Transcript LCC HL7 Tiger Team 2013-05-15

Longitudinal Coordination of Care
(LCC) Workgroup (WG)
HL7 Tiger Team
Service Oriented Architecture (SOA) Care Coordination Services
(CCS)
May 15, 2013
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Meeting Etiquette
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From S&I Framework to Participants:
Hi everyone: remember to keep your phone
on mute 
All Participants
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
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Agenda
• Introductions
• Goals
• Schedule
• Discussion of Cara Plaan’s patient story as a baseline for
representing and prioritizing Risks and Health Concerns
– Ongoing comments can be submitted and viewed on wiki:
• http://wiki.siframework.org/LCC+HL7+Tiger+Team+SWG
• Call scheduled with HL7 Patient Care Work Group to discuss
Risks and Health Concerns
– Wednesday, May 15 at 5pm ET
• Next Steps
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Schedule – May 2013
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
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THURSDAY
FRIDAY
SATURDAY
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3
4
9
10
11
16
17
18
23
24
25
30
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11 AM ET:
Overview of HL7
LCC Domain
Analysis Model
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6
7
8
11 AM ET
Discussion: Risks,
Health Concerns,
Barriers
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13
14
15
11 AM ET
Discussion: Risks,
Health Concerns,
Barriers
5 PM ET Touch
Point with PCWG
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20
21
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11 AM ET:
Discussion:
Preferences and
Prioritizations
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11 AM ET: Map
out how to assign
Care Team
Members to
prioritizations
Work Group Schedules
LCC WG
SWG Meeting
LCC Leads
Date/ Time
Projects
LTPAC SWG Larry Garber
Terry O'Malley
Weekly Mondays, 11-12pm C-CDA: Transfer Summary, Consult Note, Referral Note
EST
LCC HL7 Tiger Russ Leftwich
Team
LCP SWG
Bill Russell
Sue Mitchell
Jennie Harvell
Weekly Wednesdays, 11LCC WG comments for HL7 Care Plan DAM
12pm EST
Weekly Thursdays 11- 12pm C-CDA: Care Plan, HomeHealth Plan of Care
EST
HL7 WG
SWG Meeting
HL7 Patient Care WG
HL7 Lead
Participating LCC
Date/ Time
Members
Susan Campbell
Bi-weekly Weds, 5 Laura H Langford 6pm EST
Lindsey Hoggle
Russ Leftwich
Elaine Ayers
Stephen Chu
Michael Tan
Kevin Coonan
HL7 Structured Documents Bob Dolin
Sue Mitchell
WG
Brett Marquard Jennie Harvell
HL7 SOA WG CCS Project Jon Farmer
Susan Campbell
Enrique
Meneses
(facilitators)
Stephen Chu
HL7 Patient Generated
Leslie Kelly Hall
Document
Projects
Care Plan DAM
Care Coordination Services
(CSS)
Weekly Thursdays,
CDA (various)
10-12pm EST
Weekly Tuesdays 5 - Care Coordination Services
6pm EST
(CSS)
Weekly Fridays, 121pm EST
Patient-authored Clinical
Documents
Discussion Overview
• Use the following patient story as baseline for a more
tangible discussion about Risk, Health Concerns,
Barriers and Preferences with the PCWG
• How best to designate and represent these
considerations in the patient story, 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
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High Level Health Concerns
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Patient Preferences
Directive
Description
8.4
State of Patient preferences for other medically-indicated treatments
8.4.1
Antibiotics
8.4.1.1
Use oral, IM or IV
8.4.1.2
Use oral only
8.4.1.3
Use oral only for symptom relief or comfort
8.4.2
Medications
8.4.2.1
Give any medication that is clinically updated
8.4.2.2
Give medications only for relief of symptoms or comfort
8.4.2.3
Do not administer medications except for pain relief
8.4.3
Transfusions/Any blood product
8.4.4
Hospital Transfer
8.4.4.1
Transfer for any situation requiring hospital-level care
Continued on next slide
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Patient Preferences, cont’d…
Directive
Description
8.4.4.2
Transfer to hospital for severe pain or severe symptoms that cannot be
controlled otherwise
8.4.4.3
Do not transfer to hospital but treat with options available outside hospital
8.4.5
Medical Workup
8.4.5.1
Perform any medical tests indicated to diagnose and/or treat a medical
condition
8.4.5.2
Perform limited medical tests necessary for symptomatic treatment or comfort
8.4.6
Dialysis
8.4.6.1
Give chronic dialysis for end-stage kidney disease if medically indicated
8.4.7
Artificially Administered Fluids and Nutrition
8.4.7.1
Artificially administer fluids and nutrition if medically indicated
8.4.8
Other Orders
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Cara Plaan: A Patient Story
Cara Plaan is a 48 year old woman who recently had a
blood clot in her left leg after a cross country auto trip.
She has been placed on Warfarin, custom fitted
stockings, and advised to not sit for long periods. She
declined an alternative anticoagulant therapy, which was
described to her as effective and safer, but much more
expensive. She is a lactovegetarian. She is a smoker.
There is a history of breast cancer in three female
maternal relatives. She has only recently become
employed after a period of unemployment and does not
currently have health insurance.
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Cara Plaan: Risk 1
• 48 year old woman who recently had a blood clot in her left leg
after a cross country auto trip.
• At increased risk above general population (special population)
• Risk of recurrence of clot as well as embolism—is this
represented as prior history or future risk?
• Intervention: education, instruction
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Cara Plaan: Risk 2
• Placed on Warfarin, custom fitted stockings and advised not to
sit for long periods of time.
• “Extrinsic” risk as defined by current DAM—risk of bleeding
comes from intervention
• Extrinsic vs. intrinsic might not be relative here. Person’s
immobilization reason (airplane vs. bed rest) should not change
classification of risk.
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Cara Plaan: Risk 3
• She declined an alternative anticoagulant therapy, which was
described to her as effective and safer, but much more
expensive.
• Barrier or treatment preference?
• Decision modifiers (factors that weight the logic and choices)
• A barrier or treatment preference that rises to the level of
intervention becomes a health concern
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Cara Plaan: Risk 4
• She is lactovegetarian.
• Implications for medication therapy—is this a health concern?
• Requires a plan, monitoring, special diet,
documentation…appears to be health concern based on action
requirement
• Actions in model include interventions, monitoring, watchful
waiting and therapeutic nihilism
• Preservation of wellness must be planned, so it becomes a
health concern
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Cara Plaan: Risk 5
• She is a smoker.
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Cara Plaan: Risk 6
• There is a history of breast cancer in three female maternal
relatives.
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Cara Plaan: Risk 7
• She has only recently become employed after a period of
unemployment and does not have health insurance.
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For Next Week
• Discussion on Preferences and Prioritizations
• Map out how to designate preferences and
prioritizations
• Determine how to best represent/model preferences
and prioritizations
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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
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]
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Background Slides
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SNOMED IG Definitions
3.4 Observation, Condition, Diagnosis, Concern
NOTE: 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 ]
Continued on next slide
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SNOMED IG Definitions, cont’d…
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).
Continued on next slide
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SNOMED IG Definitions, cont’d…
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.
Continued on next slide
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SNOMED IG Definitions, cont’d…
"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.
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Risks
• 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
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Barriers
• 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
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Preferences
• Preference
• Definition
• How are preferences represented?
• Positive vs. negative preferences
• Overview as it relates to care plan exchange and
workflow
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