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

Chronic Disease Management

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

1. Registry of patients with Chronics Diseases
   • Collection of statistics,
2. 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

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

- 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 developing 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)

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