PCC FHIR CarePlanning for CareTeam Management

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Meet Every Other Friday 1-2pm EST

  • Webex
    • Call-in toll-free number (US/Canada): 1-866-469-3239
    • Call-in toll number (US/Canada): 1-650-429-3300
      • Meeting Number: 929 505 915
      • Meeting Password: Meeting1

Friday December 7, 2018 - Meeting Notes

  • Attendees
    • John Moerke
    • Chris Melo
    • John Donnelly
    • Emma Jones
    • George Dixon


  • Request to join the care team are functionalities not actors. Will need to define the needed functionality
  • How to bring the care planning and care team together
    • Care Plan contributor will need to know the activities the care team participant is engaged with.
      • Care Plan actor will need to go find someone (e.g. in network insurance providers) and when you find them add it to care team.
      • Care plan contributer - could leverage MCSD - provider directory profile from ITI- (FHIR flavor of both HPD and CSD) as an optional grouping
    • Need a transaction between the care plan contributor and the care team
    • Do systems treat this functionality as separate systems? If not as separate systems then it's internal system communication
  • When we look across the marketplace today, how likely is care team coordination using separate systems - one for care planning and the other for care team management?
  • IHE does value when it does coordination of multiple transactions rather than single transactions
  • Care team could be initially created with nothing but a set of roles. However, this would be outside of care coordinating/planning for a patient
  • When adding a member to a careTeam resource, the participants are part of the attribute of the team
  • When adding a care team member as part of the activity of the care plan (activity.performer) - means more than just adding a care team member.
  • Suggestion: Care team and care plan profiles should be merged into one. Could there be a possibility for a market need for a software that does nothing but manage a team? Or is there a need to merge into one bigger profile and have one actor that does both. Another reason to Keep the profiles separate and update the care team profile would work nice if the care plan and care team resource have enough attributes in them to know what to do for the process of care team management when care planning.
  1. Leave it 2 profiles but recognize that the care team will use the care plan transactions as long as the resources carry enough information to not have a side channel.
  2. If we don't have all the transactions defined will either have another side channel or merge the 2 profiles together.
  • Do you envision in today's mark space - there will be one piece of software to manage the care plan and ask a different software to manage the care team?
  • Care plan stakeholder is an integral part of managing the team.
  • Underlying resources to build the 2 pieces are very different. Care team one is more generic. The actual implemented solution will be individual endpoint(s).
  • Conclusion - one aspect is people management and the other is clinical management. People will write care plan with specific role and or specific name - this would mean a role for person and role to the care plan - historic relationship to the patient.
  • Payers have care coordinators that manage patients [care managers] and are trying to get into this space.
  • IHE actor definitions are software entities.
  • Care Team coordinator actor - merging the profiles makes the documentation easier and also supports the dynamic aspect of the care planning orchestration.
  • Care coordination has a care plan contributor and a care team aspect
  • Action Item 1: Ask to review at PC CP DAM call - care coordination with the ability to coordinate care teams as well as the clinical care - We think these need to go together.
  • Action Item 2: - CCS - what are the actions for the functionality of adding some one to the care team
  • Action Item 3: Ask the broader community if a) implementations do Care Team management as standalone systems b) If it is more likely that systems will merge both.
    • I.e. Should both DCP and DCTM profiles get merged so that Care Coordination will include both care team management and care planning aspects? (emma will send to group to review first)
  • Next Meeting - Dec 21st.
  • Meeting adjourned at 14:08

Friday December 21, 2018 - Meeting Notes

  • Attendees
    • John Moehrke
    • Michael Clifton
    • Thierry Dart
    • Emma Jones
  • Discussion
    • Is the care team tied to the patient?
      • Care Team is for the care plan and the care plan is specific for the patient.
        • Is this a particular kind of care team?
        • Action Item: Question for HL7 Care Team DAM - Would having a care team with a category of "Care Plan" - a Care Plan focused care team
      • Question to interoperability community
        • Thierry will share with European partners
    • Review of care team aspect of the care planning.
  • IHE PCC topic
    • Mapping of IHE CDA templates to C-CDA templates. Michael will provide proposal for next cycle. This is work that Epic will use. Other vendors would need to be able to expect these templates.
  • Next Meeting - Jan 4, 2019.
  • Meeting adjourned at 13:30

Friday January 4, 2019 - Meeting Notes

  • Attendees
    • Emma Jones
    • George Dixon
    • Jeff Danford
    • John Moehrke
    • Thierry Dart
    • Michael Clifton
  • Discussion
    • Care plan has specific what. Need to find persons to take action
    • For systems that manage the care plan, do they also manage the care team? If so, it may be easier to manage by combining the two profiles
    • Need to define the API that messaging between the thing that manages the care team and the pieces being managed (the What)
      • Care plan is collection of actions that is so variable
      • Functionally need people committed to a specific task - sound like it should be an all one profile
      • Plan management is independent from team management.
    • Need Transaction that the team manager will execute to fill out the team.
    • Planning on utilizing FHIR operations
    • Goal to to Update a care plan with a list of actions that you want performed.However, everybody will not be available
      • Care team members will be invited to join the care team - as they acknowledge and accept the invitation they become active members of the care team
      • Struggle is that the transactional model that IHE has grown to love can be cumbersome when used for RestFUL
      • John Describes an interaction model that is simpler
    • the problem with Care team is that it doesn't lend itself well. May need to do a messaging service (communication tool from a care team and a response back - Communication request and communication)Care team member can see the care plan once response is affirmative
    • Keep the use of communication - ITI profiled it for this purpose but not a clean set - open to whatever is the most appropriate messaging strategy on how to accomplish the what.
    • Need to look at the other IHE re-usable parts
      • Suggest ITI profile (Alert communication management) - this will leverages re-use - this profile uses provider directory (if can find them in the provider in the directory, shows the expected endpoint)
        • this profile is open to many methods of communication
        • initially we can should consider using this profile or consider if a change to it can be made.
    • Transactions - should only need one transaction with the applicable set of trigger events that are the transactions we currently have.
    • Action Item: Emma will work with John at HL7 WGM to see if what PCC has need to change now. This change will make the RestFul world happy. Will end up with one transaction per resource with the applicable transactions.
    • Care Team work flow
      • Doesn't seem to have support for states if participation
  • Action: May need to Define extension in the participant element such as confirmed participation, requested participation, tentatively accepted participation, etc
  • Action Item: Emma will find out from LHSWG if CT-DAM specifies acceptance attributes
  • Next Meeting - February 1, 2019.
  • Meeting adjourned at 14:00

Friday February 1, 2019 - Meeting Notes

  • Attendees
    • John Donnelly
    • Holly Miller
    • Michael Clifton
    • Thierry Dart
    • George Dixon
    • Jeff Danford
    • Emma Jones

DCP Profile Updates

  • Discussion
    • Reviewed Actors, Transactions and grouping.
    • Questions:
      • Should role related responsibility be a transaction? ACTION: Emma will look at other profiles and see how this is handled.
      • Suggestion - If there are role related activities, assign by role, not by individuals.
        • If not a transaction, need to state as pre-requisites in the document that this is needed
    • Next steps - 3 weeks until F2F
      • ACTION: Emma will send updates to the profile via email and will ask Sara to schedule a call on Feb 22 to discuss any outstanding topics.

Care Team Section

  • Discussion
    • Follow up from HL7 Example Task force meeting on thursday about a care team section with structured entries
    • IHE CDA-DSS Profiles have use cases for a care team section and points to the HL7 Care Team text only section created by example task force. Should IHE be the venue to create a section that utilizes entries? Will Add this to the agenda for discussion as to -
      • Is IHE the venue to take on this work?
      • Is there an IHE/HL7 process to follow?
      • Emma will provide the straw man that has been initiated for a care team entry template.

Friday February 15, 2019 - Meeting Notes

  • Attendees
    • Thierry Dart
    • Chris Melo
    • Emma Jones
    • Michael Clifton
    • Adam Bell

DCP Profile Updates

  • Reviewed DCP profile updates - see Feb 9th version on FTP
  • Review High level workflow - See workflow V1
  • ACTION: Emma will update use case for next weeks call and also include subscription in high level workflow.

Other PCC Items

  • Agenda Prep for F2F
    • Suggestion: beginning of the week discuss existing work items
      • Proposed Agenda
        • Monday Day 1 Q1: DCP (for Care Team Managment)
        • Q2 Care Team Section - (brief) Proposal for a CP; initial discussion - gaps, process, etc
        • Q3 CPs
        • Q4 New Business, other projects (e.g. better specifying content and uses of data instead of just rendering the data)
        • Tuesday Day 2 AM: DCP (for Care Team Managment)
        • Q2 - CT detailed proposal
        • Q3 CPs
        • Q4 New Business, other projects
        • Wednesday Day 3 AM: DCP (for Care Team Managment)
        • Q2 - CT - next steps
        • Q3 CPs
        • Q4 New Business, other projects
        • Thursday Day 4 AM: Profile/CPs updates
  • Action: Michael will initiate Release a call for proposal ASAP
    • Follow ITI process
  • Care Team Section (entries required) Proposal
    • ACTION: Emma will provide initial brief proposal.

Friday February 22, 2019 - Meeting Notes

  • Attendees
    • Emma Jones
    • Michael Clifton
    • Sarah Bell

DCP Profile Updates

  • Discussion
    • Use Case updates presented
    • Plans for the F2F Agenda