Care Management

Introduction

This is a draft of the Care Management Profile (CM) supplement to the PCC Technical Framework. This draft is a work in progress, not the official supplement or profile.

Profile Abstract

The Care Management Profile (CM) provides a mechanism for EHR and other HIT systems to communicate information to Care Management systems in support of specialized care programs.

Glossary

Term

Definition

Issue Log

Open Issues

1. Issue
2. Issue

Volume I

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• Care Management - The Care Management profile supports the exchange of information used between EHR systems and applications used to provide care management for specific conditions

Dependencies

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Integration Profile	Dependency	Dependency Type	Purpose
Care Management

Profile Name

The Care Management Profile (CM) supports the exchange of information used between HIT systems and applications used to manageme care for specific conditions.

The collection of this data that is increasingly available through health care IT applications can greatly improve outcomes by supporting health management, substantially reducing healthcare costs. Special purpose care management systems are used more and more to support disease specific management, wellness programs and public health monitoring. These special purpose health management systems have been developed to manage the care of patients with respect to diverse conditions, including chronic diseases such as diabetes and cancer, and tracking and managing immunizations provided against infections diseases. These systems presently utilize ad hoc data gathering to collect information from diverse health IT systems to populate data repositories, which are then used to support care management activities for a variety of patient populations. Information is provided to these systems from a wide variety of sources, including:

• Physician Offices
• Imaging Centers
• Laboratories
• Surgery Centers
• Inpatient Settings
• Insurance Providers

In order to manage the care of the patient using these special purpose health management systems, numerous data points are routinely gathered. The data gathered varies based upon the condition being managed. There is a need to be able to easily configure healthcare IT systems to transmit these data points, either on an ad hoc, or a scheduled basis, and to automate the transmission of this information to these systems.

The purpose of this profile is to systematically define the data gathering requirements of these systems in a way that supports existing and future system deployments, without the need for special purpose data gathering interfaces to be developed.

Use Cases

Use Case Name 1

One or more paragraphs describing a clinical scenario.

Use Case Name 2

One or more paragraphs describing a clinical scenario.

Actors/Transaction

The diagram below shows the actors oif the Care Management profile.

Care Management Actor Diagram

Care Management Actors and Transactions

Actor	Transaction	Opt.	Section
Guideline Manager	Guideline Notification	R	PCC-7
	Request Guideline Data	R	PCC-8
Care Manager	Guideline Notification	O	PCC-7
	Request Guideline Data	O	PCC-8
	Care Management Data Query	R	PCC-9
	Care Management Update	R	PCC-10
Clinical Data Source	Request Guideline Data	O	PCC-8
	Care Management Data Query	O	PCC-9
	Care Management Update	R	PCC-10

Options

Care Management Options

Actor	Option
Clinical Data Source	HL7 Version 2 Option
	Care Record Option
Care Manager	Guideline Management Option

HL7 Version 2 Option

A Clinical Data Source Actor that implements the HL7 Version 2 option sends updates using HL7 Version 2 messages to the Clinical Data Manager.

Care Record Option

A Clinical Data Source Actor that implements the Care Record Option sends updates using HL7 Version 3 messages defined in the Care Record DTSU to the Clinical Data Manager, and must support the Care Management Data Query transaction.

Guideline Management Option

A Care Manager that implements the Care Manager Option supports the Guideline Notification transaction.

Process Flow

Care Management Process Flow

More text about process flow

Actor Definitions

Guideline Manager

The guideline manager actor is responsible for managing the guidelines used to create care plans, and for communicating those guidelines to other systems.

Care Manager

The care manager actor is responsible for supporting the management the care of patients with respect to a specific health condition. It gathers information about the care provided and current health status of the patient.

Clinical Data Source

The clinical data source actor is responsible for gathering and supplying information about the care provided and current health status of patient.

Transaction Definitions

Guideline Notification

The Guideline Notification transaction reports a the content of new and/or updated guidelines to interested parties. The purpose of this transaction is to alert systems that need to act on clinical guidelines of the availability of new guidelines.

Request Guideline Data

The Request Guideline Data transaction supports the capability of systems to query for the contents of an identified guideline.

Care Management Data Query

The Care Management Data Query transaction supports the capability for systems responsible for monitoring the health status and care provided to one or more patients to request that information from systems that may have it.

Care Management Update

The Care Management Updagte transaction supports the capability for systems that have information about the health status and care provided to one or more patients to share that information with external systems that need to monitor that information.

Volume II

Transaction 1

Use Case Roles

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Actor

Actor 1

Role

Role of Actor 1

lather, rise and repeat for each actor

Referenced Standards

STD

Description

Interaction Diagram

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