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

Managing the care of patients with chronic illness is recieving a great deal of attention in national and regional projects. In part this is because these patient's healthcare providers see this as an area where care and outcomes can be greatly improved, and healthcare costs substantially reduced. In order to manage the care of these patients, several data points need to be routinely gathered that vary based upon the condition being managed. There is a need to be able to easily configure healthcare IT systems to gather these data points and submit them to chronic disease management system, either on an ad hoc, or scheduled basis. There is also a need in Healthcare IT systems to easily identify the patients to which chronic disease management protocols apply, and who might benefit from enrollment in such programs.

There are two different levels for automation of chronic disease management. At the first, or entry level, is simply the collection of, and reporting of various statistics to disease management systems. This is very similar to quality reporting profiles. The next level is a more active approach, which includes enabling decision support systems to actively alert providers, patients, or other interested parties to actively perform care activities, triggered by the current disease state recorded in the chronic disease management system. Such actions may include alerting providers or case managers to recent changes in various measures for a patient, automatically contacting patients to remind them of new visits or other scheduled activities to perform, et cetera.

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:

Diagnosis: does the patient fit the Chronic disease profile? Y/N/maybe later? Identify the person that we will track.
Disease registry: registry, maybe composed of flags in patient health records identifying them as patients whose data need to be tracked
Determine which data elements need to be tracked
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