Focused Care Management: Difference between revisions

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Revision as of 22:15, 15 October 2007

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

Chronic Disease Management

(13 votes) (overwhelming Canadian support) Steve: Two different approachs:

Registry of patients with Chronics Diseases
- Collection of statistics,
Active Disease Management
- Ensure enforcement of regime (see HL7 order sets)

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

A Canadia Healthcare Scenario.

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>

<Delete this Category Templates line since your specific Profile Proposal page is no longer a template.>

@@ Line 10: / Line 10: @@
 ==2. The Problem==
-=== Chronic Disease Management === (13 votes) (overwhelming Canadian support)
+=== Chronic Disease Management ===
+(13 votes) (overwhelming Canadian support)
 Steve:
 Two different approachs:
 # Registry of patients with Chronics Diseases
-Collection of statistics,
+#* Collection of statistics,
 # Active Disease Management
-Ensure enforcement of regime (see HL7 order sets)
+#* 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)
 ==3. Key Use Case==