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Longitudinal Coordination of Care
LCP SWGThursday, May 30, 2013
• S&I Update• Announcements and Reminders• Use Case 2.0
– Schedule and Outline– 12.0 Dataset Requirements– David Tao’s Comments on Base Flow, Alternate Flow,
Assumption sections
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Agenda
• LCC WG participation in HITPC MU SWG #3 Care Coordination– Summary of May 24th meeting– Care Plan discussion scheduled for June 4th, 2013
• 11:30am – 1:30pm ET• Participate online: https://altarum.adobeconnect.com/mu; Audio:
1-877-705-2976
• Reminder to register for 2013 LTPAC HIT Summit– Date: June 16-18, 2013– Location: Baltimore, MD– http://www.ahima.org/Events/EventCalendar/Event.aspx?Id=b88011a0-3d9f-45cc
-8454-60837c37baaf
• Call for Pilot Participation!– If you or someone you know is interested in piloting Transitions of Care and/or
Care Plan Exchange, please contact us at: [email protected], [email protected], [email protected]
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ONC S&I Update
• Next week’s Thursday LCP call will be at 5:00-6:00pm ET
• Meeting Reminders (next week)– LTPAC SWG meeting – Monday at 11am ET– LCC HL7 Tiger Team SWG meeting – Wednesday at 11am ET– LCP SWG meeting – Thursday at 5pm ET
• Visit the LCC Use Case 2.0 Wiki Page for all current artifacts to review: (http://wiki.siframework.org/LCC+WG+Use+Case+2.0)
– Use the comment form to provide feedback on UC sections (http://wiki.siframework.org/LCC+Use+Case+2.0+Comments)
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Announcements and Reminders
Work Group SchedulesLCC WG
SWG Meeting LCC Leads Date/ Time Projects
LTPAC SWG Larry GarberTerry O'Malley
Weekly Mondays, 11-12pm EST
C-CDA: Transfer Summary, Consult Note, Referral Note
LCC HL7 Tiger Team
Russ Leftwich Weekly Wednesdays, 11 - 12pm EST
LCC WG comments for HL7 Care Plan DAM
LCP SWG Bill RussellSue MitchellJennie Harvell
Weekly Thursdays 5 - 6pm EST (starting June 6)
C-CDA: Care Plan, Home Health Plan of Care
HL7 WGSWG Meeting HL7 Lead Participating LCC
MembersDate/ Time Projects
HL7 Patient Care WG Russ LeftwichElaine Ayers Stephen Chu Michael Tan Kevin Coonan
Susan Campbell Laura H Langford Lindsey Hoggle
Bi-weekly Weds, 5 -6pm EST
Care Plan DAMCare Coordination Services (CSS)
HL7 Structured Documents WG
Bob DolinBrett Marquard
Sue MitchellJennie Harvell
Weekly Thursdays, 10-12pm EST
CDA (various)
HL7 SOA WG CCS Project Jon Farmer Enrique Meneses (facilitators) Stephen Chu
Susan Campbell Weekly Tuesdays 5 - 6pm EST
Care Coordination Services (CSS)
HL7 Patient Generated Document
Leslie Kelly Hall Weekly Fridays, 12-1pm EST
Patient-authored Clinical Documents
LCC Use Case 2 Development ScheduleItems in italics will drawn directly from the LCC Project Charter or created offline directly from other sections and will be included in the end-to-end review
Date Item Homework (Due Wednesday COB)
3/11 – 3/18
10.0 Scenario (User Stories, Base/Alternate Flow, Functional Requirements)
Review: User Stories
3/25 – 3/26
3.0 Use Case Scope (Background, In / Out of Scope, Communities of Interest)
Finalize: User Stories, Base Flows, In / Out of ScopeReview: Communities of Interest, Assumption
4/1 – 4/2
3.4 Communities of Interest Finalize: Communities of Interest, Assumptions, Pre-Conditions, Post-ConditionsReview: Actors and Roles5.0 Use Case Assumptions
6.0, 7.0 Pre-Conditions, Post Conditions
4/8 - 4/11
Finalize: Assumptions, Pre-Conditions, Post-Conditions, Communities of Interest8.0 Actors and Roles
Finalize: Assumptions, Pre-Conditions, Post-Conditions, Actors and Roles
4/15 – 4/18
Finalize: Communities of Interest, Assumptions, Actors and RolesReview: Base/Alternate Flows, User StoriesActivity Diagrams
Review: Base Flows, Activity DiagramsFinalize: Base Flows, Activity Diagrams
4/22 – 4/25
11.0 Risks, Issues, and Obstacles Finalize: Risks, Issues and ObstaclesReview: Sequence Diagrams
10.4 Sequence Diagram
5/2 – 5/16
10.3 Functional Requirements Finalize: Sequence Diagrams, Functional Requirements, Use Case Diagrams, AppendicesReview: Community Feedback, Dataset Requirements9.0 Use Case Diagrams
Appendices
5/23 Community Feedback12.0 Dataset Requirements
Review: Dataset Requirements
5/30 12.0 Dataset Requirements End-to-End Review (preliminary)
• 1.0 Preface and Introduction**
• 2.0 Initiative Overview– 2.1 Initiative Challenge Statement**
• 3.0 Use Case Scope– 3.1 Background**– 3.2 In Scope– 3.3 Out of Scope– 3.4 Communities of Interest
• 4.0 Value Statement**
• 5.0 Use Case Assumptions
• 6.0 Pre-Conditions
• 7.0 Post Conditions
• 8.0 Actors and Roles
• 9.0 Use Case Diagram
Use Case Outline
•10.0 Scenario: Generic Provider Workflow– 10.1 User Stories– 10.2 Activity Diagram
o 10.2.1 Base Flowo 10.2.2 Alternate Flow
– 10.3 Functional Requirementso 10.3.1 Information Interchange Requirementso 10.3.2 System Requirements
– 10.4 Sequence Diagram
•11.0 Risks, Issues and Obstacles
•12.0 Dataset Requirements
•Appendices
– Related Use Cases– Previous Work Efforts– References– Glossary
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** Leverage content from Charter
Draft sections complete
Content available for review
• Care Plan Document Descriptive Data Elements – Document Description– Document Change– Presentation– Question
• Context• Privacy and Security• Patient
– Patient Data– Encounter Event – Keep?– Observation Event – Keep?
12.0 Dataset Requirements
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• Care Plan Data Elements– Health Concerns
• Active issues affecting health and well-being that require management• Inactive issues that provide context to proposed interventions (example: hx +PPD and proposed steroid use)• Type
– Med/Surg Issues
– Nursing diagnoses
– Function
– Behavioral: mood, cognition, DSM IV, V
– Environmental (housing, community supports, employment, transportation, legal
– Health maintenance, prevention
– Risks
– Barriers to intervention
• Descriptive Data– Current Management
» Active
» Inactive
– Status
» USE LIST OF CODES TO BE PROVIDED BY BILL
– Impact on Health or Wellbeing
» High
» Medium
» Low
» Unknown
– Severity (SOMEONE TO PROVIDE THE ICD10 structure for the dimensions of severity/progression/stability/etc)
– Priority Type
» Patient
» Physician
» Result
– Priority Level
» High
» Medium
» Low
12.0 Dataset Requirements
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• Care Plan Data Elements– Interventions
• Status• Assessments
– Goals or Desired Outcome of Interventions to address Health Concerns
• Status• Timeline • Milestones
– Overall Goals for Care– Longitudinal Care Team
• Members (Patient, Principle Care Physician, Care Plan Manager, Principle Healthcare Provider, Principle Care Giver, Others (Relevant Specialists, Therapists, SW, etc)
– Identification and Contact Information– Responsibility to Health Concern Set / Responsibility for Intervention
(includes assessment)
12.0 Dataset Requirements
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• Care Plan Process Elements– Input data
• All potential Health Concerns– Problems– Risks– Barriers
• All potential Interventions
• All potential Goals
– Prioritization• Decision Making
– Probabilities– Preferences– Overarching Goals– Potential Interventions
12.0 Dataset Requirements
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• Show Use Case 2.0 document– 10.2.1.1 – Base Flow for Scenario 1 comments– 10.2.2 – Alternate Flow Text comments– 5.0 – Assumptions (already modified)
David Tao’s Comments from the Wiki
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