Longitudinal Coordination of Care (LCC) Workgroup (WG)

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

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 • Hold = Elevator Music = frustrated speakers and participants • This meeting is being recorded • 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. • 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. Agenda • Introductions • Goals • Schedule • Debrief on submitted HL7 SOA CCS Ballot comments • Overview of HL7 Patient Care Workgroup Care Plan Domain Analysis Model • Begin discussion to elicit comments for submittal as part of September ballot • Next Steps

4. Goals • 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

5. Schedule – May 2013

6. HL7 Ballot Comments Debrief • Care Coordination Service Comments ballot • Comments aggregated from last 3 weeks TT calls • Submitted to HL7 for ballot close April 29 • Aggregated comments will be posted on wiki for review • Comments to be reviewed by CCS in coming weeks • HL7 CCS project has offered to review with LCC • Target to have normative ballot for functional model Sept 2013 • CCS will have dependency on Care Plan DAM • CCS ballots functional model, not Care Coordination Service

7. PCWG Domain Analysis Model Overview • The Domain Analysis Model (DAM) was created by the HL7 Patient Care WG (PCWG). • The goal of LCC is to review the DAM and provide input from a provider perspective and to harmonize elements that overlap with LCC efforts around care plan exchange and workflow. • Ideally comments will be rolled into the DAM before it goes to ballot in September. • The DAM is illustrated in the following two slides.

8. Domain Analysis Model Plan Structure Overview Plan Structure Overview Top Level Model Structure ** Attributes, some classes and associations hidden for this illustration (Assumes that Instructions are Actions. Master All-care Plan (MAP) that shows the interrelationships is missing) General Definition: A “list of steps with timing and resources, used to achieve an objective. See also strategy. It is commonly understood as a temporal set of intended actions through which one expects to achieve a goal. “ Wikipedia Plan Types: Care Plans, Plans of Care, Treatment Plans ** The abstract plan is a modeling technique to represent shared components. The Model Captures: Who - Patient, Care Team, Family, other Support Individuals... Why – Concerns, Risks and Goals What – Proposed and Implemented Actions, Interventions, Instructions, Outcomes Observations, various types of Reviews When - Effective times, completion times, update times Where –Steward organization, place of service for interventions HL7 Patient Care - Care Plan Initiative

9. Domain Analysis Model

10. Care Plan Workflow Overview • The care plan workflow illustrated in the following four slides is the LCC’s vision of the relationships among care plan components. • Goal is to identify overlap and harmonization opportunities between the DAM and the LCC’s care plan workflow. • This workflow diagram was developed as a collaborative effort by individuals in the LCC Work Group: Larry Garber, MD Terry O’Malley, MD Bill Russell, MD Joanne Lynn, MD Laura Heerman Langford, PhD, RN Russ Leftwich, MD Susan Campbell, PhD, RN Jennie Harvell Sue Mitchell, RHIA

11. Care Plan Workflow

12. Care Plan Relationships

13. Care Team Member Responsibilities

14. Registries and Clinical Support in Patient Centered Medical Home

15. Points for Discussion • Define differences between Risks and Health Concerns, map out how to categorize them • Define Barriers, map out how to categorize them • Define Goals, Concerns and Interventions, map out how to designate prioritization of each • Map out how to mitigate irrational choices (this could fall under Risk discussion, as well) • Map out how to assign Care Team Members to prioritized Goals, Concerns and Interventions • Patient priorities vs. Care Team Member priorities • Align terminologies, definitions and Use Cases between PCWG and LCC

16. For Today’s Discussion • Map out the process for defining Health Concerns • How to determine what is a Risk vs. Health Concern vs. Barrier • For next week: Discussion of Risks (Intrinsic vs. Extrinsic), Health Concerns, Barriers as they relate to LCC’s vision of care plan exchange and workflow

17. 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

18. 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 Gallegoevelyn.gallego@siframework.org • Sub Work Group Lead • Russ Leftwichcmiotn@gmail.com • Program Management • Lynette Elliott lynette.elliott@esacinc.com • Becky Angeles becky.angeles@esacinc.com