PCC FHIR CarePlanning for CareTeam Management

Meet Every Other Friday 1-2pm EST

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• • • Meeting Number: 929 505 915
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• See here for DCTM profile implementation artifacts

Friday December 7, 2018 - Meeting Notes

• Attendees
  • John Moerke
  • Chris Melo
  • John Donnelly
  • Emma Jones

Discussion

• Request to join the care team are functionalities not actors. Will need to define the needed functionality
• How to bring the care planning and care team together
  • Care Plan contributor will need to know the activities the care team participant is engaged with.
    • Care Plan actor will need to go find someone (e.g. in network insurance providers) and when you find them add it to care team.
    • Care plan contributer - could leverage MCSD - provider directory profile from ITI- (FHIR flavor of both HPD and CSD) as an optional grouping
  • Need a transaction between the care plan contributor and the care team
  • Do systems treat this functionality as separate systems? If not as separate systems then it's internal system communication
• When we look across the marketplace today, how likely is care team coordination using separate systems - one for care planning and the other for care team management?
• IHE does value when it does coordination of multiple transactions rather than single transactions
• Care team could be initially created with nothing but a set of roles. However, this would be outside of care coordinating/planning for a patient
• When adding a member to a careTeam resource, the participants are part of the attribute of the team
• When adding a care team member as part of the activity of the care plan (activity.performer) - means more than just adding a care team member.
• Suggestion: Care team and care plan profiles should be merged into one. Could there be a possibility for a market need for a software that does nothing but manage a team? Or is there a need to merge into one bigger profile and have one actor that does both. Another reason to Keep the profiles separate and update the care team profile would work nice if the care plan and care team resource have enough attributes in them to know what to do for the process of care team management when care planning.

1. Leave it 2 profiles but recognize that the care team will use the care plan transactions as long as the resources carry enough information to not have a side channel.
2. If we don't have all the transactions defined will either have another side channel or merge the 2 profiles together.

• Do you envision in today's mark space - there will be one piece of software to manage the care plan and ask a different software to manage the care team?
• Care plan stakeholder is an integral part of managing the team.
• Underlying resources to build the 2 pieces are very different. Care team one is more generic. The actual implemented solution will be individual endpoint(s).
• Conclusion - one aspect is people management and the other is clinical management. People will write care plan with specific role and or specific name - this would mean a role for person and role to the care plan - historic relationship to the patient.
• Payers have care coordinators that manage patients [care managers] and are trying to get into this space.
• IHE actor definitions are software entities.

• Care Team coordinator actor - merging the profiles makes the documentation easier and also supports the dynamic aspect of the care planning orchestration.
• Care coordination has a care plan contributor and a care team aspect

• Action Item 1: Ask to review at PC CP DAM call - care coordination with the ability to coordinate care teams as well as the clinical care - We think these need to go together.
• Action Item 2: - CCS - what are the actions for the functionality of adding some one to the care team
• Action Item 3: Ask the broader community if a) implementations do Care Team management as standalone systems b) If it is more likely that systems will merge both.
  • I.e. Should both DCP and DCTM profiles get merged so that Care Coordination will include both care team management and care planning aspects? (emma will send to group to review first)

• Next Meeting - Dec 21st.

• Meeting adjourned at 14:08

Friday December 21, 2018 - Meeting Notes

• Attendees
  • John Moehrke
  • Michael Clifton
  • Thierry Dart
  • Emma Jones

• Discussion
  • Is the care team tied to the patient?
    • Care Team is for the care plan and the care plan is specific for the patient.
      • Is this a particular kind of care team?
      • Action Item: Question for HL7 Care Team DAM - Would having a care team with a category of "Care Plan" - a Care Plan focused care team
    • Question to interoperability community
      • Thierry will share with European partners
  • Review of care team aspect of the care planning.

• IHE PCC topic
  • Mapping of IHE CDA templates to C-CDA templates. Michael will provide proposal for next cycle. This is work that Epic will use. Other vendors would need to be able to expect these templates.

• Next Meeting - Jan 4, 2019.

• Meeting adjourned at 13:30

Friday January 4, 2019 - Meeting Notes

• Attendees
  • Emma Jones