Transcript LCC HL7 Tiger Team 2013-05-08

Longitudinal Coordination of Care
(LCC) Workgroup (WG)
HL7 Tiger Team
Service Oriented Architecture (SOA) Care Coordination Services
(CCS)
May 8, 2013
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Meeting Etiquette
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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
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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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Schedule – May 2013
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
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THURSDAY
FRIDAY
SATURDAY
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11 AM ET:
Overview of HL7
LCC Domain
Analysis Model
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6
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11 AM ET
Discussion: Risks,
Health Concerns,
Barriers
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11 AM ET
Discussion: Risks,
Health Concerns,
Barriers
5 PM ET Tentative
Touch Point with
PCWG
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11 AM ET: Map
out how to
designate/model
Prioritizations
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11 AM ET: Map
out how to assign
Care Team
Members to
prioritizations
Overview: Health Concern
• Health Concern
• Definition
• Overview as it relates to care plan exchange and
workflow
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Care Plan Glossary Definition
of Health Concerns
• 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:
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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)
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High Level Health Concerns
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Overview: Risk
• 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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Overview: Barrier
• 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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Overview: Preference
• Preference
• Definition
• How are preferences represented?
• Positive vs. negative preferences
• Overview as it relates to care plan exchange and
workflow
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Points for Discussion
• 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
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Care Plan Workflow
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Care Plan Relationships
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For Next Week
• Define Goals, Concerns and Interventions, map out how to
designate prioritization of each
• Map out how to mitigate irrational choices
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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
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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