Longitudinal Coordination of Care (LCC) Workgroup (WG)HL7 Tiger Team Service Oriented Architecture (SOA) Care Coordination Services (CCS)

May 29, 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

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• 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

Agenda

• Introductions

• Goals

• Schedule

• Discussion of patient story as a baseline for representing and prioritizing Goals, Outcomes and Assessments

– Ongoing comments can be submitted and viewed on wiki:

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

• Next Steps

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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 Touch Point with PCWG

19 20 21 22 23 24 2511 AM ET:

Discussion: Goals, Outcomes and Assessments

26 27 28 29 30 3111 AM ET:

Discussion cont’d Goals, Outcomes and Assessments

Schedule – June 2013SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

2 3 4 5 6 7 8

11 AM ET: Discussion

Prioritization

9 10 11 12 13 14 1511 AM ET

Discussion TBD

16 17 18 19 20 21 2211 AM ET

Discussion TBD

23 24 25 26 27 28 2911 AM ET:

Discussion TBD

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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 Thursdays 11- 12pm EST (through May 30)Weekly Thursdays 5-6pm EST starting June 6

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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• Discuss Goals, Outcomes and Assessments• How best to designate and represent these

considerations, 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

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Care Plan Glossary Definitions

• Goals• A defined outcome or condition to be achieved in the

process of patient care. Includes patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes.

• Suggest changing “condition” to “status”• Outcomes

• Status, at one or more points in time in the future, related to established care plan goals.

• Needs to be measurable• Assessments

• (Not currently defined in Care Plan Glossary)

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• Goalso Types of goals

Computable Behavioral Overarching Absolute preferences

o Proponent of a goal (who proposed the goal)o Supports full disclosure, transparency and aligns with MU

(CDS)o Agreement/acceptance of goalo Suggest rewriting as “agreement to the goal statement” and

clinician documents by what means the agreement has occurred Care team members Patient

o Prioritizationo Links to care team members/accountability

Goals

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• Outcomeso Intermediate outcomes/statuso Desired outcomes

Outcomes

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• Assessmento Observation/monitoringo Status/progresso Goal review

Goal vs. desired outcomeo Goal update

Acceptance

Assessment

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• Discussion on Prioritizations• Map out how to designate prioritizations• Determine how to best represent/model prioritizations

For Next Week

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

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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

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Background Slides

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3.4 Observation, Condition, Diagnosis, ConcernNOTE: 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

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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

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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

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"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…