Dynamic Care Planning Meetings

This Profile team meets on Mondays 10-11:00 EST Please navigate to https://himss.webex.com for call in information.

Profile Supporting documents are here [1]

Monday November 30, 2015

Attendees:

• Anne Diamond
• Lisa Nelson
• Emma Jones
• Keith Boone
• Amit Popat
• George cole
• Denise Downing
• Elena Vio
• Gunther Meyer
• Did I miss someone?

Goal for Today's call 1. Need to determine the Use cases we will need 2. Discuss concerns with scope and infrastructure and what we were thinking about profiling in terms of CCS Capabilities

• Use Cases
  • Decided we should do two - transition of care and chronic disease management (Chronic disease management - can be useful in Canada)
  • To assist with marketing suggestion made to ensure we include support of MU CCDS
  • Recommendation made to not be specific with use of 'Post-acute' - need to keep it high level and more generalized. Post-acute means different things to different folks
  • Suggestion to flush out the use case before we work on the transactions and actors

• Scope and infrastructure
  • Reviewed the CCS capabilities we may need to support
  • Discussion about the scope of what we will profile - the CCS capabilities- this will be the actors and transactions.
  • Suggestion made to focus on care Plan management capabilities primarily
  • Discussion about combination of subscribing and publishing - can be logically and virtual
  • Discussion about not needing to do anything special to have a transaction that is to 'create the plan'. Let that be a pre-condition, one or more care plan exists and this is the process to get those plans aligned and centralized

• George presented the 'Back of the napkin' idea
  • Actor A provides content, actor B pulls data out of the care plan
  • Certain set of FHIR operations - can get multiple FHIR servers to synchronize their activities. There is a subscription resource in FHIR that can set up queries to query- resource describing a query
  • Discussion about resolving patient identity. Community EMPI, PDQ - use of PQm
  • First approach is to do a handshake about what patient we're talking about - we would have to profile this -
    • First we have to know the identity - an agreed upon identity Or Use chaining - care plan associated with patient.
  • Lisa presented her 'Star' idea
    • Federated - Use a network of some sort. Community exchange will handle the staring. Lisa's Star.

Call ended. Next meeting Monday Dec 7th

Monday Dec 7, 2015

Attendees

• Lisa Nelson
• George Cole
• Emma Jones
• Keith Boone

Lisa suggests adding this use case [2]as one of the purple boxes to the diagram Keith emailed http://wiki.siframework.org/electronic+Long-Term+Services+and+Supports+%28eLTSS%29+References#eLTSS

Discussion about Actor transaction with updator as an actor.

Various actions:

• Contribute
• Read
• Read various pieces and put in the reconcile view - the updator

• • Content updater is a combination of content creator and content consumer.

• • Content updator actor came into existence with ITI - XWD profile.

Discussion around the relationship to CP 211 Keith Question: For dynamic care planning, what are the systems trying to accomplish for their users?

CRUD - Create Read Update Delete

What are the different systems doing?

Discovery services is needed.

Main question - how do I find content for a patient?

• • Talk to the patient - this is just one way
  • Another case is when patients show up in care settings where the patients have never been seen before

Need a way to figure out who the care team is and how to get information from them.

Flesh out the Use Cases - here's a patient who doesn't have all the information and how to get the information Then from there, what do you ?

1. Connecting with a patient dynamic care plan 2. Content of the care plan - what meds they are on, problems, social history, etc.

Need to clarify the use case because this does not seem much different from QED Need to understand how this is different from other work that have been done?

• • How to fix the new thing.
  • Need a scenario and talk thru what's actually happening and how this dynamic care planning will help. How is this different from xds and QED

Action Item: Summarize existing story boards.

Next Meeting: monday Dec 14th

Monday Dec 14, 2015

Attendees

• Lisa Nelson
• George Cole
• Emma Jones
• Keith Boone
• Anne Diamond

Note: the ITI/DSTU 2 synchronization call is overlapping with this call - it's from 9-11 est. Call information is on himss.webex site. No need to change the dynamic care planning call time. PCC folks can call into the ITI/DSTU call for the first hour then come to the dynamic care planning call.

Review of the chronic conditions storyboard summarization (posted on the ftp site).

• Discussion:

• • Need to use 'verb' when describing actions on the dynamic care plan to make the concept clearer. Dynamic care planning is something that is continuously happening - a living moving thing.

Review of HL7 definition of Synchronization

• Discussion:
  • What does the 'made available' mean? What is the expectation?
    • 'Made' available does not mean 'locked'. We will not use the check-out, locked, update and check-in model (like sharepoint does with document editing)
    • We want to be able to see when someone is editing or changing the dynamic care plan. Be able to see posts. The closest example to experience this might by your interaction with google doc.
      • We talked about doing subscriptions. CCS Monitor Change Capability is subscription
      • Also need 24/7 access to the dynamic care plan

Dynamic care planning diagram

• Discussion:
  • A view collected from distributed content (distributed from various care planning)
  • The big circle involves all the little circles - as you bring into focus all of these little blue circles they could merge into a bigger blue circle
  • We need to be able to represent how different providers want different content in their view. Certain things they care about other things they don't care about. Like having different views of the same thing

Action Items:

• Diagram - Make the circles round and change plan to planning
• Lisa will provide example diagrams to show different views of the same thing (Emma will post on the ftp site)
• Emma will post use case summary on the FTP site.
• Emma will start updating volume one with the Use case
  • we will use the HL7 chronic condition use case and provide the summarization concepts to depict the dynamic care planning

Next call Monday Dec 21. Monday Dec 28 call will be cancelled due to the holiday.