Transcript Coordination of Care Service (CCS)

Coordination of Care Service (CCS)
Initial Submission
Contents
Submission Team Members
Coordination of Care
Scope
Symbols
Coordination Of Care Service – Platform Independent Model
Care Team Membership Model
Care Team Permissions Domain Model
Care Team Note Security Model
Care Team Communications Domain Model
Care Plan Domain Model
Care Plan Operations
Care Plan Exchange Model
Reconciliation Domain Model
Reconciliation Operations
Coordination Of Care Services Implementation Considerations
Coordination Of Care Services – PSM For Web Services
Coordination Of Care Services – PSM For CCDA
Coordination Of Care Services – PSM For FHIR
Coordination Of Care Services – PSM For Direct
Submission Team
Anujgopal Sreekanth
Curt Vanriper
Douglas Golub
Dev Nathan Kalyan
Emma Jones
Gunther Meyer
Michael Nelson
Tracey Coleman
Laurie Wissell
THE BIGGER PICTURE
MediSked’s story in Care Coordination
Our Story in Care Coordination
MediSked, LLC was founded in 2003 to help provider agencies support individuals to receive the best possible quality of care,
choice, and do so in a cost effective way. The software and services provided by MediSked, LLC fill a previously unmet need for
individuals receiving long term services and supports. The population focuses around people with intellectual and developmental
disabilities, traumatic brain injury, aged and physically disabled, and children.
Mission: We are dedicated experts, committed to the same goals as those we support.
MediSked’s story in care coordination begins with a passion and understanding for supporting individuals’ health, safety, goals, and
valued outcomes. Through implementation of systems and processes with a person-centered focus, MediSked, LLC became
established as a leading EHR vendor for providers in the long term services and supports space with Connect – Agency Management
Platform.
5
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
5
Our Story in Care Coordination
The advancement of EHR standards and data sharing across medical, specialists, therapists, and long term services and supports
providers enabled MediSked, LLC to provide the first platform for data sharing and business intelligence in the long term services
and supports space with Connect Exchange – Multi-Agency Business Intelligence Platform.
The next frontier in Care Coordination involves systems for care management, centered around the person, with focus on care teams
and payer entities. MediSked’s Coordinate – Care Management Platform provides full care coordination capabilities and portal
functionality to those care teams and individuals receiving long term services and supports. Conventional standards that focus
around problems and issues with the person require a different perspective and architecture in the long term services and supports
space. People’s disabilities are life-long, ever changing, and part of a meaningful life – not a problem. MediSked’s position in Care
Coordination fills an unmet need in this space and offers a unique perspective to best support this population of individuals.
6
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
6
Systems and Capabilities
MediSked
Assess
Assessment
Tools
Care
Coordinat
ion
Platform
PersonCentered,
Provider and
Circle of
Supports
Portals
Provider Electronic
Health Records
Message Routing
and Data
Warehouse
Admin, Reporting
& Business
Intelligence User
Interface
HIEs & RHIOs
Administrative
and State
Oversight
DME Vendor(s)
Pharmacy Benefits
Manager (PBM)
7
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
7
OMG CCCS Submitter Standards
MediSked’s membership in OMG and submission and adherence to care coordination service standards
stems from a commitment to long term services and supports. As this space suffers from a lack of
standards, the transition to managed care and care coordination presents a strategically important
opportunity for MediSked, LLC to be on the cutting edge of standards and software functionality
readiness. It helps set the stage for standards in our segment of the industry.
•
Care team membership
•
•
Care team permissions
Care team communications
•
•
Care plan
Reconciliation (goals, interventions, health concerns, outcomes, problems medications, medication
allergies)
8
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
8
Meet Evan…
Evan is an adult with an
intellectual disability who would
like to be more independent
The Care Team’s Goal: Assist Evan in living
more independently and help him find a
job
Pertinent Data in Portal: Assessments and
plans detailing Evan’s job skills,
independent living skills, communication
skills, and travel skills – along with the
forms and documents needed for a
successful job search
Outcomes Improved by Data:
Evan’s job coach is able to help him
identify and apply for employment
opportunities tailored to his strengths, Evan
sets and works on goals that will help him
achieve more independence so that
eventually he can move into his own
apartment
9
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
9
Meet Mary…
Mary is an elderly individual who
needs guardianship
The Care Team’s Goal: Support
Mary with successful housing and
health outcomes
Pertinent Data in Portal: Mary’s
heath history, circle of supports, and
plans detailing Mary’s needs
Outcomes Improved by Data:
Finding housing options (assisted
living) to meet Mary’s needs,
ensuring visits to her primary care
physician, and
successfully supporting Mary in
achieving her health goals
10
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
10
THE BIGGER PICTURE
Allscripts CareInMotion
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
11
CARE
COORDINATION
ANALYTICS
•
•
•
•
Manage cost
Identifies and stratifies
Clinical outcomes
Financial results
•
•
•
Managing utilization
ACO success
Preventative/ Chronic
Care
•
Engage patients
•
Better outcomes
•
Manage every
patient continuously
CareInMotion
PLATFORM
•
•
•
Accurate patient data
Exchange
Aggregate
CONNECTIVITY &
DATA AGGREGATION
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
PATIENT
ENGAGEMENT
12
Allscripts Strategy
Community
Aware EHR
Population Health
Management
PHARMACY
HOSPITAL &
HEALTH SYSTEMS
POST ACUTE
CARE
COORDINATION
ANALYTICS
Allscripts Community Architecture
SPECIALIST
PHYSICIAN
PRACTICE
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
Precision Medicine /
Consumer Solutions
CLINICAL
OMICS
CareInMotion
MOBILITY AND
WEARABLES
Precision Medicine/
Consumer Solutions
PLATFORM
INTELLIGENT
INTERVENTION
CONNECTIVITY &
DATA AGGREGATION
PATIENT
ENGAGEMENT
RESEARCH
13
Collaborative Care delivers the right capabilities for tackling
chronic/complex patients
See
Plan
Execute
Deliver visibility into relevant
clinical information
Develop and manage goforward plan and team for
cohorts of patients
Collaborate across the entire
care team
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
14
Care Coordination = Care Teaming
Care Coordination is inherently a teaming challenge; high value organizations enable
care teams to flexibly and effectively collaborate on a common care path
“High-value health care organizations
deliberately design microsystems —
including staff, information and clinical
technology, physical space, business
processes, and policies and procedures
that support patient care — to match
their defined subpopulations and
pathways.”
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
“The first principle in structuring any
organization or business is to organize
around the customer and the need. In
health care, that requires a shift from
today’s silo-ed organization by specialty
department and discrete service to
organizing around the patient’s medical
condition.”
15
Addressing the core unmet need means delivering a network
solution, not an EMR centric solution
Relationship multiplicity and integration requirements with
EMR solution prohibit scalability in reaching care team
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
Network solution reaches every possible care team
member, monetizing richness of access
16
Execute across the healthcare continuum
Ambulatory
Acute
Post Acute
Community
Consumer
Physician Practices
Clinics
…
Hospitals
Health Systems
…
Home Health
Long-Term Care
Hospice
Private Duty
…
Pharmacies
Labs
Specialists
In- and out-of-network
physicians
YMCA’s
…
Patient Engagement
Technologies
Portals
Wearable Tech
Personalized Medicine
…
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
17
Beth, 71 years old
Collaborative Care Tomorrow
• T2DM
• Hip breaking down, needs replacement
Care Team : 10+ Providers
Clinical Data
Plan of Care
Community
Health
Providers
Plan of Care
Rehab
DME
Community Portal
Access
Home
Health
Specialists &
Hospital
Endocrinologist
PCP + Care
Navigator
Access at the point
of care (CC Agent)
Hip & Knee
Surgery
Wound
Care
Single
Care Plan
•
Patient
Patient Portal Access
Dietician
•
•
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
Coordinating care around a common
patient history AND a common
understanding of roles and responsibilities
Easy to create sub-care teams for specific
care plan segments
Easy to engage peripheral/community
providers & the patient’s family
18
Coordination of Care Functions
Coordination of Care – Functional Capabilities
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
20
Coordination of Care
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
21
Scope
Specifications for Web services based on:
• Platform-Independent Model (PIM) And
• Platform-Specific Model (PSM)
This defines the capabilities and interfaces for Coordination of Care Services.
These models fulfill the requirements specified in the normative sections of the
HL7 ‘Coordination of Care’ Service Function Model while improving the
simplicity and functional completeness of the service interface.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
22
Symbols
Diagrams are developed using the
UML 2.0 standard, so please refer to
UML documentation for details on the
symbols used.
Symbol Description
HER
Electronic Health Record
PCP
UI
Primary Care provider
Family Doctor
User Interface
GUI
Graphical User Interface
CDS
Clinical Decision Support
WSDL
Web Service Definition Language
TLS
Transport Layer Security
Successor to SSL or https
Consolidated CDA (Clinical Document Architecture)
A consolidation of various CDA templates and implementation guides that had been
developed by various organizations
CCDA
HL7
IHE
FHIR
PIX
XDS.b
HPD
eMPI
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
Health Level-7
Standards body for Healthcare standards
Integrating the Healthcare Enterprise
Standards body for Healthcare standards
Fast Healthcare Interoperability Resources
Patient Identifier Cross-Referencing
An IHE standard for matching patient identifiers
Cross-Enterprise Document Sharing
An IHE standard for managing the sharing of documents
Healthcare Provider Directory
An IHE standard for supporting the management of healthcare provider information,
both individual and organizational, in a directory structure
enterprise master patient index
An enterprise wide system that links patient information from various systems together
23
Coordination of care service – Platform Independent Model
cmp Care Plan Exchange Components
There are a number of services that enable the
management of Care Team, Communication
between participant and the exchange of Care
Plans.
There is also a fine grained Care Plan service
through which any element of a Care plan can be
updated. Support for this is optional for the EHRs.
«Contributing System»
Acture EHR
Connectivity for one EHR
is shown here
«Contributing System»
Ambulatory EHR
«Contributing System»
Other clinical system
«Contributing System»
Post-Acuste EHR
«interface»
CarePlan Serv ices
(Optional)
(Optional)
(Optional)
(Optional)
«interface»
CarePlan Serv ices
«interface»
CarePlanExchange
Serv ices
«interface»
CareTeamMembership
Serv ices
«interface»
CareTeamPermission
Serv ices
«interface»
CareTeamCommunications
Serv ices
«interface»
Reconciliation Serv ices
«In the cloud»
Care Coordination Hub
Finally, there is a reconciliation service that performs
reconciliation. It is stateless and can be leveraged
by an participating EHR.
«In the cloud»
Care Coordination
Application
Legend
Required
(Dotted) Optional
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
24
Coordination of care service – Platform Independent Model
class Care Management - High Lev el
CareTeamPermissions
-
MembershipType :MembershipTypeEnum
1
CareTeam
-
The following model provides an overview of the
main objects of the domain models
Relationships between the main models are
described in this PIM
ActivePeriod :Period
Identifiers :Identifier[1..*]
1
LastModifiedDate :DateTime
Name :string
0..*
CareTeamParticipant
+Participant
0..* -
ActivePeriod :Period
Id :Identifier
ParticipantType :CodeableConcept
1
+Patient
Patient
0..*
0..1
CareTeamNote
Please note that this model is not complete. Once the Care
Plan PIM is completed this diagram will be updated
+Patient
-
1
Active :boolean
ID :Identifier
LastTimeModified :DateTime
Subject :string
0..*
Care Plan
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
25
Care Team Membership Model
class Care Team Membership model
CareTeamParticipationStatus
-
AcceptanceStatus :AcceptanceStatusEnum
1
CareTeam
The Care Team object represents the root of the
Care Team.
-
ActivePeriod :Period
Identifiers :Identifier[1..*]
1
LastModifiedDate :DateTime
Name :string
+Participant
0..* -
CareTeamParticipant
+Members
ActivePeriod :Period
0..*
Id :Identifier
ParticipantType :CodeableConcept
0..*
0..*
1
The Care Team contains all the Care Team
Members that participate in the care of the
Patient.
CareTeamMember
-
PrimaryContactMethod :int
+ForwardedTo
0..*
Constraint: The
DomainResource must
be one of the following
types
A Care Team is always about a particular
patient, so patient is a required attribute
Practitioner
Organization
Patient
+Patient
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
0..1
RelatedPerson
Group
+SubjectGroup
0..1
26
Care Team Membership Operations
Care Team Invitation workflow
Add Care Team Members
act Care Team Membership Inv itation
act Add Care Team Member
Initial
Please see the following
diagram for more detail
Search
Does the CareTeam Member exist?
Lookup Cate Team member
using the
FindCareTeamMember
Operation
Start
[No]
Add Care Team Member
Care Team Member
must have a primary
contact method
:CareTeamMember
Start
Retriev e / Find prospectiv e
CareTeamMember in the
local system, Prov ider
Directory or Patient Directory
Inv ite a CareTeamParticipant and set
status as prov isional using the
Inv iteCareTeamParticipant operation
:CareTeamParticipant
Send an inv itation to the
CareTeamMember v ia their
preferred contact method
:CareTeamParticipationStatus
See the
Accept,
Reject or
Forward
swimlanes
Not Found
[Not Found]
:CareTeamParticipant
Member found?
Invitation contains links
for

Accept

Reject

Forward
Accept
User signals acceptance
Lookup CareTeamMembers
that match this
CareTeamMember search
obj ect using the
FindCareTeamMember
operation
Populate the Provider,
Patient, Organization,
Related Person based on
the information you
looked up
[Yes]
:CareTeamMember
SearchoObj ect :
CareTeamMember
Add the CareTeamMember
as a new obj ect
Mark Status as Accepted
Not Found
Final
End Accept
Via link.
Link contains reference
to the
CareTeamParticipant
Reject
Found
Mark Status as Rej ected
User signals rej ection
:CareTeamParticipant
Via link.
Link contains reference
to the
CareTeamParticipant
End Reject
Forward
User signals forw ard
:CareTeamParticipant
Mark Status as Forw arded
Care Team Member Inv itation
(This Activ ity Diagram)f or a
the member(s) that you
forw ard to
Update the appropriate
[Found] fields. This should at least
be the identifier in your
system. Might be other
fields
Update the eMPI, if
appropriate (Done by the
CCC Serv ice)
Found Final
Via link.
Link contains reference
to the
CareTeamParticipant
:CareTeamMember
:CareTeamMember
Associate the members to
the current participant
End Forward
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
27
Care Team permissions domain model
class Care Team Permissions Model
CareTeam
-
Identifiers :Identifier[1..*]
LastModifiedDate :DateTime 1
CareTeamParticipant
+Participant
0..* -
ActivePeriod :Period
Id :Identifier
ParticipantType :CodeableConcept
1
A Participant is assigned one and only one Role.
0..*
-
Active :boolean
ID :Identifier
LastTimeModified :DateTime
Subject :string
SecurityRole
0..*
+RequiredRoles
ID :Identifier
Name :string
Predefined :bool
1
1
Each time they participate they are assigned a different
Security Role.
0..*
CareTeamNoteSecurityLev el
-
While this may seem restrictive, keep in mind that a Care
Team Member can participate in a Care Team as multiple
participants.
1
CareTeamNote
SecurityPersmission
CareTeamNoteType :CareTeamNoteTypeEnum
ID :Identifier
Predefined :boolean
-
Granted :boolean
ID :Identifier
The participant will only be able to see
ProfessionalNotes if they are granted the
permission to the
ViewProfessionalCareTeamNote activity
1
SecurityActiv ity
-
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
+DeniedActivities
ActivityType :ActivityTypeEnum
ID :Identifier
28
Care Team communication security model
Each Care Team Note is associated with a Security Level. Examples of security levels could be

General Note - Entire care team can access this note

Professional Care Team Note - All care team members Care Team members with Professional roles can access this note but
no others
Each Security Level is associated with multiple roles.
The logic is the following when determining access to a Note for a Participant.

Lookup the roles of the Participant

Lookup the roles required for the Security Level

Perform an intersection
o
If the intersection is not empty, then the participant has access to the Note.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
29
Care Team Communications domain model
class Care Team Communication model
CareTeam
-
CareTeamNote
ActivePeriod :Period
Identifiers :Identifier[1..*]
1
LastModifiedDate :DateTime
Name :string
0..* +SubjectsToIgnore 0..*
Active :boolean
ID :Identifier
LastTimeModified :DateTime
Subject :string
1
Subject is unique across
all notes associated with
the Care Team
0..*
+Participant
0..*
CareTeamParticipant
-
CareTeamNoteComment
-
+ParticipantsToIgnoe
ActivePeriod :Period
0..*
Id :Identifier
ParticipantType :CodeableConcept
Active :boolean
DataCreated :DataTime
FormatAsHTML :boolean
NoteTexr :string
+Associated Information
0..*
ReferenceInformation
1
CareTeamNoteNotificationIgnoreRules
-
ID :Identifier
DocumentReference
ClinicalReference
-
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
reference :Reference
-
reference :Reference
30
Care Plan Domain model
class Care Plan
+RelatedGoals
0..*
1
GoalRev iew
Goal
0..*
Outcome
0..* Barrier
ActivePeriod :Period
Code :int
Confidence :ConfidenceEnum
DeferredUntil :int
HCPPriority :PriorityEnum
Name :int
0..*
PatientPriority :PriorityEnum
State :GoalStateEnum
DeferredReason
0..*
-
GoalMilestone
State :StateEnum
-
ProgessFreeText :string
ProgressPercentage :bool
Time :DateTime
1
0..*
+WhenAchieved
GoalEv aluation
1 -
1..*
0..*
Code :int
DateTime :DateTime
FreeText :string
MeasurementPeriod :Period
Modifier :ModifierType
Strategy
+ContainedCarePlans (Proposed)
0..*
1
Patient
-
Notes :string
Care Plan
+Patient
ActivePeriod :string
-
Interv entionRev iew
1..*
1
-
0..*
ReviewDate :DateTime
Interv ention
HealthConcern set?
-
0..*
CDS rules?
HealthConcern
-
ActivePeriod :Period
0..*
Code :int
FreeText :string
Status :StatusEnum
ActivePeriod :Period
AssociatedItemStatus :StatusEnum
Code :int
FreeText :string
Frequency :Period
HoldReviewDate :Date
PlannedReviewDate :DateTime
Reocurance :Period?
Status :StausEnum
Interv entionEv aluation
-
Code :int
FreeText :string
FutureDate :DateTime
+RelatedInterventions
Activ ity
CareteamInterv entionRelationship
Has task like
attributes
-
CareTeamMembertType/Role
OwneshiprPeriod :Period
CareTeamParticipant
-
ActivePeriod :Period
Id :Identifier
ParticipantType :CodeableConcept
0..*
Problem
Instruction
0..*
Medication
0..*
Order
ClinicalReference
-
reference :Reference
FamilyHistory
SocialHistory
PastSurgicalHistory
PastMedicalHistory
MedicationAdministration
Result
Observ ation
e.g. a finding
Can be a Document
Reference
If the HealthConcern is a
problem, link to the
same orders and
medications as the
Problem
Legend
Clinical Element part of encounter or clinical information
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
31
Care Plan Domain Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
32
Care Plan Review model
class Care Plan Rev iew
CarePlanRev iew
1
ReviewDate :DateTime
1
HealthConcernRev iew
-
-
1
Care Team::CareTeamParticipant
0..*
+Reviewers
ReviewDate :DateTime
1..* -
0..*
ActivePeriod :Period
Id :Identifier
ParticipantType :CodeableConcept
0..*
0..*
0..*
HealthConcern
-
1..* 0..* -
Care Plan
ActivePeriod :Period
Code :int
0..*
FreeText :string
Status :StatusEnum
-
Status :StatusEnum
1..*
Goal
ActivePeriod :Period
Code :int
Confidence :ConfidenceEnum
DeferredUntil :int
HCPPriority :PriorityEnum
Name :int
PatientPriority :PriorityEnum
State :GoalStateEnum
Interv ention
-
ActivePeriod :Period
AssociatedItemStatus :StatusEnum 0..*
Code :int
FreeText :string
Frequency :Period
HoldReviewDate :Date
PlannedReviewDate :DateTime
Reocurance :Period?
Status :StausEnum
0..*
0..*
GoalRev iew
-
ReviewDate :DateTime
Not all interventions
would be linked to an
outcome
0..*
0..*
-
1..*
Outcome
Interv entionRev iew
-
ReviewDate :DateTime
DateRecorded :DateTime
Met :bool
ProgressTowardGoal :percentage
0..*
Interv entionEv aluation
-
GoalEv aluation
Code :int
FreeText :string
FutureDate :DateTime
-
Observ ation
Code :int
DateTime :DateTime
FreeText :string
MeasurementPeriod :Period
Modifier :ModifierType
Not all Observations will
be linked to an
intervention or a goal
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
33
Care Plan Exchange Model
cmp Care Plan Exchange Components
act Care Plan Exchange
Contri buti ng System A
CareManager i n the Cl oud
CareManagement Appl i cati on
Contri buti ng System B
«Contributing System»
Acture EHR
Start
Connectivity for one EHR
is shown here
Clinical and/or Care plan information is
captured in the EHR (Acute, Post-Acute or
Ambulatory).
«Contributing System»
Ambulatory EHR
«Contributing System»
Other clinical system
Information entered is marked as
complete and ready to be shared
«Contributing System»
Post-Acuste EHR
Information is compiled (e.g. CCDA
doc)
«interface»
CarePlan Serv ices
(Optional)
(Optional)
(Optional)
Find the Patient Identfier
MatchingCriteria :
Patient
Patient Matching
(Optional)
Patient and Identity
Management
:Identifier
«interface»
CarePlan Serv ices
Share the compiled
information
Receiv e the Information
«interface»
CarePlanExchange
Serv ices
«interface»
CareTeamMembership
Serv ices
«interface»
CareTeamPermission
Serv ices
«interface»
CareTeamCommunications
Serv ices
«interface»
Reconciliation Serv ices
Store the document
«In the cloud»
Care Coordination Hub
Extract the information
Local and external
items
Technical Reconciliation
Local only, external only,
similar, exact match
Reconciliation is
performed for every
clinical item, e.g.
medication and every
care plan item, e.g. goals
Clinical reconciliation
Update, Add or Delete
ClinicalItem
Consolidate the Information
(e.g. CCDA document w ith
Consolidated Care Plan)
«Optional»
Care Manager makes
changes to the Care Plan
This step illustrated other
actors updating the Care
Plan
«Optional»
Consolidate the Information
(e.g. CCDA document w ith
Consolidated Care Plan)
«In the cloud»
Care Coordination
Application
Notification of update
:Care Plan
Notification of update
Notify User
User v iew s the CarePlan
(e.g. as a document)
«Optional»
If discrete information is
av ailable. Incorporate the
information
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
Legend
Required
(Dotted) Optional
34
The following is an example of the structure of a reconciliation result
Reconciliation Domain Model
class Reconciliation
+LocalUnique
0..*
ReferenceInformation
ReconciliationResult
-
+ExternalUnique
Errors :string[]
0..* -
0..*
Goal
ClinicalReference
reference :Reference
1
1
+Identical
+LocalObject
+ExternalObject
+Similar
SimilarObj ect
0..*
SimilarAttribute
+SimilarAttributes 0..* -
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
AttributeName :string
ExternalValueFormattedString :string
LocalValueFormattedString :string
Attribute reference is
implicit via the Attribute
Name
Reconciliation-Result
|
|-- Source Unique (Type List<Medication>
|
|-- External Unique (Type List<Medication>
|
|-- Identical (Type List<Medication>
|
|--Similar (Type List<SimilarObject>
|
…
|
First SimilarObject
|
|--Source object (Type Object<Medication>
|
|--External object (Type Object<Medication>
|
|-- Similar attributes (Type
List<SimilarAttributes>
|
…
|
First SimilarAttribute
|
|--LocalValueFormattedString
(string)
|
|-ExternalValueFormattedString (string)
|
|--AttributeName (string)
35
Reconciliation Operations
The Reconciliation UI (Clinical Reconciliation) allows the user to make decisions as to what changes to apply back to the local system,
e.g. Add, Modify, Delete. It is important to understand that these should be the final decisions and input from the user, and that
another reconciliation should not happen in the local system.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
36
Template & Tagging
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
37
Coordination Of Care Services Implementation Considerations
•
•
•
•
•
Security
Sharing of information
Clinical Decision Support
Identifiers
Screen Sharing and Collaborative Review and Editing
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
38
Coordination Of Care Services
– Platform Specific Model For Web Services
AcceptInvitation
We see this being implemented typically as a URL, not a SOAP service endpoint. In
other words the Prospective Participant can click on a link to signal their response
RejectInvitation
We see this being implemented typically as a URL, not a SOAP service endpoint. In
other words the Prospective Participant can click on a link to signal their response
ForwardInvitation
We see this being implemented typically as a URL, not a SOAP service endpoint. In
other words the Prospective Participant can click on a link to signal their response
MatchPatient
Not required if PIX is supported
ShareCarePlan (Document)
Not Required if XDS.b is supported
A PSM model for Web Services will be supported for all services, with these exceptions above
Conformance criteria – Security
• TLS
• WS-Security
• WS-Federation
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
39
Coordination Of Care Services
– Platform Specific Model For CCDA
This section WILL describe how the Care Plan model described previously maps into a CCDA document.
Client applications that use the AddCarePlanDocument operation need to make sure that this mapping is
followed correctly.
This mapping will be provided for a later submission once the PIM is stable. Changes to HL7 CCDA
Care Plan may be suggested at the same time.
Conformance criteria – Identifiers and Provenance
Identifiers and provenance information for all data elements that are shared should be provided.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
40
Coordination of Care Services
-Platform Specific Model for FHIR
Will be provided for a later submission once the PIM is stable.
The goal with this standard is definitely to support FHIR, since we feel that this is a standard that is gaining a lot
of traction in the Healthcare industry. However, FHIR, and especially the Care Team and Care Plan FHIR
resources are immature. We will track FHIR closely and make a decision whether we will support FHIR for the
version 1.0 final submission later.
Because we see that FHIR is a REST-full implementation, we are not, at this point, planning to provide a specific
REST implementation as part of this standard. We might change our opinion later, if FHIR adaption lags or if
FHIR fails to meet it’s promises. But at this time developing another RESTful PSM does not make sense to the
authors.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
41
Coordination of Care Services
- Platform Specific Model for IHE
We are expecting the following IHE profiles to be used by this standard
• PIX
• XDS.b
• HPD
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
42
Coordination Of Care Services
– Platform Specific Model For Direct
We are expecting the following Direct profiles to be used by this standard
• DirectMessaging
• DirectText
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
43
THANK YOU
Care Team Membership Operations
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
45
USE CASE Walkthrough
Introduction to the Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
47
Structure
•
•
•
•
•
PIM
•
Classes with Attributes
e.g. CareTeamParticipant
•
Operations
•
e.g. InviteCareTeamParticipant
•
PSM SOA / Web Services
Operations grouped into Services
•
e.g. CareTeamMembershipService
•
Classes are used as parameters
•
PSM CCDA
CarePlan and CareTeam classes map to CCDA
•
PSM REST (FHIR)
Classes become resources
•
Operations and resource operations or extended operations
•
PSM IHE
Some operations will map to IHE
•
e.g. XDS.b
•
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
48
Pre-requisites
•
•
•
•
•
•
EHRs are registered with the Care Coordination Hub
PIM
• N/A
PSM SOA / Web Services
• Service identities setup
• Certificates exchanged
PSM CCDA
• N/A
PSM REST (FHIR)
• EHRs and Applications have been registered with the Care Coordination Hub
PSM IHE
• Certificates exchanged
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
49
Coordination of Care – Use Case
UC ID / Name
UC3 – Multiple problems / Health concerns that require care coordination assistance
Description
A PCP identifies multiple problems that need management by multiple specialties- maybe within the organization but
also outside of the organization. Some are medical related and some are not (i.e. financial, social, mental, etc.). Care
coordination is needed to prevent falling through the cracks.
Actor(s)
Triggers
Assumptions
Preconditions
Post-conditions
Patient, PCP, specialty providers, nurse, social work, care coordinator
Referral order(s) entered in the system
All involved parties have ability to register as a care team member for this patient
Workflow
Scenario
Care Team Members (i.e. Healthcare Providers as well as Non-Healthcare Providers) will be provided with a Care
Plan
Care Team Members (i.e. Healthcare Providers as well as Non-Healthcare Providers) will have access to a multidisciplinary Care Plan
1.
Provider sees patient (for whatever reason at whatever facility type)
2.
Provider Determines patient needs to be admitted to acute care/ hospital
3.
Care Coordinator notified of patient admit to begin the Care Coordination process
4.
Discharge planning include multiple referrals – inpatient rehab, eventual home care
5.
Social worker speaks with the patient and learns of other health concerns
6.
Care Coordinator contacted to coordinate the referrals and address the patient’s health concerns (incl. nonmedical related).
Note: Adding a care team
Miss Everyman had a surgical procedure done approximately two weeks ago. She is complaining of a fever, and has
noticed the wound site is red and hot. Mrs. Everyman is seen by her PCP who determines she needs to be admitted to
the hospital.
The Care Coordinator is notified of Mrs. Everyman’s admittance and begins the care coordination process. The social
worker conducts an interview with Miss Everyman. During the interview process, the social worker learns Miss
Everyman was diagnosed with chronic depression prior to her surgical procedure, and the complications from surgery
have made her less motivated to participate in her care. She is a single parent with no income, and transportation
who is having difficulty managing the complications from surgery.
When the patient is ready to be discharged, she receives a referral to an orthopaedic surgeon (specialist) for followup care, a referral to home health nursing (wound care), and physical therapy (PT). A Care Plan is initiated.
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
50
Use Case Assumptions
• The EHRs (Ambulatory, Acute and Post Acute) have all been
registered
• The following are members of the Care Team already
• Surgeon
• PCP
• Hospital
• Care Coordinator
• The patient is an existing patient with the following
• Surgeon
• PCP
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
51
Step 1: Surgeon sees the patient
The following are Captured in the Surgeon's EHR
•Encounter
•Procedure
•Instruction
Note
•The surgeon does not capture a care plan
•The base clinical items (e.g. CCDA items) are part of the PIM
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
52
Step 2: Surgeon exchanges information with Care
Coordination Hub
• This could happen when the encounter note is signed
• CCDA document is produced
• [PIM] Invoke MatchPatient operation on the Care Coordination Hub
• [PSM IHE] PIX/PDQ
• [PIM] Invoke ShareCarePlan operation on the Care Coordination
Hub
• [PSM IHE] XDS.b
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
53
Step 3: The information is incorporated into the Care
Coordination Hub
• "Parsing" of the CCDA document
• Technical Reconciliation
• Clinical Reconciliation
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
54
Reconciliation Overview
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
55
Technical Reconciliation
• Uses the Terminology Service to expand the input data
• E.g. For Medication, determine the brand and the ingredients
• Uses rules to determine how similar items are
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
56
Reconciliation Domain Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
57
Reconciliation User
Interface
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
58
Reconciliation Result
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
59
Step 4: The new information is shared
• Consolidate the Information
• Produce a new CCDA document (Consolidated Care Plan)
• Share Consolidated Care Plan with the Care Team Member's EHRs
• [PIM] ConsolidatedCarePlanChangeNotification
• [PIM] RetrieveConsolidatedCarePlan
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
60
Step 5: Patient sees the PCP
• PCP can see the surgery information via the new Consolidated Care
Plan that was Shared
• PCP Captures
• Problems
• Fever
• Wound condition
• Intervention
• Send patient to Hospital
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
61
Step 6: PCP Transitions the Patient to the Hospital
• Please note, there are referral Use Cases here that we will not go
into at this time
•
• PCP shares the Care Plan with the Care Coordination Hub
• [PIM] Invoke MatchPatient operation on the Care Coordination Hub
• [PSM SOA] Part of the CareplanExchangeService
• [PIM] Invoke ShareCarePlan operation on the Care Coordination
Hub
• [PSM SOA] Part of the CareplanExchangeService
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
62
Step 7: Patient Is admitted to the Hospital
Same as before, the encounter is shared with the Care Coordination
Hub
We are not going to go into detail here, but we assume that the
relevant clinical information is shared from the Acute or ED EHR as
appropriate, using the [PIM] ShareCarePlan described previously
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
63
Step 8: Care Team Membership
• The Care Coordinator adds a Social Worker to the Care Team
• The Social worker is not part of the Care Team
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
64
Care Team Membership
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
65
Step 8: Care Team Membership (Continued)
• Determine that there is not social Worker on the Care Team
• [PIM] FindCareTeam
• PatientID is the parameter, returns CareTeam
• [PIM] GetCareTeam
• Identifier of the CareTeam
• Find the Social Worker
• Can be in
• Care Coordination Hub
• HPD
• Local EHR
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
66
Step 8: Care Team Membership (Continued)
• [PIM] FindCareTeamMember
• Search criteria are pre-populated
• (CareTeamMember is not part of the CC Hub)
• [PIM] InviteCareTeamMember
• [PSM] will typically be via email
• [PIM] AcceptMembershipInvitation (Social Worker)
• [PSM] will typically a URL indicating their acceptance
• CC Hub will ask the user to create credentials
• Single Signon can be used
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
67
Step 8: Care Team Membership (Continued)
• Invite the Social Worker to the Care Team
• [PIM] InviteCareTeamParticipant
• [PSM] will typically be via email
• [PIM] AcceptParticipantInvitation (Social Worker)
• [PSM] will typically a URL indicating their acceptance
• A CareTeamParticipant object will be created
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
68
Step 9: Care Coordinator uses Care Team Communication in the
Care Coordination Hub to communicate with the social worker
• [PIM] AddCareTeamNote (Care Coordinator)
• [PIM] FindNote (Social Worker in their EHR)
• Note that this can be used for Notifications as well via poling
• OR
• [PIM] CareTeamNoteUpdateNotification
• [PIM] AddCareTeamNoteComment
• Note: At this point the Care Cordinator can also create an activity
for the Social Worker to see the patient
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
69
Care Team Communication
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
70
Step 10: Social Worker meets with Patient
• Social Worker meets with Patient and determines the following
• Health Concern: Clinical Depression
• Health Concern: Single parent, no income, no transportation
• Same as before, the encounter is shared with the Care Coordination
Hub and all participant notified of the changes
• We are not going to go into detail here, but we assume that the
relevant clinical information is shared from the Acute or ED EHR as
appropriate, using the [PIM] ShareCarePlan described previously
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
71
Step 11: Care Coordinator gets the patient ready to be
discharged
•
•
•
•
•
•
•
[PIM] CreateCarePlan
Intervention: Follow up Care with Orthopedic Surgeon
Intervention: Referral to Home Health
Intervention: Physical Therapy
Goal: Patient is Ambulatory
Goal: Patient can take care of wound
Goal: Wound is healed
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
72
Care Plan
Domain
Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
73
Health Concern Domain Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
74
Step 12: Review
A week later, the Care Coordinator schedules a review. During the review it
becomes apparent that the patient is not going to PT
• The review can take place in a “Virtual Huddle Room”
• No specific technologies are proposed. The submitters feel that existing
conferencing and screen sharing technologies are sufficient for the first
release
• Simultaneous editing by multiple participants will be taken up in a
future release of the standard if there is demand for it.
• During the review, all goals, interventions and health concerns are
evaluated, outcomes are noted
• New goals and interventions can be added
• The review is only complete if every item has been reviewed
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
75
Care Plan Review
Domain Model
Copyright © 2016 Allscripts Healthcare Solutions, Inc.
76