Focused Care Management

1. Proposed Profile: Focused Care Management

• Proposal Editor: Kboone
• Profile Editor: TBD
• Date: N/A (Wiki keeps history)
• Version: N/A (Wiki keeps history)
• Domain: PCC

2. The Problem

Allie' geeky proposal

Docs are not getting a whack upside the head. Potentially use Arden Syntax to express criticallity, how big is the whack! Hockey stick might be needed.

Relevant Clinical Results

Requests for imaging studies with very little or not clinical information. If radiologists could get information on clinical information, might help in interpretation. Might be more applicable in terterary care where pressure to bill might not be as high, could also be dependant on nature of problem. Lesion in a bone, could be ostiomielitis, or bone tumor, what happened recently.

Simpler issue, a pharmacist might want access to lab results.

Specialists in one domain might need access to information in another domain.

May be linked to circle of care for the patient.

Might need to address issues of consent for requests after the fact.

Organ Registry

Store Information about a patient. Store Information about donors. Enable matching of patients to donors. May cross countries.

As general as from blood transfusion to organ donation, bone marrow.

=== Chronic Disease Management === (13 votes) (overwhelming Canadian support) Steve: Two different approachs:

1. Registry of patients with Chronics Diseases

Collection of statistics,

1. Active Disease Management

Ensure enforcement of regime (see HL7 order sets)

- resources willing to commit to attending some days of some IHE working group sessions to help document the profile: Dave Heaney, Some interest from Jose and Steve, MAHER(?)

Maher: How to track recommended treatment for diabetes, HBP, CHF, kidney tests, etc to form a data set. We also want to track patients who do not yet have the chronic disease, but may be at risk of developping it. Data sources are important: lab tests, patients wearing monitoring devices, etc

eg Vermont: 110 data elements that they want to monitor across different systems Problem: How do you specify what that looks like in a way that an electronic system can recognize it and start collecting the data?

eg: Arden syntax (HL7) has some mlm modules. They can take the inputs from a series of tests over a period of time and collect the tests and do a push to your inbox/screen/etc. (See Allie for more) (- may tie in with Quality domain acute and ambulatory quality measures)

=== Continuity of Care for Home care === (7 votes)

When patients leave the care environment for home. While they have nursing care at home, there is information collected from day to day. When the patient has to go back to the hospital for an intervention, that information collected at home needs to be brought back to the hospital for care, and then brought back home as well.

eg: Quebec software for nursing home care spent a year with nurses documenting their workflow to model the software (they would be a good candidate for sponsoring the profile!!! PG Documents) Daily/Weekly/Monthly updates and prioritization and scheduling.

Wait Times

Ties in with CDM: recording the wait times which allows us to detect the overloads and the spaces that relate to the clinical portion of the care: eg: does the time spend waiting for decisions affect this condition? Or: Supply and demand: linked with scheduling. Identify resources needs as well as resources surplus and redistribute the surplus to the areas with needs. There is no standard for communication of those, nor taxonomy. Indicators and thresholds are not uniform. Standard needed: "Decision to treat" data elements

3. Key Use Case

<Describe a short use case scenario from the user perspective. The use case should demonstrate the integration/workflow problem.>

Somebody defines a protocol for disease management. Systems need to be initialized with this protocol. It will look like: 1. Diagnosis: does the patient fit the Chronic disease profile? Y/N/maybe later? Identify the person that we will track. 2. Disease registry: registry, maybe composed of flags in patient health records identifying them as patients whose data need to be tracked 3. Determine which data elements need to be tracked 4. Gather X data elements about the patient

Generalize this to a more general protocol, not just data gathering. FHTs (family health teams) get bonuses for following predefined steps.

See: protocol insertion proposal from last year

1. A Canadia Healthcare Scenario.

<Feel free to add a second use case scenario demonstrating how it “should” work. Try to indicate the people/systems, the tasks they are doing, the information they need, and hopefully where the information should come from.>

4. Standards & Systems

<List existing systems that are/could be involved in the problem/solution.>

• ____ Information System
• ____ Information System

ALL: Practice management, EHR, Pharmacy, Cardioligy information system, RIS, PACs, ADTs, PIX managers, XDS repository - CDM is the "ultimate user of EHR"

<If known, list standards which might be relevant to the solution>

• HL7 CDA Release 2.0
• HL7 Version 3
• HL7 Arden Syntax
• SNOMED CT
• HL7 CTS
• LOINC
• ICD9/ICD10
• DICOM / WADO

5. Discussion

<Include additional discussion or consider a few details which might be useful for the detailed proposal>

<Why IHE would be a good venue to solve the problem and what you think IHE should do to solve it.>

<What might the IHE technical approach be? Existing Actors? New Transactions? Additional Profiles?>

<What are some of the risks or open issues to be addressed?>

<This is the brief proposal. Try to keep it to 1 or at most 2 pages>

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