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2017-08-11 Learning Health Systems Call

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Patient-Centered Care Team Domain Analysis Model

Facilitator Russell Leftwich Note taker(s) Emma Jones
Attendee Name Affiliation

X Russell Leftwich InterSystems
X Lori Macdonald Tennessee Department of Health
X Stephen Chu Brisbane South Primary Health Network
X Evelyn Gallego ONC
X Joe Quinn
X Anne W
Laura Heermann-Langford Intermountain Healthcare
X Emma Jones Allscripts
Jeff Brown Cancerlinq
Lisa Nelson Individual
Dave Carlson VA
X Robert Hausaum IHTSDO
X Michelle Miller Cerner
X Didi Davis Sequioa Project
Matt Rhan
Michael Padula
Serafina Versaggi VA


  • Chair: Russell Leftwich
  • Scribe: Michelle Miller
  • Motion to approve previous call (Aug 4th) minutes: Stephen moved/Emma second

Care Team Governance

  • Care team is virtual and defined by who touches the patient. Team members don't usually work for the same organization and don't report to the same entity. From a modeling stand point need to determine governance and also where people have governing roles.
  • In the past, S&I framework and LCC talked about who's on the team. Have a broadening expection that a team is defined by relationships to the patient.
  • Several components of team governance
    • Governance:
      • Structure,
        • accountability and responsibility
      • Principles,
      • Policies,
      • Processes -
        • consent,
        • planning,
        • contracting,
        • service delivery,
        • decision mkaing,
        • risk/dispute mitigation,
          • resolution,
          • escalation;
    • Are we covering the entire spectrum of this?
      • Will need to account for all the possibilities. If yes, from the modeling perspective, need to consider these components
    • Governance include the operational business aspects or policy and practices in place including any contracts that may exist.
    • First assumption is that homecare teams are not the same - sometimes they're contracted and sometimes not.
      • Suggest rolling this under processes. Would best practices be included? Business practices such as clocking hours would be included as business services.
      • Would be considered as governance components.


  • Is the patient the leader of the team? Have to be taken into consideration on a case-by-case basis.
  • In past years, PCP has been defined as a leader of the team but this exploration does not assume such. Would depend on the level of literacy and capability of the patient or caregiver.
  • In our use cases, should we describe the leader of the team?
    • Self-directed individuals can be the leader of the team. Also in long tearm care care givers can be the leader.
    • Suggest the possibility for modeling
  • Use Case #1 - We need a use case where there is no clear leader - Truly collaborative team functions without a real leader but everybody does their job as long as they all communicate.

Team management

  • Use Case #2 - no real leader because there is no communication - e.g. individuals seeing a chiropractor and the other care providers are not aware. Nobody is coordinating or is aware. Patients with no insurance and providers not communicating. Virtual care team that does not know the other care team members exists. People seeking care from non-medical folks.
  • Navigators - goes to multi-specialty meetings to keep all care-givers in the loop.

Planning vs service delivery

  • Care coordination services work - some people participate in the planning process in a functional role (e.g. meals on wheels). Is there value in sorting the care team members value set into delivery role and planning role?
    • Might be challenging because these roles interchange and are often use case dependent.
    • Would have to be on a case-by-case basis or care team by care team basis.
    • Is it worth the effort to map or tag the different role?
      • There are a few examples - meals on wheels or home care services (service delivery roles)
      • chronic diseases care manager or care coordinator would be in the planner role. This is an important attribute to assign family members. Some provide the service and part of the planning process. When a patient has 2 children - one the primary care giver and the other only helps out once a year - Planning and/or service are attributes of each care team member. Agreement that these need to be included in the modeling.
      • Tagging should be done in a case-by-case basis. Eacg role need to be tagged with planning and/or care delivery

Decision making

  • Related but separate in care team responsibility.
  • The patient and/or family member always have a decision making role by legal definition but other care team members have decision making authority. This goes back to the CCS calls about decision making and whether a provider specialist is preference to other care team member - where their preference is expressed as recommendations that comes as 'decision making'. The surgeon recommends a procedure - the patient may have a preference of one procedure or another or not having the procedure at all. The procedure is a recommendation.
  • In real life the preference/recommendation comes out more as a "thou shall have it" but we consider the patient as the decision maker - they have to accept or reject.
  • Decision making often comes down to negotiations. In the end, all care team members involved will have to accept the decision of a single individual.
  • Negotiation is a CCS capability. Model as a process thru the structural concept of communication.
  • Have to instill collaboration among care team members.

Related attributes

  • Consent - for the patient to treatment and patient consent to access other information.
    • Some of the functions are tied to the leadership or planning role.
      • The consent have to be transferable to other care team roles. If a care team role is fulfilled by an organization the consent transfers to the other organization. Same with coverage - the consent transfers to the person covering. The consent have to be transferable. This is needed to enable care coordination service.
    • Agree the concept of consent will need to be unpacked.
  • 1. consent for establishment of the care plan and any clinical intervention
  • 2. consent for the care team membership
  • 3. information sharing - this is more difficult to crack. Done by implicit consent at the level of required-ness to provide the care to the patient.
  • Can we leverage the DS4P work? See ONC DS4P Initiative
    • Requirement for digital signature - all providers have to sign and the patient as well. The signature is agreement that care is as planned.
  • Leverage a consent framework between the consumer and the care provider will have to leverage consent between the organization and the patient.
  • Action Item: Stephen will work on providing a use case for individual providers consent on a care team.


  • One of the essential functions to enable all of this