all preference information including advance directive preferences, which are linked to a repository or separate document.

• Recommend listing out and defining “Other preferences” under Types of Preferences.

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Preferences

Care Preference Attributes (Care Plan DAM Specification, p64):

A care preference is a statement expressed by the patient, custodian or caretaker responsible for the patient in order to influence how their care is delivered.

A preference expresses a personal choice and may be driven by cultural, religious and moral principles. As such it is a principal component of patient centered care and autonomy. Care preferences serve as modifiers of the Care Plan which influence how the plan is personalized for the individual.

A care preference may be specified prospectively to influence future care planning and treatment or it may be expressed and recorded at arbitrary decision points during interventions.

A preference expresses a request to fulfill a patient's choice or desire. The choice may be a strong and absolute statement such as an end of life directive. The request could also be a desire to be fulfilled if possible given care team capabilities and resources.

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PreferencesAttribute Name Data Type Description

preference Code Descriptive code which specifies the type of the patient preference

reason Code[0..*] Captures a reason indicator for the preference. The reason may be classified as cultural, religious, moral/ethical. The reason is a factor which should already be included in considering the strength of the preference. It is explicitly indicated in the model in order to provide context for handling with sensibility.

effectiveDate DateTime The date/time the preference becomes effective for consideration when providing care

expressedBy Role The individual who expressed the preference. This is typically the patient but it may also be the patient's caretaker (for a young child or a patient who is not able to decide for themselves).

strength LevelType The strength indicates flexibility in the interpretation of the patient's choice by the care team participants. The strength may be High and indicate an absolute choice driven by moral principles, cultural or religious principles. Or it may indicate an important desire which the patient has but for which the patient has flexibility. The strength may have a value of either High (absolute choice) or Low (desired choice).

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Preferences

notes Note[0..*] Optional notes about the preference. The note captures a text narrative, date of the note and the individual making the note.

media URL[0..*] Optional link to external documentation supporting the preference (e.g. scanned advance directive or legal documents on file).

activationCriteria Criterion[0..*] Specifies how the preference is matched to an Intervention and the conditions under which it is activated.

alternatePreference CarePreference[0..*]

A list of ordered alternate preferences acceptable to the patient or caretaker in case the primary preference cannot be fulfilled. The ordering indicates the next best alternative for the patient.

acceptance AcceptanceReview[0..*]

Captures acceptance or acknowledgement of the preference by one or more care team members. Acceptance represents alignment of the patient and providers understanding.

unfullfilledReason[0..1] Captures the reason why a preference cannot be applied during an intervention in which the preference should apply. This property can only be set for preferences associated with a Health Activity

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Priority

• Recommend not including Priority in interventions. Actions that were considered and not chosen as part of the intervention should be included elsewhere in the Care Plan.

• Recommend adding a text field with Priority so that comments can be captured with priority rankings.

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Priority

Figure 7 Associations Activity, Health Goal, Health Concern, Health Risk and Care Barriers

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Levels of Association

• Recommend including associations in model for traceability (assignment of responsibility, payment, etc.): provide a bucket for association/responsibility level, bucket for functional role, and bucket for identification of responsible/associated individual or entity• Recommend that High, Medium, Low be used as

association/responsibility level designators for both Health Concerns and Interventions.

• Recommend that association should include individual and organization under functional role (Care Team Members may have more than one role inside an organization)

• Recommend that Health Concerns and Interventions also include type of association (e.g., fee for service, consent, other)

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Levels of Association

Figure 8 Activity Associations

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Care Team Member: Role, Cardinality

• Recommend establishing a taxonomy to support how the association/relationship will be used (e.g., as a messaging filter to only send information to certain entities and/or showing who is involved and their sub-roles and/or other).

• Recommend establishing Care Team Member cardinality:• Health Concerns to Team Member

• Recommend Health Concern can be zero to many cardinality, with SHOULD conformance

• Goals to Team Member• Recommend Goal can be zero to many cardinality,

with SHOULD conformance• Interventions to Team Member

• Recommend Intervention (Plan Activity) can be zero to many cardinality with SHOULD conformance

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Team Member Cardinality

Figure 6 Core Components of the Plan

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• Recommend a way to account for facilitation of the Care Plan (“steward” role or other)

Care Plan Facilitation

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Care Plan Facilitation

Figure 6 Core Components of the Plan

Opportunities to Engage in HL7 Balloting

Ballot Period

Fall 2013 CDA Implementation Guide Ballot Cycle:•Ballot Pool Sign-up: July 25, 2013 through Sept 9, 2013 •Must join the ballot pool before Sept 9.•Ballot Opens: Aug 16, 2013 •Ballot closed: Sept 16, 2013

HL7 Ballot Website: http://www.hl7.org/participate/onlineballoting.cfm?ref=nav

HL7 Ballot Information Page

Hl7 Balloting Home Page

Contains:

•Sept 2013 ballot calendar

• Non-Member balloting participation instructions

•Participation in balloting is available for HL7 Members and Non-Members (any interested party)– For Non-Members, there is a small administrative fee ($50) to

participate

Access the HL7 Ballot WebsiteInstructions and all links needed are on the homepage:

Members and Non-Members must sign in to access the ballot desktop:

Non-Members will need to create a profile to participate

Join the Ballot PoolAfter logging in, you will see a list of the available ballots on your Ballot Desktop:

Select “Join Ballot Pools” from the menu on the right side of the screen:

• Select ballot(s)to join from the left column:

Join the Ballot Pool

Review Ballot Packages• Ballot desktop includes ballot pools that you joined:

• Understand ballot documents

• Review ballot comment spreadsheet and instructions

Comment Spreadsheet

Be specific about location Copy and paste from Ballot Artifact

You don’t have to have proposed wordingbut specificity clarifies

Tell us what you think is wrong or could be better

Be sure to indicate if you want to be present during resolution of any/all comments

Vote Types- Affirmative• Affirmative Vote with Comment- Suggestion (A-S)

– Use this if the committee is to consider a suggestion such as additional background information or justification for a particular solution

• Affirmative Vote with Comment – Typo (A-T) – If the material contains a typo such as misspelled words, enter A-T

• Affirmative Vote with Question (A-Q)

• Affirmative Vote with Comment (A-C)

Vote Types- Affirmative• Examples of affirmative votes:

Vote Types- Negative• Negative Vote with reason, Major (Neg-Mj)

– Use this in the situation where the content of the material is non-functional, incomplete or requires correction before final publication.

– All Neg-Mj votes must be resolved by committee.

• Negative Vote with reason, Minor (Neg-Mi)– Use this when the comment needs to be resolved, but is

not as significant as a negative major.

Vote Types- Negative• Examples of negative votes:

Cast Your Vote

• Cast your overall vote• Affirmative votes must have comments of an affirmative nature

(Comment, Suggestion, Typo or Questions)• Negative votes must have one or more negative comments

(Negative Vote with Reason – Major or Minor)

• Attach the comment spreadsheet

• Submit your comments by the ballot close date: Monday, Sept 16, 2013

• Select the “Vote” tab:

Following the Comment Period• Reconciliation:

– Starts during the working group meeting (Sept 22-27)– Continues during scheduled conference calls

• Overall committee vote– Incorporate changes and publish– Incorporate changes and back to ballot– Withdrawal of negatives

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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.org

• Sub Work Group Lead• Russ Leftwich cmiotn@gmail.com

• Program Management• Lynette Elliott lynette.elliott@esacinc.com• Becky Angeles becky.angeles@esacinc.com