Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture...
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Transcript of Longitudinal Coordination of Care (LCC) Workgroup (WG) HL7 Tiger Team Service Oriented Architecture...
Longitudinal Coordination of Care (LCC) Workgroup (WG)HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS)
May 8, 2013
1
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
• Introductions
• Goals
• Schedule
• Discussion of Risks, Health Concerns, Barriers and Preferences as they relate to LCC’s vision of care plan exchange and workflow
– Ongoing comments can be submitted and viewed on wiki:
• http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG
• 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 – May 2013SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY
1 2 3 4
11 AM ET: Overview of HL7
LCC Domain Analysis Model
5 6 7 8 9 10 1111 AM ET
Discussion: Risks, Health Concerns,
Barriers
12 13 14 15 16 17 1811 AM ET
Discussion: Risks, Health Concerns,
Barriers
5 PM ET Tentative Touch Point with
PCWG
19 20 21 22 23 24 25
11 AM ET: Map out how to
designate/model Prioritizations
26 27 28 29 30 3111 AM ET: Map out how to assign Care Team Members to
prioritizations
6
• Health Concern• Definition• Overview as it relates to care plan exchange and
workflow
Overview: Health Concern
7
• Health concerns reflect the issues, current status and “likely course” identified by the patient or team members that require intervention(s) to achieve the patient's goals of care, any issue of concern to the individual or team member.
• “Problems” and “diagnoses” will capture medical/surgical diagnosis but are insufficient to capture the full array of issues that are important to individuals. Health concerns include:• Medical/surgical diagnoses and severity• Nursing/Allied Health/Behavioral Health issues• Patient reported health concerns• Behavioral/Cognition/Mood issues• Functional status, including ADL issues• Environmental factors (e.g. housing and transportation)• Social factors including availability of support and relationships• Financial issues (e.g. insurance, eligibility for disability)
Care Plan Glossary Definition of Health Concerns
8
High Level Health Concerns
9
• 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
Overview: Risk
10
• 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
Overview: Barrier
11
• Preference• Definition
• How are preferences represented?• Positive vs. negative preferences
• Overview as it relates to care plan exchange and workflow
Overview: Preference
12
• Define how Risks, Barriers and Preferences relate to Health Concerns, map out how to categorize them
• Represented as Health Concerns
• Perhaps represented as negative preferences in model
• Is the opposite of a Risk a “mitigating factor” (in relation to decision support)?
• Discuss how Risks, Barriers and Preferences relate to Goals and Interventions, map out how to categorize them
Points for Discussion
13
Care Plan Workflow
14
Care Plan Relationships
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• Define Goals, Concerns and Interventions, map out how to designate prioritization of each
• Map out how to mitigate irrational choices
For Next Week
Proposed Next Steps
• Schedule Touch Point meeting(s) with PCWG• Update discussion schedule• Finalize LCC’s Comments by August 4, 2013 for
submittal as part of September Ballot
17
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 [email protected]
• Sub Work Group Lead• Russ Leftwich [email protected]
• Program Management• Lynette Elliott [email protected]• Becky Angeles [email protected]