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

July 19, 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

• Discussion of Team Member’s association with and level of involvement for Health Concerns, Interventions, Goals

• Discussion of how to represent Team Member’s relationship to the Patient

• 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

• Ongoing comments can be submitted and viewed on wiki:

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

Goals

Schedule – July 2013SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

1 2 3 4 5 611 AM ET

Discussion Plan Activity Data

Element Attributes

7 8 9 10 11 12 1311 AM ET

Discussion Team Member

Relationship to Patient

14 15 16 17 18 19 201:30 PM ET Continued

Discussion Team Member

Relationship to Patient

21 22 23 24 25 26 2711 AM ET

Discussion TBD

28 29 30 3111 AM ET

Discussion TBD

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

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• Continued discussion of how to represent Team Member’s association with and level of involvement for the following data elements (to align with LCC Use Case 2): • Health Concerns• Interventions• Goals

• New discussion of how to represent Team Member’s relationship to the Patient• Is this represented in current model? Does it need to be?• Is it the individual involved in care planning process, do they have a

role in updating the care plan, or do they simply have access to the Care Plan?

Tiger Team Discussion Points

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• How to represent Team Member’s association with and level of involvement for the following data elements:• Health Concerns• Interventions• Goals

• How to represent these associations• Primary, secondary? Other?

Team Member Responsibility Discussion

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• Identify Team Member’s association with and level of involvement for Health Concerns

Team Member Responsibility – Health Concerns

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• Identify Team Member’s association with and level of involvement for Interventions

Team Member Responsibility – Interventions

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• Identify Team Member’s association with and level of involvement for Goals

Team Member Responsibility – Goals

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• New discussion of how to represent Team Member’s relationship to the Patient• Is this represented in current model? Does it need to be?• Is it the individual involved in care planning process, do they have a

role in updating the care plan, or do they simply have access to the Care Plan?

• Example: A patient might see a specialist (any care team member in a specialized domain – behavioral health, nutrition, physical therapy, etc.) once, or it might be intended that the patient will see the specialist only as needed, at intervals from years to days. Such a specialist seen only once or at intervals of years apart would not likely be involved in care plan updates or in all information exchange about the patient.

Team Member Relationship to Patient

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• What attributes should be captured?• PCP, specialist acting as PCP, independent consultant, task

specific care team member• Intensity or level of engagement – one time, as needed, specified

intervals frequent or infrequent• Relationship to other care team members?• Date of last encounter?

• Care plan governance or read only access• Communications separate from governance?

Team Member Relationship to Patient

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• New discussion of how to represent Team Member’s relationship to the Patient• Is this represented in current model? Does it need to be?• Is it the individual involved in care planning process, do they have a

role in updating the care plan, or do they simply have access to the Care Plan?

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Team Member Relationship to Patient

Proposed Next Steps

• Next Touch Point meeting with PCWG is July 24• Update discussion schedule• Finalize LCC’s Comments well before August 4, 2013 for

submittal as part of September Ballot (HL7 PCWG needs time to incorporate any comments)

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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