Care Team Management

Dynamic Care Team Management (DCTM) Profile

• Meeting every other Monday 4:00 – 5:00 pm EST (first meeting Dec 5th, 2017)
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Updated DCTM profile materials are located at IHE PCC FTP Site

Volume 1 Call #1 - Dec 5th, 2016

• Addendees*
  • Emma Jones
  • George Cole
  • Lisa Nelson
  • Chris Melo

• Changed the colors on the CareTeamFlow_chronicCOndition vsd diagram to match the chronic condition story board care team summarization analysis - see [1]here for these documents
• Ideally there should be Sub care teams with an overall team. Need to support - see submitted FHIR Change request with supporting documentation - 11342 [2]
  • Condition-focused team may span multiple episodes
  • Need to have care team referencing other care teams - gforge item submitted to support this.
  • Need to have the same structure as care plan
  • Need Care team relationship
  • Share care team is a view that would make up a representative of the overarching care team for the patient and will be able to get at a shared care team structure.
  • Will be able to get to the sub teams from the care plan.
• Should we pick one from the green set and one from the yellow set? - see slide 3 of [here]
• Need some use cases - encode the rules by picking one from the green list and one from the yellow list.
• Lisa: main use case is to be able to take people off a team when the provider is no longer providing care- if need to ask the machine who was on the care team for the purpose of coordinating care and in the context of value-based care - who's getting paid to take care of you, need to be consistent - payor need
• If condition changes need to have a current care team that provides effective care - clinical need - care coordination
• Will share "Care team" references with Stephen Chu - [3]

• Action Items
  • Payer - need brief examples of when Payer will need types of care teams
  • Clinical - need brief examples of when clinical will need types of care teams
  • IT - - need brief examples of when systems will need types of care teams
  • Care coordination - - need brief examples of when care coordination will need types of care teams

Volume 1 Call #2 - Dec 19th, 2016

• Addendees*
  • Emma Jones
  • Jeremiah Myers
  • Chris Melo
  • George Cole
  • Stephen Chu
  • Denise Downing
  • Lisa Nelson

Use Case discussion

• How are care team members removed from the care team? Reason for the question is to determine boundary [added to open issue list]
  • If episode-focused, When the episode is over
  • If encounter-focused, When the encounter is over
  • If condition focused, when the condition is resolved
  • If care coordination focused - when the provider takes himself off the care team
  • people can get off the care team either manually or in an automated way. If automated, need to build in exceptions, need to consider business rules with decision logic.
• what's the scope of an episode?
  • Concept of episode is used in chronic care - where the episode is a continuum
  • In acute care, the episode is like encounters
  • this is a definitional issue, RIM specific topic.
• Is there multiple care team resources tied to the patient or is there multiple versions of care team resource?
  • Functionally, even in a single episode, there can be multiple care teams. If the teams operate concurrently, is determined by the patient condition. These types of clinical work flow should be determine.
  • Single instances can nest the care team and have multiple instances
  • Care plan has a referenced to the multiple care teams

Volume 1 Call #3 - Jan 30th, 2016

• Addendees*
  • Emma Jones
  • Russ Leftwich
  • Chris Melo
  • Stephen Chu
  • Denise Downing

• CCS care coordination functional model - need to add to discussion area how CCS plays into this profile.
• added to open issues - need discussion in volume 2 of how notification of updates occur.

Calls before F2F in Feb

• Jan 2 - New Year Holiday - Cancelled.
• Jan 16 - Cancelled due to conflicts with HL7 WGM
• Jan 30

Volume 2+

Please use this IHE dedicated Zulip chat for FHIR related questions and discussions IHE FHIR Zolip Chat

• Volume 2+ Call scheduled
  • Monday March 13, 2017
  • Monday March 27, 2017
  • Monday April 10, 2017 - Cancel. Not needed.

Monday March 13, 2017 - Meeting

• Attendees
  • George Cole
  • Chris Melo
  • Emma Jones

Reviewed:

• Open issues list
• Volume 2 Transactions

Plan for Next Call:

• Forge Tool
• Action Item - need FHIR naming convention for the profile. Will ask on PC FHIR call and/or post question to Zulip.
  • for care plan IHE profile did the following
    • profiledResourceName.profile.date
    • Suggestions: careTeam_dynamic_profile_[date]; careTeam_Subscription.structuredDefinition.date; StructureDefinition.IHE.DynamicCareTeamManagement.CareTeam.date

Monday March 27, 2017 - Meeting

• Attendees
  • Emma Jones
  • Thomson Kuhn
  • George Cole
  • Jeremiah Myers
  • Denise Downing

Agenda

• Review Chapter 6 - content Module
  • Care Team Resource
  • Subscription Resource
• ForgeTool profiling will have to be done after STU3 updates - See here for forge STU3 update schedule

Today's version of the profile is here here

• Reviewed Care Team and Subscription resource profiling.
• Added 2 open issues to be discussed further at F2F
  • Add email as channel type to subscription resource? Is email a useful subscription type for care team in addition to rest-hook?
  • Do we need do something to tag the care team as dynamic? Comparable to templateIDs in CDA to show conformance. How are others doing this when they profile FHIR resources?

April 10th call not needed. Jeremiah will cancel